Common Wealth Fund Webinar February 5, 2013 Primary Care in The Netherlands: General Practitioners in the Lead Jako Burgers, MD, PhD Dutch College of General Practitioners Common Wealth Fund Webinar February 5, 2013

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

Primary Care in Netherlands: Basic Characteristics 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) 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

Can other countries learn from Dutch general practice? 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 9