3.4 Out of pocket payments
OOP expenditure increased between 2011 and 2015, mainly as a result of an increasing mandatory deductible (although this is not included in the national statistics) and shifting costs from public to private sources by excluding services from the basic benefit package (see Fig3.8). Over this period, the health care allowance decreased and OOP expenditure increased. The share of taxes increased in 2014 as a result of the shift of long-term care services to the municipalities. Consequently, the income-dependent contribution for residential long-term care has decreased, since care that was previously supplied under the AWBZ has now shifted to the Zvw (home nursing and inpatient mental care from one to three years) and to the municipalities.
3.4.1 Cost-sharing (user charges)
Table3.4 shows cost-sharing for health services in the Netherlands.
Health Insurance Act (Zvw)
For basic health insurance, a compulsory deductible of €385 (in 2016) is levied for all individuals aged 18 or older. The deductible is levied on all health care expenditure except general practice care, maternity care, home nursing care and integrated care (for diabetes, COPD, asthma and cardiovascular risk management). The deductible is also levied on pharmaceuticals and diagnostic tests prescribed by GPs. The deductible includes expenditure on outpatient pharmaceutical care, but excludes co-payments for pharmaceuticals. The deductible is paid to the health insurer and should reduce moral hazard, that is, the use of additional or more expensive medical services caused by the fact that expenditure is (partly) compensated by insurance (Schut & Rutten, 2009). About 51% of the insured paid the full deductible in 2013 (Vektis, 2015). Most health insurers allow payment in monthly instalments.
Health insurers may choose not to charge this deductible, as a way to steer patients to good quality care. Since 2009 this option is used when patients (1) use preferred medicines (also see section 3.7.2), or (2) follow preventive programmes for diabetes, depression, cardiovascular diseases, COPD (such as chronic bronchitis) or overweight. In 2015 a few health insurers applied this principle (Independer, 2015; Ziektekosten-vergelijken.nl, 2015). In the programme “Quality pays off” (“Kwaliteit loont”), launched in 2015, the Minister encouraged health insurers not to charge the deductible when the insured go to contracted providers (Ministry of Health, Welfare and Sport, 2015a).
In addition to the compulsory deductible health insurers offer a voluntary deductible, varying between €100 and the legal maximum of €500 per year. The level can be chosen each year by the insured. The choice for a voluntary deductible results in a reduction of the premium. The reduction of the yearly premium usually equals about 50% of the voluntary deductible (in 2015, for a voluntary deductible of €500, an average reduction on the premium of €236 was given, with a range of €150 to €324) (Dutch Healthcare Authority, 2015d). Health care expenses are first balanced with the compulsory deductible and then with the voluntary deductible, so in 2016 a voluntary deductible of €500 results in a deductible of €885 (€385 + €500) for the patient. In 2015, 12% of the insured chose a voluntary deductible, and most of them (69%) chose the maximum voluntary deductible (Vektis, 2015). For the voluntary deductible the same exemptions are in place as for the compulsory deductible (general practice care, maternity care and home nursing care). Insurers are not allowed to extend the compulsory and voluntary deductibles to complementary VHI reimbursements.
For outpatient mental care, since 2014, no OOP payments other than the mandatory deductible are levied. Before 2014, an OOP payment of €20 per session was levied and a maximum of five sessions were covered.
The type of health plan also has potential influence over the total amount of cost-sharing. The insurers may offer two kinds of policy: a benefits in-kind (natura) policy and a restitution (restitutie) policy. The type of policy influences the access the insured has to health care providers: with the in-kind policy the patient has a right to care, although full reimbursement may be limited to contracted providers, while the restitution policy gives the patient the right to have compensation for the costs of care.
The in-kind policy implies that insurers have to provide care to their insured persons through health care providers that are contracted by the insurer. The insured person does not receive a bill for the provided care. If the insured person decides to choose a non-contracted provider, the health insurer may establish the level of the compensation for the insured person. The compensation should, however, be such that the choice of a non-contracted provider remains a financially feasible option. Providers are obliged to publish their tariffs for non-contracted care (see also “walk-in” tariffs in section 3.3.4). A relatively new development among in-kind policies is the selective policy. This plan, which includes only a limited number of contracted health care providers, is often (but not always) cheaper than the conventional in-kind policy. Patients who go to a non-contracted provider are reimbursed to only 50–90% from what is usually paid in the market or, if applicable, the legally set maximum tariffs. Although jurisprudence ruled that 75% reimbursement was the minimum, the budget policies were offered in anticipation of the abolition of freedom of choice, which failed to pass the Senate in December 2014. For non-budget policies the reimbursement is normally between 75% and 80%. About 7.5% of the Dutch population purchased a selective policy in 2015 (Dutch Healthcare Authority, 2015d). On average budget plans are €118 per year cheaper than other in-kind policies.
The second type of policy is the restitution policy, which grants the insured reimbursement of their health care bill and a free choice of provider. In principle, the insured pay the bill out of pocket and are reimbursed afterwards by the health insurer, although in reality expensive health care bills are paid directly by the insurer. The health insurer is not allowed to limit reimbursement for the insured person. However, the health insurer does not have to reimburse more than is considered reasonable in the Dutch health care market (in a court ruling “reasonable” is described as in accordance with the market (Staat der Nederlanden, 2005)). The health insurer is obliged to mediate between patient and provider to facilitate the care requested by the insured person.
In practice, there are also combinations of these two policies. For instance, some insurers offer a restitution policy, but provide the opportunity to pay bills directly to contracted providers. In 2015 about half (48%) of Dutch citizens had an in-kind policy, approximately a quarter (23%) had a restitution policy, about a fifth (21%) had a combination policy and 7% had a selective policy. The percentage of insured having a selective policy increased from 3% in 2014 to 7% in 2015, while the percentage of those with an in-kind policy remained constant between 2014 and 2015 (Vektis, 2015).
Long-term Care Act (Wlz)
For long-term residential care, there exists a complicated system of income-dependent cost-sharing requirements, in the form of co-insurance with an OOP ceiling. Co-insurance means that the user pays a fixed share of the cost of a service, with a third party paying the remaining share. There are two types of co-insurance rates: the high co-insurance rate and the low co-insurance rate. For the first six months of care, all patients pay the low co-insurance rate. If patients have a partner and/or dependent children at home, they continue paying the low co-insurance rate after six months, but all other patients then have to start paying the high co-insurance rate. The amount of the co-insurance depends on the patient’s income and 8% of their assets. The low co-insurance rate is 12.5% of income (in other words, the insured pays up to 12.5% of his income, and the remaining costs, if applicable, are paid via the Wlz), with a €159 minimum and a €833 ceiling per month in 2015. The high co-insurance rate consists of the patient’s total taxable income and part of their assets, with a maximum of €2285 per year in 2015. The patient may keep a fixed pocket money and dressing allowance (€3517 for single people and €5471 for couples per year). The co-insurance for inpatient residential care is calculated and levied by the CAK. Compared to neighbouring countries, cost-sharing is very low (in the Netherlands it was €1.1 per capita in 2013, compared to €90.6 in Belgium and €142.1 in Germany (OECD, 2015)).
Home help, social support and aids
For home help, social support and aids such as wheelchairs, municipalities are allowed to ask recipients to share in the cost on the basis of their income. However, municipalities are free to set their own maximum OOP payments. There is an anti-accumulation regulation available for households receiving both Wlz-care and Wmo-care. Households do not pay more than the maximum Wlz-contribution, except when in one household one member uses residential care and another sheltered housing. In that case both recipients have to pay the maximum contribution for couples, which is divided proportionally between the recipients (Ministry of Health, Welfare and Sport, 2015c). In 2015 compensation of 33% on the total cost-sharing amount was abolished. The effect on individual households depends on their income and on measures taken by the municipality, such as the option to remit cost-sharing for the lowest income groups.
For youth care, a parental contribution is applicable for children who reside outside their parental home. The amount is set nationally and in 2015 amounted per month to €75 – €133, depending on the age of the child.
VHI may cover costs of care not included under the Zvw, such as dental care, classes and physical therapy. VHI may not cover the mandatory deductible.
As of January 2018, the cost-sharing for long-term care (provided under the Long-term Care Act) is lowered for people living in nursing homes and who have a partner living at home and for people who receive nursing home care at home. Previously, 12.5% of their income was included in the calculation of their out-of-pocket contribution, this is lowered to 10%. As a result, the contributions may be lowered with 30 to 150 euro per month for people with an average income. The measure addresses the problem of stacking of contributions for different types of care (such as the mandatory deductible for medical care, contributions for the care provided by the municipality, and long-term care contributions). From 2011 to 2017, the out-of-pocket expenditure for a couple with an average income of which one is chronically ill has more than doubled. (source: www.zorgvisie.nl/de-jonge-verlaagt-eigen-bijdrage-wlz/)
3.4.2 Direct payments
Direct payments are made for services that are excluded from the basic benefit package. Most notably this includes the majority of dental care for those over 18 years, physical therapy (for persons without a chronic indication), walkers, contraceptives, benzodiazepines (sleeping pills and tranquillizers), statins (lipid lowering medication), acetylcysteine (reducing the viscosity of mucous secretions) and cosmetic surgery without a medical indication. These services are considered either inessential, ineffective or affordable by individuals. It is permissible to purchase complementary VHI for these services.