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Primary Care in The Netherlands: General Practitioners in the Lead
Jako Burgers, MD, PhDDutch College of General Practitioners
Common Wealth Fund Webinar
February 5, 2013
2Characteristics of the Dutch health care system
• Complete coverage for all residents (< 1% uninsured)
• All patients are registered in one general practice
• General practitioner is gatekeeper to hospital and
specialist care
• Balance between external, governmental systems and
internal, professionally led systems for quality
improvement
2
• 10,000 general practitioners (GPs), 7,800 own practice
• 100% have practice assistant, 80% practice nurse
• GP is family physician covering whole population • GPs offer out-of-hours service covering whole country• 60% of income is capitation fee, 30% fee-for-service,
10% special services (1-2% P4P)• No co-payment for GP visit• Satisfaction with GP is high (8 on scale from 0 to 10)
Primary Care in Netherlands: Basic Characteristics
3
Health Information Technology
• Eight different software programs for general practice
• All support electronic drug prescription, incl. prompts
• Most support ordering of laboratory testing, imaging,
and referral to hospital care, incl. info on waiting time
• Generating panel information and feedback on
performance is slowly improving
• E-mail consultation and refill request is increasing
4
Access and perceived barriers
• Increasing problems with paying bills or out-of-
pocket costs: from 5% in 2007 to 42% in 2012
• Significant reduction of coverage in basic health care
package and increasing premiums in 2012
• Waiting times have reduced due to increasing
competition between hospitals and public reporting
• Access to GP and after-hours care is well perceived
5
Care Coordination• Practice nurses support chronic care (diabetes, COPD,
cardiovascular risk management), and increasingly elderly care
• Involving specialized practice nurse in mental health care is ongoing
• Communication between medical specialist and GP:– brief message on same day on hospital admission and discharge– full letter after 2 to 4 weeks (on paper or electronically)– phone consultation on demand– use of local protocols strongly varies per region
6
Financial incentives
• Additional care contracts on diabetes, COPD, and cardiovascular risk management (some insurers)
• Flu vaccination ($ 12 per patient), cervix screening ($ 14 per patient)
• Practice nurse (0.4 fte per 2,350 patients)• $ 20 for home visits versus $ 10 for doctor visits and
$ 5 for phone calls
7
Quality Assurance
• Continuing Medical Education is mandatory for re-license (every 5 years)
• Participation in peer review groups is mandatory• 40% of GPs applied for practice accreditation, including:
Assessment of organizational/structural capabilities Clinical performance feedback Patient satisfaction survey
• National research institute and some insurers provide feedback on test ordering and hospital admission
8
Key factors for success:
•National government supports primary healthcare
•Strong, well-accepted national professional organization
•Payment system supports regular doctor and integrated patient care
•Longstanding evidence-based guideline program
•Collaboration and local peer support are essential
Can other countries learn from Dutch general practice?
9