The Netherlands

Even that the Dutch healthcare system is labelled as a system of social security it in fact a mixture of a social security system, legalised with the Sick Fund Law of 1964, compulsory insuring against sickness all Dutch under a certain income level, and a national health service, legally arranged in 1968 with the Exceptional Medical Expenses Act, covering all Dutch citizens for long-term care.

The federal government under the Ministry of Health, Welfare and Sports has a responsibility for and financial control of healthcare. The Ministry plays a regulating role in the field of planning, insurance financing, tariffs, prices and fees. Government policy is to guarantee healthcare which is easily accessible, high quality, affordable and efficient.

The health care system is primarily publicly financed but privately provided. With the exception of the eight university hospitals all hospitals are private institutions. The role of governments is basically to create conditions for quality care. The mandatory health insurance is responsible on financing and health insurance is based on a separate law.

Employees with incomes below a certain level have a compulsory social insurance covering about 60% of the Dutch population. There are about 50 different funds which are organised mainly geographically. The contributions rates are the same (50/50) for both employees and employers. Private, tough not compulsory, medical insurance is available voluntarily for those well-off not covered by the general programme. Services that are not covered by the insurance schemes can be obtained by additional private insurance. The Exceptional Medical Expenses Act is compulsory insurance for emergency services regardless of the level of incomes.

Primary care is free of charges for all publicly insured but privately insured may have co-payments. Same principle holds in the case of hospital care. Pharmaceuticals have a reference prices and excluded items have no coverage.

The incomes of health care providers come from different sources. About 10% of healthcare is directly paid from public funds. Approximately 80% of the costs are covered by the health insurance premiums and some 9% trough patients own contributions. Primary care providers get their incomes based on fee-for-service payments in the case of those on higher income brackets and on age differentiated capitation fee in the case of lower income and publicly insured ones. GP:s have also the gate-keeping task. Hospitals have their budgets fixed by the government to ensure compliance with the goals of the government but the budgets are adjusted based on the Dutch DRG system.

Investments are financed trough the incomes from services. Hospitals are not getting support from the local or central governments. Hospitals can, therefore, decide part of investments independently but major investment must be made according to the national plan. Separate research fund for academic hospitals are available in state budget (relatively about 15% more) but research costs are included in prices in other hospitals.