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Chapter 8 | The impact of the crisis on the health system and health in the Netherlands
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Overspending was also recorded in the area of specialist care; overspending in
this area was much greater (in both absolute and percentage terms) compared
with GP care. One of the reasons for overspending in the area of specialist care
was that the tariffs of medical specialists had been, since the introduction of
a system based on DRGs, known as diagnosis and treatment combinations
(diagnose behandel combinaties; DBCs), in 2005, based on normative times
assigned to treatments. These appeared to have been incorrectly calculated. 2
However, it was initially (2008) compensated from additional government
revenue recorded in that year and no measures to reduce it were implemented,
pending research into the causes of the overspending (Ministry of Health, 2008).
In later years, overspending in specialist care was addressed by implementing
tariff cuts (see section 3.1).
In the area of pharmaceuticals, a so-called clawback mechanism had been in
place since 1998. Pharmacies received price reductions from the pharmaceutical
industry when buying pharmaceuticals; to redistribute this profit from
pharmacies to consumers, a fixed percentage of the reductions was taken back
by the government (i.e. clawed back) (Schäfer et al., 2010). This percentage
was set at 6.28% and up to a maximum of €6.80 per prescribed medicine, with
some temporary increases in 2007 and 2009–2010 (for administrative reasons
rather than because of the financial crisis). 3 The clawback was abolished in
2012, when free prices for pharmaceutical care were introduced (Foundation
for Pharmaceutical Statistics, 2012). According to Boonen et al. (2010), the
government's attempts to claw back part of the discounts offered to pharmacies
were only marginally successful. This was because suppliers increased the prices
of pharmaceuticals to compensate pharmacies for the clawback – this was
possible as long as the prices were set below the legally set maximum prices.
Overspending in the area of pharmaceuticals in 2007 and 2008 was modest
(Table 8.2) mainly because of the preferred pharmaceuticals policy. Since 2005,
health insurers were allowed to identify preferred pharmaceuticals for the three
most frequently used active substances: omeprazole, simvastatin and pravastatin.
From these categories of pharmaceuticals, reimbursement occurs only for
those that are at the same price level as the cheapest pharmaceutical (mostly a
generic) plus 5%, assuming that active ingredients, concentration and mode of
administration are similar. This means that if a patient chooses a non-preferred
drug, the extra cost of this drug compared with the preferred drug is no longer
2 Overspending in the area of specialist care may also be the result of the relatively low number of specialists: the number
of specialists has been traditionally restricted to limit supplier-induced demand; however, restricting the number of
specialists is no longer a solution in a more market-oriented system as it may reinforce their bargaining position and
hence their ability to influence prices upwards (Schut, Sorbe & Høj, 2013).
3 The 2007 increase was introduced because certain financial targets agreed between the pharmaceutical industry, the
Ministry of Health and the Association of Health Insurers were not met. The 2009–2010 increase was imposed because
part of the 2008 clawback was actually not clawed back as there was a court ruling against it. After this was overruled
in an appeal, the Dutch Health Care Authority (Nederlandse Zorgautoriteit) decided to have the shortage in clawback
amount compensated via an increase in the clawback percentage.