Direct Contracting may offer ACOs a unique opportunity
The Direct Contracting model includes a unique feature allowing accountable care organizations the ability to contract with providers.
Oct. 7, 2009
Roeleke Uildriks and Ji Kwen Ng, healthcare actuaries in Milliman's Amsterdam office, weigh in on a proposal to improve healthcare for Dutch citizens by providing an alternative model for home healthcare.
Q: You briefed us before about the recently revised Dutch healthcare system. Lately, you’ve been working on a new care provider proposal that would create added value to the system. Tell us about it.
Uildriks: The concept is called SOS Doctors, and it is borrowed from a successful program in France, SOS Médecins. Arnold Verhoeven, a Dutch citizen who now lives in France, learned that there, one can call for a doctor to visit at home, anytime, 24/7. He wants to improve the quality of care here, and he is convinced this would be an important improvement. We were asked to analyze the financial impact an initiative like this would have on healthcare costs, and present it to government and physician representatives.
Q: How do the government and the healthcare system in the Netherlands view this idea?
Uildriks: They are concerned a service like this will raise healthcare costs, because people will be calling all the time. And of course, utilization will increase.
Ng: Physicians are worried, too. The National Association of General Practitioners (GPs) is worried about the quality of care, because they claim that the SOS Doctor will not have a personal relationship with the patient or have access to the patient’s record. Of course, when a person goes to the emergency room the specialist does not know the patient or have the patient’s records, either.
Q: Why would home visits increase utilization?
Ng: Because copays are not allowed in the Dutch healthcare system, so there would be no reason not to call. In France, they have a copay, which is 10 or 15 Euros. The insurance company pays the rest of the cost. Many people who don’t get their care from a GP will drive directly to the hospital, or call an ambulance and get their care in the emergency room. Those people can benefit from SOS Doctors.
Uildriks: There are three areas of utilization with this initiative. One is substitution between GP visits and SOS Doctor visits. Then there are SOS Doctor visits that substitute for emergency room visits and ambulance rides. And third, there are extra SOS Doctor visits, for situations where the person might not have seen a doctor at all if not for the service. The second area is where money can be saved for the system.
Q: How can the SOS approach help save money?
Uildriks: We looked at the system in France and used it to anticipate the financial impact in the Netherlands. We found that the feared increase in healthcare costs was not likely to materialize.
Ng: In the Netherlands we have improper use of acute care, like “unnecessary” ambulance rides. Also, a notable number of patients who visit the emergency room could be helped in a more cost-effective way by a GP; in particular, two-thirds of patients who visit an emergency room are self-referred, without any physician input, and this service might help curb those numbers. The experience in France shows fewer emergency room visits and fewer ambulance rides due to the presence of such a home-health service. Since care in the second line is much more expensive than SOS Doctor visits, we believe this would save money for the healthcare system, not to mention provide better care.
Q: Does the Dutch healthcare system include home visits now?
Ng: In theory, you can get a GP to come to your home here. Twenty years ago, if you called a GP in the middle of the night, he would come. But there are very few GPs who are willing to make house visits now. A recent survey, commissioned by SOS Doctors, shows that half of parents with young children have experienced situations where a physician home visit was needed. In more than 70% of those cases the doctor refused to come.
Uildriks: Doctors don’t feel like they are paid enough to make house visits, so they don’t want to do them, unless of course there is medical necessity to make the house visit. There is hardly any financial incentive for them to come to a patient’s home.
Ng: There are two reasons for this. First, about 40% of a GP’s income is capitated, so they receive the payment whether or not they see patients. The second reason is that home visits are not very profitable for the GPs. They are paid more for a house visit than they are for an office visit – 13.5 Euros instead of 9 Euros – but house visits are more time-consuming.
Uildriks: So when you need a doctor, you call a GP. Usually, you get an assistant who performs a kind of triage that can have the effect of keeping you from reaching the GP. If you cannot reach the GP, you may decide to get in the car or call an ambulance and go to the hospital emergency room. Sometimes these trips are unnecessary, and therefore unnecessarily expensive.
Q: Will SOS Doctors be added to the healthcare system in the Netherlands soon?
Uildriks: It is proving to be difficult to get it implemented in the Dutch system, because the government and the insurance companies worry that it will increase healthcare costs. In the Netherlands, you cannot set up a new service in healthcare without applying for it and being given a tariff. Mr. Verhoeven, the man behind this initiative, tried to get a tariff for the service, but the government refused to give it until recently. They said they needed more information about what the implications were from the government’s perspective. And doctors, afraid of the competition, feared that citizens would substitute an SOS Doctor visit for an in-office visit with their GP. Our analysis disputed this conclusion, though, indicating that GPs do not have a lot to fear from competition by SOS Doctors.
Ng: Things have started to change, though, as the government has recently agreed to establish a tariff for the services of SOS Doctors. According to SOS Doctors they will be allowed to begin providing services from January 1, 2010. Also, several insurers are expressing interest in adding SOS Doctors in their supplementary coverage and negotiations are under way. The most recent development is that there is a fair chance that at least one Dutch insurer will cover SOS Doctor services in their supplementary insurance. This coverage will then reimburse half of the price for a visit. Other countries are also showing interest in the SOS Doctors idea.
A new model for healthcare at home?
THIS INTERVIEW Oct. 7, 2009 Roeleke Uildriks and Ji Kwen Ng, healthcare actuaries in Milliman's Amsterdam office, weigh in on a proposal to improve healthcare for Dutch citizens by providing an alternative model for home healthcare. Q You briefed us