By Wilma Zwijnenburg
Wilma Zwijnenburg from Omring, The Netherlands largest long-term care provider, discusses how the sector is adapting to recent policy changes. —Report from a presentation at the 2009 conference of the MUHC-ISAI
In the early 20th century, long-term care was privately funded, and services were organized without state intervention. In 1968, The Netherlands was the first country to introduce collective funding. Other countries followed and increasingly comprehensive long-term care programs started to grow. The role of government in long-term care and home care expanded, with public funding collected from mandatory income-related contributions. Fees and tariffs were centralized, and there were increasing efforts to control spending. Home care organizations transformed from small local community-based organizations to big regional organizations. New contracting models were developed and there was a shift to competition.
Major changes began in the 1980s. Tight cost containment policies were introduced in nursing homes, starting with the regulation of supply and restriction on the number of building licenses accorded for nursing homes. As a result, the proportion of GDP spent on long term care remained more or less stable, around 3.5%, for about 15 years. But waiting lists grew longer, and the public decried the inflexibility and the low quality of the services. After several court challenges, a law was passed upholding the right to quality long-term care, and government funding was increased. From 2001 to 2003, there was a cost explosion primarily led by the drive to reduce waiting lists.
The challenge of controlling costs
After 2003, efforts to restrain long-term care spending were renewed. Tight regional budgets were introduced for providers, and income-adjusted co-payments were imposed on home care. Some entitlements were de-listed from government-run long-term care insurance (AWBZ — see below), and part of the long-term care budget was transferred to local government. This shift was accompanied by a move from provider-based to client-based budgeting. Nursing homes introduced care service packages with defined hours and types of care and corresponding case-based budgets.
The Netherlands now has 2.4 million elderly people; 14% of the population is over 65 and 20% of those are over 80. By 2015, 24% of the population will be over 65, of which 38% will be over 80; 3.6% of the population uses long-term care. The grey wave has arrived. The effort to control the costs of long-term care in this context includes a shift in financing rules. By 2012, government wants to see a significant shift of responsibility for long-term care from AWBZ to local governments through the WMO and to independent (private and social) insurers. We are entering an era of significant change.
Nursing care and rehabilitation will become the responsibility of independent insurers and housing costs will be removed from the care package and become the responsibility of the individual. Independent insurers will also assume responsibility for the care chain, the movement of patients between the hospital, nursing homes, home care, and general practitioners (GPs). The GP will assume a more important role, and ensure that people not go too quickly into nursing homes or hospitals. What is still unclear is whether everything about personal care will be transferred to local government and independent insurance, out of central government control.
The boards of long-term care organizations are shifting from voluntary, local and self-appointed, to professional and paid boards. They are also now being held accountable for quality and finances. Administration has grown increasingly complex under new legislation that separates funding streams. As a long-term care and home-care provider, Omring has to bring these streams together to serve the patient’s various needs. As well, independent insurance companies all have different rules.
We are seeing a greater shift from inpatient to outpatient care and shorter stays, which have intensified demand for long-term care services. Health professionals need to expand their activities to accommodate a larger and sicker outpatient clientele.
The challenge to providers
The Netherlands does not want to spend more on health care. So it has to figure out how to provide good service and stay on budget. For Omring, one of Holland’s largest home and long-term care providers, this involves redefining the mission statement and strategy, and focusing on the empowerment of patients. It is impossible to change the care programs within the facilities without support from patients and their families, and we have to work with them to design care programs in which they can take part.
We also have to equip families and volunteers to provide certain aspects of care, professionalize them to some extent. Otherwise they will not help, and we will have a big problem. We have to return home care organizations to the small neighbourhood teams they once were, and work with the GPs to do that. And we have to train our staff in new competencies and skills to work in concert with patients’ families, not see them as a burden on their daily process. We are responding to the new requirements, but are not sure we will have a chance to fully implement our program before the political winds change direction.
There are enormous risks in the current government agenda with regard to long-term care and home care. Will Dutch society accept the barriers to care? Less collective solidarity, and more differentiation? Fewer automatic social rights? In anything more than basic care, there will be a differentiation in care provision. Last but not least, will we be able to retain our staff? Will people become doctors, nurses and caregivers in this new society? Rationally, they may be able to accept that there is differentiation in care, but emotionally many will find it difficult.
Laws governing long-term care and home care in Holland
Via the Exceptional Medical Expenses Act (AWBZ), all Dutch citizens automatically pay a premium and are insured for care and support in the event of long-term illness, disability or old age. The AWBZ distinguishes between six functions: personal care, nursing, supportive counselling, motivational counselling, temporary or permanent residence in a nursing home or care home and treatment during recovery from an operation or disorder. To take advantage of the AWBZ provisions/facilities, people apply to the Care Assessment Centre (CIZ), which assesses eligibility according to a person’s health and residential and living arrangements. On January 1, 2007, home care was dropped from the AWBZ and included as “domestic assistance” in the Dutch Law on Social Support (WMO) administered by local governments.