|
The Netherlands
In The Netherlands the social security system including
healthcare, is organised on an insurance basis. There are two health
insurance. schemes, the AWBZ wh ich covers 100 per cent of the popu
latior for long and/or expensive illnesses, and the ZFW or sick fund
systerr which covers 60 percent of the population.Both schemes are
compulsory, the second being for those eligible on grounds of age or
income. Those insured under the ZFW consist of the following:
•
employees with an income less than a predetermined level than those
people with an income only from the social system,
• the elderly,
those aged 65 and over with an income less thar the predetermined
level.The remainder of the population around (40 percent) are
coverec by private insurance for their 'short-term illness' and
primary care. Expenditure on healthcare accounts for around nine per
cent ol the Gross National Product (GNP).
Primary healthcare
In The Netherlands the term primary healthcare embraces a rathel
wider concept than in many other European countries, including as it
does both an ambulatory mental healthcare sector and also the
so-called Cross on Home Care Organisations. These organisation1
provide services covering aspects of both nursing and welfare
Primary healthcare also includes external treatment, maternit)
nursing care and pharmaceuticals, as well as the general medical
service. Pharmaceuticals account for 35 per cent of primary care
expenditure, with the general medical services accounting for <.m\)
1 6 per cent. Forty-seven per cent of all Dutch general
practitioner1 work as single-handed free. An increasing
number are working ir teams, in group practice, in health centres
and partnership. Of the roughly 7000 general practitioners in The
Netherlands, 625 are dispensing doctors as well and provide the same
medication of the same quality as pharmacists.In the sick fund
system a patient must first consult a genera practitioner before
consulting a specialist, except in specia circumstances. Almost all
private insurance companies also demanc a referral of the general
practitioner to the medical specialist.The general practitioner
therefore determines access to othel parts of the healthcare system
and is the point of referral. In the national statistic studies (CBS)
it is estimated that the average palii'nl insured by the sick funds
consults the general practitione'r about 4.5 times year, but the
consultation rate for private patients is almosi four times a year.
This is an enormous increase compared with ter years ago (respectively
3.5 and 2.5 times per year), which is, among others, caused by the
ageing of the Dutch population.The Netherlands is the most densely
populated country in the Community with a ratio over twice that for
the Community as c whole. However, the population is concentrated in
the west ano south of the country. The population is at its least
dense in the north, With over 7,000 general practitioners including
an increasing numlx-i of female general practitioners ±19 per cent
and part time working general practitioners, the ratio of general
practitioners to population is 1:2,300 which in ordinary
circumstances might be regarded a' high. Nevertheless, it is felt
that with thedensityofthe population, the general practitioner
distribution is sufficiently good as to pennii easy access by any
patient to a general practitioner. There is a free choice of general
practitioner by the patient, subject only to distance and the
willingness of the doctor chosen to offer a full range ol medical
services and for a sick funds patient to have contact betweer his or
her sick fund general practitioner.
The remuneration of the general practitioner
The general practitioner receives payment for treatment of
patients in two ways: by means of a subscription or capitation fee
for those patients insured by a sick fund and by item of service for
private patients. In both cases the appropriate rates are determined
on the basis of a theoretical gross remuneration based on a notional
2,350 patients. This level of income isanaloguedwith that of a
higher civil servant. The gross capitation fee consists of a net fee
with additions for practice costs, pension contributions and for
patients over 65 years of age and for patients living in private
areas. The net fee is the income of the higher civil servant grossed
up for various allowances and divided by 2,350.The item of service
is also a fee for the private patient determined from a theoretical
gross remuneration, but this is divided by the average number of
acts or services which would be rendered in a private practice
consisting of 2,350 patients. The average income before deducting
professional expenses of a general practitioner is currently (1996)
1 20,000 guilders, but expenses are relatively high; professional
costs are 140,000 guilders. The net income of the general
practitioner amounts to around 1 70,000 guilders, which has to be
compared with a salary before taxation deduction for social
insurances and pension fund.Due to the increasing pressure in the
work of the general practitioner, also caused by the desired changes
in the position of the general practitioner as a gatekeeper in the
cure and care, several measurements, which will have effects on the
remuneration. For example, the payment has increased for sick fund
assured patients being over 65 and living in so-called deprived city
areas.
|