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262 Economic crisis, health systems and health in Europe: country experience
Reduction of overspending
Overspending has been a long-standing problem in both primary and specialized
care. Since 2008, if health care providers exceeded the amounts agreed in the
contracts, they have had to pay back the amount overspent in the next year.
This was done in the form of tariff measures (Table 8.5). Such tariff measures
have been applied to care provided by GPs, medical specialists and hospital
facilities and to some extent also to pharmaceutical care (clawbacks). Tariff
measures applied to medical specialist care appeared not to be very effective,
since the overspending in the area of specialist care remained relatively high
in 2009–2011 (at 13–52%; see Table 8.2), whereas overspending on GP care
and on the use of hospital facilities remained below 10% of their respective
budgets in the same period. More measures to curb overspending have been
implemented since the emergence of the crisis.
Changes to somatic care
In 2009, the normative times assigned to treatments by medical specialists
and the compensation for supporting specialists (e.g. radiologists, medical
specialists who are not the main responsible physicians and treating physicians)
were reconsidered (i.e. recalculated with new assumptions) 7 and the Health
Care Authority formulated measures aimed at recovering overspending. For
example, the budget for tariffs for medical specialists was cut by €375 million
in 2009 (Table 8.5). The announcement of further cuts in 2010 (€512 million)
led to many protests by medical specialists, resulting in an agreement in
December 2010, signed between the Association of Medical Specialists (Orde
van Medisch Specialisten), the National Hospital Association (Vereniging van
Ziekenhuizen) and the Ministry of Health. 8 The budget for specialized care
was to be capped at €2 billion per year in 2012, with the growth in budget
limited to 2.5% per year until the tariffs of medical specialists become part of
the free negotiations between providers of secondary care and insurers, which
is assumed will happen in 2015 (Association of Medical Specialists, National
Hospital Association & Ministry of Health, 2010). At present (2014), 70%
of hospital care is subject to price negotiations between insurers and hospitals,
while the remaining 30% of tariffs is set by the Health Care Authority. However,
7 Treatment times for medical specialists and supporting specialists are difficult to estimate and remain approximations
of actual treatment times.
8 Agreements between the Ministry of Health and health care providers or health insurers are concluded by their respective
umbrella associations on their behalf. These associations have no means of controlling production of health care services
or to sanction any unwanted behaviour of their members. The system of agreements works because there is always the
latent threat that the Ministry of Health can impose measures, such as tariff cuts, if the agreed terms are not met (e.g.
if there is overspending). Since the role of the government in the Dutch health care system is to watch from a distance
rather than to be directly involved, the preference is to use agreements negotiated between the parties instead of imposing
measures in a one-way fashion by the Ministry of Health. It is assumed that the health purchasing market (insurers
purchase care from health care providers) will provide sufficient incentives for both insurers and providers to produce
health care of good quality at acceptable prices. It is important to mention that the use of agreements between parties
is part of Dutch political culture and such agreements also exist in other sectors, for example in the education sector.