What are we doing for appropriate care?

The National Health Care Institute is working on appropriate care in various ways

The National Health Care Institute has various tasks to help achieve appropriate care. Appropriate package management means for example that we no longer only ask whether care works and for whom but also impose conditions on how care may be provided and by whom. We are also working on a package agenda covering over 50 treatments, medicinal products and medical devices for which it needs to be clear by the end of 2025 whether and how they will be or may remain in the basic health insurance package, as well as the arrangements that will then apply to ensure appropriate care for patients.

We help discuss and think through the processes of procuring and contracting appropriate care. We collect good examples of appropriate care so that they can be progressed and we identify the biggest pain points in some major areas of care.

Appropriate care in the basic health insurance package

The National Health Care Institute manages the basic health insurance package. We are working to ensure that the care provided by the basic insurance is good, accessible and affordable for all. This does not mean that we have a full picture and control over all care entering the basic package: for most care that is provided, healthcare professionals and health insurers decide for themselves whether it should be reimbursed. This makes a lot of care available quickly but including many treatments where it is not at all certain if they genuinely work or for whom they work best. There is no proper scientific evidence for them. This can create unnecessary care that benefits nobody – neither the patient nor society. Ensuring that the care in the basic insured package is more appropriate is letting us work on care that is only reimbursed if it has been shown to work, and where there are agreements that only patients for whom the care works will receive it. The National Health Care Institute already pays attention to this for all medicinal products and new treatments that enter the basic health insurance package after a positive recommendation from us. Thanks to the agreements in the Integral Care Agreement (IZA), we are taking additional steps towards achieving appropriate care in the basic health insurance package. 

Appropriate insured package management

We no longer work solely on managing the insured healthcare package but also on appropriate insured package management. The key difference is that appropriate package management means that we no longer only ask whether care works and for whom but also impose conditions on how care may be provided and by whom. Appropriate package management has applied since 2022 to all new care that we assess for admission to the basic insured package. We are also going to carry out more frequent reassessments of care that has been in the basic insurance package for some time and for which it is uncertain whether it genuinely works. 

Through appropriate package management, we also impose requirements on how care is delivered, which patients are eligible for it and who may provide it. We do this together with healthcare professionals, patients’ representatives and health insurers. They translate the conditions into agreements that make things clear for everyone in practice: for doctors, letting them explain things better to the patient; for patients, letting them understand better that not every treatment makes sense; and for health insurers, letting them improve care procurement. There are substantial benefits to this approach. Pressure on healthcare staff is reduced if less unnecessary care is being provided, and more money can go to care that genuinely makes a difference to someone’s health and their quality of life. 

The insured package agenda for appropriate care

An important element of appropriate package management (and one of the IZA’s agreements) is the insured package agenda for appropriate care. The package agenda covers over 50 treatments, medicinal products and medical devices for which it needs to be clear by the end of 2025 whether they will be or may remain in the basic health insurance package, as well as the arrangements that will then apply to ensure appropriate care for patients. The topics on the agenda cover hospital care, primary healthcare, mental health and long-term care. 13 topics have been designated as ‘socially important’ where good agreements should make major improvements possible. Palliative care is one example. Everybody agrees that this care, in the final phase of life, is extremely important. Ideally, you would also provide that care at home – but what if someone has no network of family, friends or neighbours? Might it not then be better to provide that care in an institutional setting? And what agreements do you make about that? What the debate will now be about is how we can get this done properly, together. The healthcare professionals, patients’ representative and health insurers are the ones who have put home-based palliative care on the package agenda. 

Contracting in appropriate care

Everyone in the Netherlands has health insurance. Health insurers reimburse care covered by the basic health insurance package and purchase sufficient care each year by signing contracts with healthcare organisations, such as hospitals and GPs. So far, payment for care has mostly been based on numbers such as a certain number of operations or treatments. Doing it this way, though, can make it especially beneficial to carry out large numbers of treatments. That is an inappropriate incentive. The amount of care should be based solely on what is necessary for the patient, not on what is financially beneficial. We are now working towards a process of procuring and contracting appropriate care. And that is going to entail quite a few changes, for example if certain activities can be funded where that is not the case now, such as longer conversations between the patient and doctor. 

In 2024, health insurers will commence procurement and contracting of appropriate care for the 2025 insurance policy year. Until then, health insurers, healthcare institutions and relevant authorities such as the Dutch Healthcare Authority (NZa) still have much to agree upon and arrange with each other. Given our role as insured package managers, we are helping them think things through and getting involved in the discussion.

Appropriate care practices

We all do it sometimes: looking at something from someone else and adopting it because we see that their idea or approach works. And that is actually, in a nutshell, what an appropriate care practice is: a properly functioning example of care organised so that the right care is delivered in the right place. We will be starting the 'Appropriate Care Practices' programme from the end of 2023.

It will ensure that healthcare professionals and health insurers can read, see, hear and learn from properly functioning examples of appropriate care – adopting and scaling up, instead of reinventing the wheel themselves and losing precious time and manpower in the process. We hope that appropriate care practices will let us make greater strides together quickly towards keeping care good and affordable for all. 

Descriptions of appropriate care

“Everyone wants to grow old but no one wants to be old” is a well-known expression. Living longer is something almost every person wants, but unfortunately having an increasingly elderly population goes hand in hand with an increase in illnesses. The ageing population is the key reason why half of all Dutch people now get cancer. The sharp growth in the number of people with cardiovascular disease is also related to ageing (with lifestyle as a close second). The ageing population is also putting pressure on long-term care, with ever more elderly people needing care while care staff numbers are not rising. 

A great deal of hard work is being done in cancer care, cardiovascular disease care, long-term care and mental healthcare to find solutions to continue delivering care to all. So far, there has not been a good overview of exactly where the pain points are, which is why the National Health Care Institute is working on ‘Signalementen Passende zorg’ (Descriptions of appropriate care) for these 4 major care domains. These are horizon-scanning reports that provide a ‘helicopter view’ of where the biggest challenges are, what solutions are already being worked with and what steps are still needed at the local, regional and national levels. 

The National Health Care Institute is creating these descriptions together with healthcare professionals, patients’ representatives and health insurers. The real work only begins with each report that is issued: implementing the agreements it contains to arrange appropriate care together for people with cancer or cardiovascular diseases, and people in long-term care and mental healthcare.