Common Wealth Fund Webinar February 5, 2013

1. Primary Care in The Netherlands: General Practitioners in the LeadJako Burgers, MD, PhDDutch College of General Practitioners Common Wealth Fund Webinar February 5, 2013

2. Characteristics of the Dutch health care system 2 • 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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