The Future of Hospitals in the Netherlands in 2015

Welcome to the project-wikipage of The Future of Hospitals in the Netherlands, A group-project for the Rotterdam School of Management Executive MBA course by: Gerben Hagenaars, Ton Jonker, Anton Koonstra, Coen van Paassen and Jeffrey Sweeney.

The scope of this project is set at: non academic ('peripheral') hospitals in the Netherlands

BACKGROUND

Medical cost and demand in healthcare are swelling. An intensifying dissatisfaction among patients, government officials, insurers, employers, clinicians and healthcare executives is noticeable. The soaring prices paid to treat the growing volumes of demanding, aging patients are prompting payers to search for more efficient ways of treatment and care. Next to that the government in Holland has introduced the new healthcare payment system with a new insurance system and diagnosis treatment combinations. The main aim of this transition is the development from a budget oriented system to a more market oriented health care system. The belief is that a market oriented system will create more incentives for efficiency, quality and innovation. Many hospitals in the Netherlands have to withstand those forces and the severe capital crunch they create.

In order to dig into the facts of this subject, we performed a thourough literature study and conducted in-depth interviews with some opinion leaders in the field of hospital care, pharmaceuticals, and insurance. We spoke with them about their expectations, and leveraged their feedback to challenge our conclusions. These two angles (literature study and interviews) are our basis in defining our scenario’s and the strategic possibilities that result.

References:

• PricewaterhouseCoopers Healthcast 2010 – Smaller World, Bigger Expectations, 1999
  
• PricewaterhouseCoopers HealtCast Tactics: A Blueprint for the Future, 2002
  

MAIN RESEARCH QUESTIONS

1. Financial Structure

• Who is financing hospitals in the Netherlands(externally)? How is this structured? Solidarity vs business?
  
• What is the influence of the new insurance system? What is the basic insurance package and what should be additional insured?
  
• What does the finance structure in a hospital look like?
  
• What are the consequences of the integrations (mergers) of health insurance companies...buying power vs. selling power of the hospitals?
  
• Who pays the costs that are a result of lifestyle induced illness? Where does ones own responsibily and risk begin? Where does solidarity stop?
  
• How far does the involvement of the government go?
  
• What is the percentage of GDP spent on healthcare in the Netherlands?
  

2. Demand for Hospital Care

3. Supply Side of Hospital Care

• What are the main changes in the labour market for physicians, nurses?
  
• What is development of technology and influence thereof on hospital care; what are costs involved?
  
• Does the movement from care to prevention continue or not? Does care remain labour-intensive? What are the costs involved?
  

4. Organization of Hospital Care

• Public owned vs private owned hospitals?
  
• Differentiated care (per indication, per type of patient)? Differentiated tariffs?
  
• Limitations to free market? Currently 'B-segment'
  
• Emergency care responsibility governments as oposite to elective care? How about 'cherry picking' or cross-subsidizing between DFCs?
  
• Other suppliers (e.g. private enterprises for diagnostics)?
  
• What are the consequences of the integrations (fusions) of hospitals with other hospitals and homes for the elderly (less and bigger hospitals, less choice where to go etc.)??
  
• In that matter: what will happen with prices when the free market for hospital care changes because of the integration of market parties
  
• Involvement of the government?
  

5. Ethical Debate

• At the the moment there is a (sort of) general opinion that we have to apply every possible technical solution to cure people, even when this is very expensive. This opinion will probably not hold because of rapid technical developments. What will happen? - change in public opinion?
  
• Role of QUALY (quality adjusted lifeyear)? A life year added in fair quality in the western world is allowed to cost appr. € 18.000
• Technological developments in genomics and biotechnology will imply a shift from cure to prevention - this implies another type of healthcare and a significant decrease in the number of hospital bed days. Uncertainty comes out of the ethical debate.
  

6. Other External Factors

• MRSA ?
  
• Birdflu?
  
• Other pandemics?
  

SYSTEMS DIAGRAMS

External Relationships     (select link for larger image)                                      Internal Relationships     (select link for larger image)

DRIVING FORCES FROM A HOSPITAL POINT OF VIEW

Internal Driving Forces
• Shortage of nurses (especially OR and IC)
• Shortage of (male) doctors (more part-time workers on all layers of the organization), Future shortage in healthcare workers effects availability hospital care negatively
• Doctors on the payroll instead of independent partnerships (fight for hospital leadership, who is the boss, the CEO or the head of surgery?)
• Professionalization of hospital management
• Enormous drive to be effective and efficient (cost cutting vs. high investments in people and technology)
• More and higher investments in ICT and other technology because of new treatment concepts demands (care and cure at a distance)
• More attention for hospital quality because of: better monitoring, peer pressure and external attention
• More competition among hospitals (also with private clinics) for the best nurses and doctors
• Increasing dependence on ‘third money stream’ (research)
• Integration of general practitioner (house doctor) in the hospital
• Specialization and concentration trends will have impact on hospital building, infrastructure and organization

External Driving Forces
National level
• Greying population will affect hospital occupancy rate and patient mix, Aging population
• The growing population of overweight people
• Population with overweight will affect hospital occupancy rate and patient mix
• Demographic factors (changing population / diversity) which cause changing needs
• Increasing Neglect of the Elderly
• Increase in Stress of Adult Workers in The Netherlands
• Empowered, more informed patients, More information available because of all kinds of new information systems (TV, internet / e-mail), Increasing Empowerment of Consumers in Healthcare System
• Empowered pressure groups and patient associations
• Environment (society) with different ethical standards (less ‘respect’ for doctors and hospital organization, belief in the manipulability of life etc.), the rise of ethics in the Netherlands
• More violence in hospitals against hospital staff (especially in the after hours but also in ‘normal’ situations)
• New threats (diseases like chicken flu, terrorist attacks with large scale casualties, MRSA etc.)
• New healthcare (market oriented) insurance system which should be able to finance the healthcare in the Netherlands (DBC’s etc.)
• Liberalization of the Dutch health care market
• Bigger influence of healthcare insurance companies on hospitals
• Market/Government problems (competition and market regulation rules will cause administrative and legal problems for hospitals)
• Hospital for the future demands other building, specifications, and infrastructure (the hospital building and infrastructure does not fit anymore)
• Hospital building and infrastructure will probably change in one main, specialized, hospital with a few outpatient clinics in the vicinity (‘buitenpoli’s)
• Other transportation models for all involved (ambulances, patients, family, hospital staff etc.)
• More specialization among hospitals based on medical intervention and/or ethical background of the patients (concentration and specialization e.g. hospitals with cardio vascular specialization vs. Muslim hospitals)
• More specialization in the ‘chain’ (diagnostics, care and cure) • Keen joint ventures between hospitals, private clinics and other partners in the chain to enforce efficiency
• New hospital organizations (hospitals with care hotels, houses for the elderly etc.) with new organization models
• Providers will integrate foreward, setting up own clinics

International level
• EU regulation will have an indirect impact on Dutch hospitals;
• International competition between hospitals in EU (and even worldwide) will have an impact on Dutch hospitals;
• New technologies (ICT, Genomics and Biotechnology) which makes hospital healthcare (prevention, care and cure) better but much more expensive;
• Changing ethical morale in society (e.g. self centred egoistic patients, manipulability of life, who pays decides etc.);
• Increasing threats of pandemics, new diseases, terrorist attacks and natural disasters will have a large impact on hospital(s) in afflicted areas;

Clustered Driving Forces

• Technology (genomics, biotechnology, E-health, medical technology)
  
• Free-market mechanisms
  
• Changing patient profiles (aging population, empowered patients, more morbidity and lifestyle)
  
• Ethical debate (to what extent does this inhibit innovation)

SCENARIOS

A drastic cure is needed: (select for larger image)


1.A drastic cure is needed
In 2006, the new financing system of hospitals with diagnosis related groups, called the DBC's, the first step towards a free market, proves to be a success. As a consequence, hospital budgetting and organization are not organized around patients, but efficiently per DBC and /or per product line: Local efficiency rules. Since the insurers by 2006 are no longer obliged to contract hospitals, medical care can be offered at other physical venues than hospitals. Under the influence of for profit insurers hospital care become desintegrated production lines. Patients have to travel miles for the different parts (doctors consult, MRI, blood tests, etc) of one treatment.

People choose their insurance only based on price, insurers compete on insurance premium and are forced to purchase hospital care with the lowest price. So, the fragmentation is financially driven by all stakeholders: insurers, hospitals and patients.

In 2007 the salary cap for hospital and insurance management is introduced by the new elected left wing government. Specialists / doctors discover liberalization and make more money with helping only the people who pay extra, result: with bad hospital- and insurer management there is no countervailing power for doctors. The part of the DBC's with the free prices, the so-called B-DBC's, is extended in 2007. As a result of power in the production lines and bad negotiating power of insurance companies, the “B-DBC’s” (free prices) lead to an increased price exceeding inflation. Continuing scarcity of the caring labor force will increase wages. Ethical and macro-financial arguments are found irrelevant in discussing the use of new technology. In the hospital care market every new medicine and technology should be possible for all patients.

Although, the new insurance is perceived as a success in 2006 because of the low premiums (below cost price), the massive losses the insurance companies make have to be made up. In 2007 huge competition makes that the premiums stay low. This translates into even more increased insurance premium for people in 2008 and 2009.

In 2009 several hospitals will go bankrupt because of bad hospital management. The cost of bankrupcy is included in the insurance premiums. Patients have no choice but to pay health insurance premiums, result: poverty and bad publicity. Cost of health care (and hospital care) in the Netherlands explodes to more than 17% of GDP in 2012. At the end (2013) politics doesn't accept it anymore and Dutch parliament initiates a parliamentary inquiry on the rsing cost of health care, the(un-)equal access to hospital care and bad negotiation of insurance companies, conclusion: government has to intervene in the free market. Government in 2015 re-introduces budgeting and private stakes in hospitals are prohibited. State hospitals are (re-)introduced.


Remarkable Recovery: (select for larger image)


2.Remarkable Recovery

The new health care system – introduced by the Dutch minister of health care, Hans Hoogervorst on January 1 2006 turned out to be a big success. After two difficult years of “child diseases” in the system and unwilling consumers and other stakeholders, the new system shows its results. Child diseases were ample: insurers abusing their strong local position, low levels of switching ability of consumers, failing systems, politicians were feeling that the had no grip on the system anymore etc. As a result the media was spreading negative publicity, claiming basically the collapse of the health care system in the Netherlands.

The new central-left government that came into force in July 2006 nearly stopped the development of the new system and proposed to renationalize health care. Prime Minister Balkenende and the re-elected Hans Hoogervorst were vigorously against the re-nationalisation proposal and started a national campaign to “save” the new health care system. In the “Night of Hoogervorst” the re-nationalisation was just put aside, with unexpected support of the smaller left-wing parties D66 and Groen Links.

In early 2008 the first reports indicated small improvements, such as lowering prices, improving quality and higher consumer satisfaction. On a globel summit in August 2008 in Denmark, Hoogervorst presented the results of the Dutch system as the successor of “Het Rijnlandse model”, known as one of the success stories of the Netherlands in the 80ties and 90ties. After this summit the media took up the positive aspects of the system. By the end of 2008, the new health care system, became a cracker. And this marked the turning point for the health care system in the Netherlands only after three years of the implementation.

Like other stakeholders, the majority of the hospitals responded promptly on the new system. For most hospitals it was clear that their function in the system would change dramatically in terms of quality and efficiency. Soon hospitals became service centers in a larger network of health care services. On the front all diagnostic services soon became privately owned companies. All hospitals become local centers for immediate help (commodity) and most hospitals developed specialties.

Financing of the system happens through contributions of all stakeholders, including private investments. There is cross-subsidising between DBCs; care as well as budgetting is organized around patients. Prevention of (life style induced) risks are a priority and individuals assume greater responsibility for their healh. Patient/consumer movement and government are happy with these developments and are fully supportive.

As the system is self-steering, central government only plays a limited (participative in stead of regulatory) role. Integrated care is one of the cornerstones of the new health care system. For a fixed monthly fee, they gain easy access to an organized system that provides integrated preventive, routine, emergency, and hospital care. Not only the organization will be integrated; also the physical place. GPs and pharmacies will have accomodation in the same building as the hospital.
The hospital plays a pivotal role in the whole network of health suppliers. There is an integrated health delivery system, which means that the entire scope of care for the community is provided and coordinated, including:

• preventive care
• well-baby and prenatal care
• immunizations
• emergency care
• screening diagnostics
• hospital and medical services
• pharmacy services

The close cooperation between all players in the health care system leads to a platfomr for innovative developments. New medical and supportive technologies (broadband, long distance observation and advice, telemonitoring, day-treatment) are developed which enables people to stay home longer and leave hospital earlier. Patients also can use software agents that arrange appointments and administration. All these developments result in less demand for inpatient care in hospitals (only 20% of current demand for peripheral hospitals in 2012). The same technological platform ensures efficiencies in (all) the relationships between hospitals, health professionals, providers, suppliers. Care is thereby less labour intensive but there are sufficient qualified health professionals willing to work in hospitals. The system flourishes by depending much on social interaction and costs are driven down. In decisions about investments, ethical arguments play an important role; community serves as a 'basis of common sense'

These organizational and technological development have an intense inpact on hospitals. By 2010 every hospitals realized a complete reorganization aimed at core activities, service level agreements with other stakeholders and consolidation. In the end of 2011 only 70 of the former 102 hospitals were left. The other hospitals did not disappear, they became privately owned clinics. In 2012 it became legally possible to privatize the hospitals. That year almost all hospitals went in to private hands, with government holding a minority position. In 2015 the number of hospitals was 50. The 50 hospitals were equipped with the latest technology and were operating effectively. Shareholders of the hospitals are now the insurers, operations companies, the government and sometimes the producers of medical equipment and medicines.

The new health care systems introduced a strong growth in innovation in the sector. Competition among insurers was not only on price but also on quality. Insurers started to work closely together with hospitals, producers of medical systems and companies that are specialized in lean and mean operations. The Electronic Patient Dossier (EPD) became a reality already in 2010 after a period of 15 years of development.

the competition on price AND quality resulted in a diversified health supply. For the consumers with a low income, there will be basic healthcare with reasonable quality (discount healthcare model - Aldi). Consumers who are willing and able to spend more on their health chose for a full service healthcare model (Albert Heijn)and for the wealthy consumers with a high healthcare demand the high care speciality healthcare model is available (traiteur). This differention in health care was onthinkable in 2005 but is a logical result of the free health care market in 2015.

European Cure: (select for larger image)


3.European Cure
The Dutch healthcare is tsunamied away by the increasing demand through the aging population, EU ruling (Decker-Kohl, Smits-Peereboom), NMA (National Authority for free competition) limits on national mergers and acquisitions among hospitals and by scarcity of (qualified) labor (2007). Also, financial structures (towards the specialists as well as towards the hospitals themselves) are complex and do not keep pace with the current practice. As a result (2008) Hospitals are unable to manage both increasing demand and the suffocating, sometimes conflicting, rules. Due to these circumstances, there is hardly any personnel and there are lots of vacancies in caring profession. Therefor Hospitals are actively looking in- and outside the country for qualified medical personel and for doctors that like to affiliate with the hospital. This scarcity increases costs (higher wages needed and selection-costs) for the hospitals yet still does not solve the problem of a shortage in work-force (2009). As patient interest is not served in the above described, new initiatives fill the vacuum. The principle of 'free movements of goods, services and people' within the EU creates a, for healthcare new, liberalized model. This model uses economies of scale and competition does not take place on a local but on EU scope. National government does not play a role herein while other countries provide well arranged healthcare; international investors (even non EU e.g. US, Arab and Russian) take over hospitals and organize specialized hospitals spread over the EU (2011). Also, EU conglomerates can insure Dutch patients at attractive rates. As the care now is internationally organized, it is highly individually driven: no solidarity. The system is only financed by the (sum of) the individual consumers and the interest in prevention comes from a strictly financial point of view. For hospitals this implicates that ownership is not longer a national issue: hospitals increasingly get obtained by foreign investors. This implicates that more than ever, the management has to apply to financial targets as monitored by international bookkeeping standards. More and more, investors place trustees on the helm of the management.
These developments lead to care that is differentiated per indication (2013): for a total hip a patient travels to Turkey, for a coronairy bypass Romania is the place to be. There, highly qualified staff is available or is recruited in other countries like India. Parallel to this, less interference of some governments in the ethical debate enables further growth of biotechnology and genomics in these countries, enabling a further preferred position in the healthcare market. Technological developments are thereby not spread evenly throughout EU: there are 'technological hotspots' providing top clinical care. Meanwhile, technology like genomics and biotechnology also drive preventive healthcare and will open markets for diagnostic testing, preventive medicine, follow up treatments and even support services such as lifestyle counselling. For the Dutch hospitals this specialization implicates that funds in research are not invested in Holland but in other countries. Top talent will follow the financial stream or will be employed by Academic hospitals and by that leave relatively routine care left for Dutch hospitals (2014). In order to survive in that market, cost leadership is important. Further rationalization of the core processes in the hospital are a result of that (2015).

4. All scenarios checked against force majeur like pandemic (e.g. birdflu).

A drastic cure is needed: With several hospital on the way to bankrupcy morale is low in Dutch health care. The crisis in health care has its affect on other government services like the police. People have very low trust in government services. Because of the low trust in government in general and more specific hospital care, people panic with the first signs of the pandemic.

The people who can afford and arrange it flee the country to other continents and in the cities riots occur. Because of the total chaos and break down of the normal life, government has no alternative than to intervene with the army. The army restores rest in the cities with as a cost a lot of casualties. After 3 weeks the country returns to a more or less stable status. Then everything becomes clear: the few people who died of the so called pandemic were old people who had died of a normal flu.....

Remarkable Recovery: tbd

European Cure: The threath of a new outbrake of either birdflu or MRSA can not be adequately managed by the described health care structure since hospitals are understaffed and unable to manage both increasing (peak-)demand and the suffocating, sometimes conflicting, rules. In the later stage of differentiated care, only specialized clinics can cope with the patients that require a specific type of care. In the Netherlands, the Academic hospitals still provide a broad spectrum of services , yet they are unable to cope with the vast amount of patients.

SOURCES OF INFORMATION

• Healthcast 2010: Smaller world, Bigger Expectations. PWC. November 1999. [1]
  
• Healthcast Tactics: A Blueprint for the future. PWC. May 2002. [2]
  
• Stress, satisfaction and burnout among Dutch medical specialists. Mechteld R.M. Visser, Ellen M.A. Smets, Frans J. Oort, Hanneke C.J.M. de Haes
  
• Market in Need of Products That Address Key Concerns of Growing Patient Population and Rising Healthcare Costs; Developing New and Innovative Technologies is the Way Forward. September 6, 2005. PR Newswire Association LLC.
  
• Specialty Cardiac Hospitals Treat Less Severely Ill Patients Than Non-Specialty Hospitals . July 12, 2005 Tuesday 12:00 PM GMT. Business Wire, Inc
  
• SER (1999) Gezondheidszorg in het licht van de toekomstige vergrijzing, The Hague: SER
  
• Rol en positie van medisch specialisten 2005; OCM/ Dr. A.C.J.M. Olsthoorn, September 2005
• www.minvwsnl
  
• www.zorgaanzet.nl
  
• www.cbz.nl
  
• www.ctg-zaio.nl
  

INTERVIEWS

• Health Care Partner PwC: The Health care chain will be vertically integrated where the different players in the chain work independantly together
  
• Director Achmea Healthcare: The DBC's will have a enormous effect on the transparancy of hospital care, on the differences in price and quality between hospitals. Furthermore DBC's will stimulate differentation and specialisation of hospitals
  
• Professor of Neurology: routine (peripheral) care vs. highly specialized (university) care will have significant impact on financing hospital care: new structure is needed
  
• Departmental head Dutch Association of hospitals: hospitals will end up in a hybrid model (partly liberalized market, partly regulated) that will jeopardize continuity; a drastic change in finance structure is needed
  
• Director regional Patient Organization South West of the Netherlands:The most neglected driving force is the ethical debate on what we allow or not allow to be health care
  
• Secretary of the board of Erasmus MC:An academic hospital can never function in a free market because of its special combination of the functions health care, research and education
  
• Health care entrepreneur/ consultant: technical development (e.g. intelligent multi agent systems) enable patients to make appointments themselves and administration will be automized. This will lead to a 20% occupancy rate of current capacity of periferal hospitals. Top clinical care will be provided by academic hospitals.