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Chapter 8 | The impact of the crisis on the health system and health in the Netherlands
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are implemented. Treatments or aids that are considered to be affordable for
individual patients and treatments or aids that are not effective or not medically
necessary may be considered for removal from the package.
Exclusions from the benefit package are not always permanent. Lobbying or
new scientific discoveries may lead to the exclusion decisions being reversed.
For example, smoking cessation therapy was added to the package in 2011,
removed from it in 2012 and reintroduced in 2013 following lobbying by
antismoking organizations (Longfonds, 2013). Coverage of dietary advice was
severely limited in 2012 (only reimbursed as part of an integrated care package
for a limited number of chronic diseases) and extended in 2013 (although with
a limitation of the number of reimbursed hours) as research into the effects of
dietary advice revealed that the abolition of dietary advice would lead to higher
secondary care consumption (Lammers & Kok, 2012).
Shifting costs to the insured
A number of measures have been taken to shift costs from public to private
sources. For example, the financial burden borne by the insured or users
of care has been repeatedly increased (e.g. by increasing the compulsory
deductible and cost-sharing; Table 8.4). These measures were mainly focused
on somatic and mental health care; however, all co-payments for mental care
were abolished in 2014, when a new remuneration scheme was introduced for
ambulatory mental health care providers (psychological care) in the primary
care sector (see section 3.4), while long-term care was largely unaffected.
Only in 2013 was cost-sharing in long-term care increased, when a share
of taxable assets was added to personal incomes to calculate cost-sharing.
However, the justification for this measure was improving equity in financing
rather than cost-shifting or cost-containment (wealthy people with high
assets and low incomes paid co-insurance based only on their incomes, which
was considered unfair). The measure was first considered in 2009, but it
took until 2013 before the Ministry of Health managed to get the regulation
through parliament and have it implemented.
However, at the same time, the most vulnerable populations have been somewhat
protected from the cost-shifting measures. For example, GP care, maternity
care and care for children were excluded from the “no-claim” regulation (and
later from the compulsory deductible), and, as of 2012, the gradual decrease
of care allowance was adjusted in such a way that people with lower incomes
experienced less reduction than people with higher incomes.