JANUARY

THE NETHERLANDS
The GP is the central figure in Dutch primary care. Although registration with a GP is not formally required, most
citizens are registered with one they have chosen, and patients can switch GPs without formal restriction.
Referrals from a GP are required for hospital and specialist care.
Many GPs employ nurses and primary care psychologists on salary. Reimbursement for the nurse is received by
the GP, so any productivity gains that result from substituting a nurse for a doctor accrue to the GP. Care groups
are legal entities (mostly GP networks) that assume clinical and financial responsibility for the chronic disease
patients who are enrolled; the groups purchase services from multiple providers. To incentivize care
coordination, bundled payments are provided for certain chronic diseases—diabetes, cardiovascular conditions,
and chronic obstructive pulmonary disease (COPD)—and efforts are under way to implement them for chronic
heart failure and depression.
In 2015, the government introduced a new GP funding model comprising three segments. Segment 1
(representing 75% of spending) funds core primary care services and consists of a capitation fee per registered
patient, a consultation fee for GPs (including phone consultation), and consultation fees for ambulatory mental
health care at the GP practice. The Dutch Health Care Authority (Nederlandse Zorgautoriteit) determines
national provider fees for this segment. Segment 2 (15% of spending) consists of funding for programmatic
multidisciplinary care for diabetes, asthma, and COPD, as well as for cardiovascular risk management; prices are
negotiated with insurers. Segment 3 (10% of spending) provides GPs and insurers with the opportunity to
negotiate additional contracts—including prices and volumes—for pay-for-performance and innovation. Selfemployed
GPs earned average gross annual income of €97,500 (USD117,000) in 2012, while salaried GPs
earned €80,000 (USD96,000).
Outpatient specialist care: Nearly all specialists are hospital-based and either in group practice (in 2012,
54% of full-time-equivalent specialists, paid under fee-for-service) or on salary (46%, mostly in university clinics).
As of 2015, specialist fees are freely negotiable as a part of hospital payment. This so-called “integral funding”
dramatically changed the relationship between medical specialists and hospitals. Hospitals now have the
responsibility of allocating their financial resources among their specialists.
There is a nascent trend toward working outside of hospitals—for example, in growing numbers of (mostly
multidisciplinary) ambulatory centers—but this shift is marginal, and most ambulatory centers remain tied to
hospitals. Specialists in ambulatory centers tend to work most of the time in academic or general hospitals.
Only a small minority of doctors working in hospitals choose to work in ambulatory centers for part of their time.
Ambulatory care center specialists are paid fee-for-service, and the fee schedule is negotiated with insurers.
Medical specialists are not allowed to charge above the fee schedule. Patients are free to choose their provider
(following referral), but insurers may set different conditions (e.g., cost-sharing) for different choices within their
policies (Schäfer et al., 2010).
Administrative mechanisms for paying primary care doctors and specialists: The annual deductible (see
above) is paid to the insurer. The insured have the option of paying the deductible before or after receiving
health care and may choose to pay all at once or in installments. Other copayments—those for drugs or
transportation, for example—have to be paid directly to the provider.
After-hours care: After-hours care is organized at the municipal level in GP “posts,” which are centers, typically
run by a nearby hospital, that provide primary care between 5 p.m. and 8 a.m. Specially trained assistants
answer the phone and perform triage; GPs decide whether patients need to be referred to hospital. The GP
post sends the information regarding a patient’s visit to his or her regular GP. There is no national medical
telephone hotline.
Hospitals: In July 2014, there were 131 hospitals and 112 outpatient specialty clinics spread among 85
organizations, including eight university medical centers. Practically all organizations were private and nonprofit.
In 2013, there were also more than 260 independent private and nonprofit treatment centers whose services
were limited to same-day admissions for nonacute, elective care (e.g., eye clinics, orthopedic surgery centers)
covered by statutory insurance.
International Profiles of Health Care Systems, 2015 117