Background Headlines

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Subject:
James Woollard, Geraldine Strathdee
Chris Nas, Eddy Faber
September 25th, 2014
Mental health policies and waiting times in the Netherlands
Background
In the UK, choice between mental health care providers became a legal right in April 2014. However, this
system is not operationally working yet and at the moment no standards in waiting times have been
developed. The NHS wishes to introduce waiting times in a useful way by April 2015, alongside other policies
and systems. The question asked is how the Netherlands addressed the issue of waiting times in mental health
care, with specific attention for these five questions:
1. What policy measures did the government take?
2. The cost of implementing waiting times - did mental health services need extra money to meet waiting
times and if so how was this allocated?
3. Was there a significant change in the use of mental health services because of the changes the
government introduced - did more people access services?
4. Were outcomes seen to improve for people with introduction of waiting times?
5. What was the experience of the Netherlands in collecting and collating data to monitor waiting times?
For answering these questions, we used three main sources to get information:
 OECD working paper on the Dutch mental health system of 2014 (Forti et al. 20141)
 RIVM paper on the cost development in Dutch mental health (Folkertsma et al 20132).
 Several publications and data of GGZ Nederland on waiting lists and number of patients.
Headlines
In the past 12 years, Dutch government initiated several policies to guarantee accessible and affordable
mental health services of good quality. Reducing waiting times was an important goal of these three policies in
2000: increase funding, introduction of primary mental health care and reduction of stigma (paragraph 1).
At first sight, waiting times did not decrease significantly in the past years (paragraph 2), despite a much higher
budget for mental health services (paragraph 3). However, this investment did lead to more supply of services
and a significantly higher demand: more people were able to use mental health services within a reasonable
time and unmet need is very low (paragraph 4). It is not calculated how long waiting times would have been
without a higher budget.
GGZ Nederland (annex 5) has monitored waiting lists in mental health care for 6 years. The experiences in the
first few years led to a new way of reporting waiting times: the realized waiting times of people whose
treatments actually had started (annex 2).
1
Forti, A., et al. (2014), "Mental Health Analysis Profiles (MhAPs): Netherlands", OECD Health Working Papers, No. 73,
OECD Publishing.
2
Folkertsma, J., A. Marijke, J. Polder, G. J. Kommer, L. Slobbe, M. van Tulder (2013), Effects of Policy Measures on Mental
Health Care Expenditures in the Netherlands, Ministry of Health, Welfare and Sport.
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1. Overview mental health policies 2000 - 2012
In 2013, Folkertsma et al (2013) published an overview of mental health and the impact on accessible,
affordable mental health care of good quality (see page 3). In an effort to improve the functioning mental
health system, the Dutch government introduced a number of policies and the sector of course responded.
Modernization of the Exceptional Medical Expenses Act (AWBZ)
In 2002, the policy on eliminating waiting lists was introduced. Health insurers were able to put more care
under contract; therefore, care suppliers could produce more care. This policy was part of the modernization
of the AWBZ. Extra production of care was needed to comply with the growing mental health care demand
and to eliminate the continuously growing waiting lists. The government released the budget maximization in
2002 and the expenditures rose with € 240 million (7.5%). The waiting times increased with 22%, the waiting
lists decreased with 7% due to more care supply. Because of this growth of expenditures, and the marginal
decrease of waiting lists, the budget maximization was reintroduced in 2003. At the same time, the number of
people with access to treatment increased significantly, the unmet need decreased significantly.
Introduction and implementation of Diagnosis Treatment Combination (DBC)
In 2008, the Diagnosis Treatment Combinations (DBC’s) were introduced and gradually implemented. Nonbudgeted care providers established themselves in the (primary) care market, which resulted in a large growth
(262%) of new and non-budgeted care providers in 2008 – 2009. The number of budgeted care providers has
been stable. Budgetary care providers did have a safety net option so the organisations could grow into a new
situation. This safety net was discarded in 2014.
One goal of DBC’s is more transparency of mental health care, but the health insurers found the transparency
insufficient. It is assumed that DBC’s provided more insight in the costs and use and thus led to more
transparency. However, a sharp increase of the administrative burden and necessary ICT investments resulted
in a one-off cost rise of 1.4 billion.
As the effect of DBC’s on transparency in quality was limited, the sector started a nation wide project in 2009
to introduce Outcome Monitoring in Mental Health with the aim to “open the black box” of mental health care
(Forti et al, 2014). It is not possible to use these data to evaluate the outcomes of these governments’ policies.
Transfer of the curative care from the AWBZ to the Health Insurance Act (Zvw)
Also in 2008, curative mental health care was transferred from AWBZ to Zvw. The curative mental health care
contains all outpatient curative care and the first year of inpatient curative care, even lengthy residence. Since
2008, the Zvw is financial responsible for the curative mental health care. The AWBZ care takes care of all noncurative in- and outpatient mental health care, as well as the second year of treatment and further inpatient
care (CVZ 2008). The AWBZ is responsible for 30% of total mental health care expenditures, while 4-6% of all
patients receive AWBZ financed care. With the transfer, parity of esteem between physical and mental health
care has been achieved. However, this change did lead to increasing waiting times. The flexibility between the
two finance systems no longer existed and the budget could not be transferred from the AWBZ to the Zvw.
Further, health insurers are confronted with waiting lists in the AWBZ. The shift of patients from primary to
secondary mental health care was therefore impeded and did lead to higher costs and a lower quality of care.
The costs of the transfer were calculated to be up to 1.1 billion Euros: €500 million more spending on mental
health care, the other €500 million a one-off administrative expenditure.
2
2002
2008
2008
Modernization of the
Exceptional Medical Expenses
Act (AWBZ)
Introduction/ implementation
of Diagnosis Treatment
Combination (DBC)
Transfer curative MHC from
AWBZ to Health Insurance Act
(Zvw)
Introduction Care
Intensity Package (ZZP’S) in
secondary MHC
Introduction co-payment in
secondary MHC
Goals
Elimination of waiting lists
Efficiency profit, more
consistency in care, cost control
Releasing budget maximization
Focus on the patient,
better distribution of costs and
more insight in care intensity
Budget is related to the actual
production of care institutions
Fostering primary MHC referral,
cost control in secondary MHC.
Input
Instruments
Through-put
Process
Due to an inadequate waiting
list registration, there was
insufficient information about
the waiting lists. However, an
increase of 6% new patients,
next to 7% increase of
production can be seen.
Output
The extent to
which the
goals are
achieved
The number of waiting patients
decreased with 7%, the mean
waiting time increased with
22%.
Outcome
Overall goals
of health care
Quality +
It is expected that expanded
treatments, more supply and
shorter waiting lists will
increase the quality of care.
Accessibility Increase of the waiting time
with 22%, but decrease of the
waiting lists with 7%, due to
more care supply.
Affordability -MHC expenditure rose with
€240 million. More supply leads
to more demand.
Cost control through efficiency,
transparency, quality and
better responsiveness
Abolition of the budget
systematic, introduction of a
new finance system
The introduction took place at
the same time as the transfer
of the curative MHC. This had
financial impact on the care
suppliers due to the late start
up of DBC declaration for the
non-budgeted MHC suppliers
and the disbursement for the
secondary MHC.
One-off cost rise of €1.4 billion.
DBC’s led to perverse
incentives in MHC care and
demand. For care suppliers the
DBC’s led to more
transparency, for health
insurers the DBC’s are
insufficient transparent.
Quality
More insight in costs and use of
care, although effect of DBC’s
on quality of care is unknown.
Accessibility +
Establishment of many new
care suppliers what leads to
better accessibility of care.
Affordability -No budget maximization, the
turnover could be much higher
than budgeted, which led to a
large increase in expenditure.
Transfer of all curative MHC
from AWBZ to Zvw. Release of
extra budget for the Zvw.
This transfer took place at the
same time as the introduction
of the DBC’s. Both policy
measures had major impact on
MHC. Secondary MHC has
waiting lists, a small part of
primary MHC also. The transfer
from primary to secondary care
is impeded by waiting lists.
No flexibility between the two
systems lead to waiting lists for
secondary and primary MHC.
The transfer led to a large
growth in MHC expenditure.
Because of longer treatment
duration, consistency in care is
disadvantageous for the MHC.
Quality No flexibility between the two
finance systems, this seems to
have a negative effect on the
quality of care.
Accessibility –
The referral is more difficult
and therefore waiting lists
arise.
Affordability -Because there is no transfer
possible between the two
systems, an increase of MHC
expenditure can be seen.
3
2010
The transition to care based on
personal needs of the patients
caused much effort of provider
and patient. Care agencies, and
in the future, health insurers,
have an important role to
support the care suppliers to
provide higher quality of care.
2012
Co-payments in the secondary
MHC (except for youth, forced
care and crisis care)
To ensure access of MHC, the
co-payment is before
introduction decreased from
€275 to €100 per DBC. For
2013, alternative measures will
be studied.
More insight in care intensity,
focusing on the patient.
However, financing per patient
appears to be too expensive, a
discount is applied to hatch
budget neutral.
The final effects of the copayment are unknown by now.
Expected is that, in the short
term, the policy measure is
highly effective to reduce the
demand of MHC.
Quality +
More insight in care, but the
effect of ZZP’s on the quality of
care is unknown.
Accessibility
With a right indication, the
ZZP’s had no positive or
adverse effect on the
accessibility.
Affordability
Actual costs of ZZP’s are higher
than current budget, the
government adjusted for this.
For the care supplier this is
detrimental when in ZZP’s
arranged care is supplied.
Quality
There is a risk that financial,
instead of medica
considerations, determine the
care supply and care demand.
Accessibility –
Health differences between
poor and rich may grow. In
other countries this
phenomenon is hardly
observed.
Affordability +
Co-payment leads to more
awareness in use of care.
However, substitution to other
sectors should be avoided
Introduction Care Intensity Packages (ZZP’S) in the secondary mental health care
In 2010, Care Intensity Packages (Zorg Zwaarte Pakketten, ZZP’s) in secondary mental health care
were introduced. A ZZP is a description of care intensity and is based on patient’s personal needs.
The budget of health suppliers depends on the care intensity of patients. The ZZP’s gain more insight
in patient’s care intensity and lead to a central role for the patient in the mental health organisations.
In addition, the costs are better distributed since the budget is based on patient’s needs. Main
drawbacks from the ZZP’s for mental health care organisation are the required complex indication of
patients, this leads in particular to a higher administrative burden.
Introduction of co-payment in the secondary mental health care
The introduction of co-payments in the secondary mental health care took place in 2012. Copayment was already introduced in the primary mental health care in 2009, which has led to
substitution of primary mental health care by more expensive secondary mental health care. The copayment was introduced to stimulate more conscious use of care and better cost control; it was
already abolished in 2013.
2. Waiting times in Dutch specialist mental health care 2000 - 2010
In January and April 2000, representatives of (para)medical professionals, health service providers
and health insurers met at the “Treek” (a forest area in the Netherlands). At these meetings, they
agreed upon standardised objectives for waiting times in non-acute healthcare. These so called Treek
Objectives should been effected on 1 January 20033.
Table 2: Overview objectives and maximum waiting times for non-acute mental health care
Admission
Diagnostics
Treatment / support
Cure outpatient
Cure inpatient
Sheltered housing
3 weeks 80%
3 weeks 80%
1 week max.
4 weeks maximum
4 weeks max.
3 weeks 80%
3 weeks 80%
3 weeks 80%
4 weeks max.
4 weeks max.
6 weeks max.
4 weeks 80%
5 weeks 80%
8 weeks 80%
6 weeks max.
7 weeks max.
13 weeks max.
Source: Treek Conference, January 2000 and April 2000
The Treek Objectives used these definitions for waiting times:
Admission/appointment:
Time in calendar days, measured at one set date every month,
between the day on which a new patient makes the first
appointment at a specialist and the day of the first session. In longterm care, the time in calendar days between the registration for
assessment and the day of assessment.
3
Source: http://www.zorgatlas.nl/thema-s/wachtlijsten/wachtlijsten-ziekenhuiszorg/het-treekoverlegstreefnormen-wachttijden-curatieve-sector
4
Assessment/diagnostics:
Time in calendar days, measured at one set date every month,
between the day on which an appointment for is made for
diagnostics/assessment and the day that diagnostics/assessments are
completed, including the result.
Time in calendar days, measured at one set date every month,
between the moment of registration in the waiting time information
system of the service provider and the day of first treatment.
Treatment/support:
Around 2004, GGZ Nederland extensively analysed the waiting lists and waiting times in mental
health care. This provided valuable insights and assisted with the development of a methodology to
measure waiting times in a meaningful way. In short, these are the most important guidelines:
1. Determine standardised objectives (in this case the aforementioned the Treek Objectives).
2. Focus on waiting times, instead of the number of people waiting
3. Determine the realised waiting times (instead of waiting times at a set date).
4. A consequence of point 3, only calculate waiting times of people no longer waiting (e.g. because
treatment has started).
Table 3 shows the waiting times in mental health care between 2002 and 2009 per calendar year for
3 age groups and for each waiting stage. The numbers are the average waiting times in weeks of all
clients in that specific calendar year. Between brackets and in italic, the percentage of clients that
had to wait longer than the Treek Objectives for mental health.
Table 3: overview waiting times mental health care between 2002 and 2009
Children / youth (0-17)
2002
2003
2004
2005
2006
2007
2008
2009
6
6
6
6
6
6
6
6
admission
(51)
(51)
(48)
(47)
(52)
(50)
(51)
(49)
Waiting stage
assessment
7
(41)
7
(42)
7
(46)
8
(50)
6
(43)
6
(37)
7
(44)
6
(40)
admission
(29)
(27)
(23)
(19)
(22)
(25)
(25)
(25)
Waiting stage
assessment
4
(24)
4
(26)
4
(28)
4
(29)
3
(26)
4
(29)
4
(31)
4
(32)
Adults (18-64)
2002
2003
2004
2005
2006
2007
2008
2009
3
3
3
2
3
3
3
3
5
4
5
6
6
5
6
7
6
treatment
(19)
(24)
(30)
(29)
(27)
(27)
(32)
(28)
3
4
4
4
4
5
5
5
treatment
(16)
(18)
(20)
(19)
(18)
(23)
(24)
(23)
Elderly (65-)
2002
2003
2004
2005
2006
2007
2008
2009
3
3
2
2
2
2
2
2
admission
(21)
(21)
(14)
(14)
(14)
(15)
(17)
(16)
Waiting stage
assessment
2
(15)
2
(16)
3
(22)
3
(26)
3
(21)
3
(24)
3
(27)
3
(27)
3
3
3
3
3
5
5
5
treatment
(13)
(17)
(14)
(13)
(14)
(21)
(22)
(21)
Source: Compilation of various waiting times reports produced by GGZ Nederland between 2004 – 2010.
As of 2010, there is no longer a national registration for waiting times in Dutch mental health care.
Mental Health service providers are still required by law to publish the waiting times for different
services and locations on their website.
3. Budget mental health care
The Gross Healthcare Budgetary Framework (Budgettair Kader Zorg, BKZ) has almost doubled from
2000 to 2010, from EUR 2.78 billion to EUR 5.09 billion, almost at exactly the same rate as costs for
health care in general during this period (figure 1).
Figure 1: Expenditure mental health care according to Health Care Budget Framework.
Source: Folkertsma et al, 2013
Mental health care costs did decrease in 2012, contrary to the current general trend in health care,
where costs are continuing to rise (Forti et al, 2014). Data also show that the increase in mental
health care expenditure was not driven by an increase in prices, but rather by an increase in volumes
(figure 2).
6
Figure 2: Increasing volume dominates increasing prices
Source: Folkertsma et al, 2013
4. Use of Dutch mental health care mental health care
Although the mental health of the Dutch population did not change much over the past decennium,
the demand for mental health care increased in this period due to social changes (figure 3).
Figure 3: absolute production of mental health care organisations
Source: Van Dijk, Knispel et al. 2011, Trimbos Institute. *No figures available of part-time therapy in 2007.
First, the government played a major role in reducing stigma, hence increasing accessibility to mental
health services. This policy led to a better-organised mental health care, faster identification of
mental problems in the primary care, and more attention for prevention. This resulted in a higher
demand of mental health care and sharp decline in unmet health care needs (Folkertma 2013).
7
Figure 4: Self-reported utilisation of medication and any form of health care because of psychiatric
problems, alcohol or drug problems (in the 12 months preceding the survey) by the Dutch
population between 18 – 64 years old
Medication (%)
Any form of mental health care (%)
Unmet need (%)
Mood disorder
36.8
58.7
8.7
Anxiety disorder
20.5
34.8
5.9
Substance abuse
15.3
29.0
5.3
ADHD
24.9
35.2
5.1
Any Axis-1 disorder
19.6
33.8
5.6
No axis-1 disorder
2.7
6.5
1.0
Total population
5.7
11.4
1.8
Source: de Graaf, R., M. ten Have and S. van Dorsselaer (2010), De psychische gezondheid van de Nederlandse
bevolking. Nemesis-2: Opzet en eerste resultaten. [The mental health of the Dutch population. Nemsis-2: design
and preliminary results]. Utrecht: Trimbos Instituut. [in Dutch]
However, the number of unique patients in 2012 has dropped from 827,300 in 2009 to 777,900 in
2012 (figure 5). This is also the case for the number of treatments (from 884,500 to 818,900). This
drop is sharper in 2012; this may coincide with the introduction of specific co-payments for mental
health care in 2012. Predictions are that the patient’s income will determine the demand of mental
health care, which means that in particular patients with a low educational level and a low income
will stop or reduce their use of mental health care. However, the co-payments were abolished after
only one year. It is not clear yet what the effect of this policy in 2013 will be.
Figure 5: Number of unique patients and treatments in specialist mental health care
900.000
850.000
800.000
number of patients
number of treatments
750.000
2009
2010
2011
2012**
Source: GGZ Nederland (2014), Sectorrapport 2012: feiten en cijfers over een sector in beweging [Mental health
industry report 2012, facts and figures on an industry in transition]. ** estimation based on period of November
2011 to October 2012.
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