Personal aids in the health sector

1. The investigation

The Court of Audit investigated the provision of medical appliances for use in the home under the Medical Appliances Regulations 1996. The system for providing medical appliances in the Netherlands dates back to the 1960s, when the first Health Insurance Funds Act and Prostheses and Medical Appliances Order entered into force. Over the years the Order has been adapted to reflect technological developments. Between 1989 and 1996 medical appliances were paid for under the Exceptional Medical Expenses Act (AWBZ), but since then they have been funded by the public health insurance funds and private health insurance companies. In 1994 the then AWBZ Regulations were extended to cover treatments and services that had hitherto been provided under the General Invalidity Benefits Act, partly in order to make medical appliances accessible to people aged 65 and over. It was also hoped that cost savings could be made by including a list of appliances eligible for coverage in the AWBZ Regulations.

The Minister of Health, Welfare and Sport is responsible for the Medical Appliances Regulations 1996.

An estimated 300,000 different types of medical appliance are available in the Netherlands under the various statutory schemes, including the Health Insurance Funds Act, the Exceptional Medical Expenses Act and the Services for the Disabled Act. The distinctions between the various acts are not always clear, so it is not easy for members of the public to work out what they are entitled to. It is not known how much money is involved in the provision of medical appliances, but the Court of Audit estimates it to have been in the region of two billion guilders (EUR 0.9 billion) in 1998. Many implementing bodies and private companies are involved in providing medical appliances.

The Court of Audit investigated, among other things, what targets the Minister of Health, Welfare and Sport had set for the provision of medical appliances in the period 1996-1999, whether they were achieved and what instruments were used. It also looked at how the health insurance funds arrange provision of medical appliances. The investigation culminated in a meeting of experts from the sector. They looked at a number of propositions in a brainstorming session via a computer network known as a Group Decision Room. They also examined case studies. The findings of this meeting have been incorporated into this report.

2. Conclusions

The Court of Audit found that the Minister has no integrated policy on medical appliances. In other words, the targets, interim targets and instruments of policy on medical appliances for use in the home are not presented in a comprehensive manner. Key concepts in the policy have not been specified in enough detail, and it is therefore unclear what the Minister wants to achieve. There is also too little policy information. It is not, therefore, possible to establish whether, and if so to what extent, the main aim of policy on medical appliances - to ensure that people receive the services and equipment they need to participate normally in society, at acceptable cost - has been achieved.

The Minister's main policy instrument - the Medical Appliances Regulations 1996 - is either not complied with in practice or it is unclear whether it is complied with. This was revealed by an investigation of four categories of medical appliance provided by five health insurance funds: hearing appliances, mobility aids, incontinence products and appliances for diabetics. The Court found that the Regulations were observed in 3% of cases where hearing appliances are provided, and 5% of mobility appliances cases. It was not possible to investigate incontinence products and appliances for diabetics, as the health insurance funds do not note in patients' records whether they have applied for such appliances. The health insurance funds have stipulated in agreements with the suppliers of the appliances that the latter will monitor proper use.

The Medical Appliances Regulations 1996 are very detailed, which makes them difficult to implement and can lead to inefficiency. They also make it difficult to respond to technological developments. This observation, together with the earlier conclusion that it is not possible to establish the extent to which targets have been met, have led the Court to conclude that there is uncertainty surrounding both the regularity and the efficiency of the provision of medical appliances.

The Court also concludes that in the past there has been a lack of essential policy information, so proposed cost control measures were not adequately underpinned. Since 2000 the Minister has launched numerous activities. As a result, more information is now available on the provision of medical appliances for use in the home to people insured under the health insurance funds. A new action plan has also been presented involving further specification of cost control measures and deregulation of the medical appliances market.

3. Recommendations

The Court found that the Minister had launched many activities in 2000 in the field of medical appliances provision. It appreciates the Minister's efforts and hopes that its recommendations will prove useful to the new plans and activities.

The Court regards the development of the Medical Appliances Monitor as a step in the right direction, but would like to see it expanded. The Medical Appliances Information Centre recently established by the Minister would also do a great deal to clarify matters in the medical appliances sector if it were to play a role in collating the available information on medical appliances (on patients with public and private health insurance, various statutory schemes and appliances provided to inpatients and outpatients).

The Minister submitted proposals to the House of Representatives in late August 2001 for the simplification of the Medical Appliances Regulations. They include leaving the fine details of the Regulations to the individual health insurance funds. It is unclear what role the other parties in the field would play. The Court recommends that the Minister set up experiments whereby these other parties are given the opportunity to provide medical appliances as they see fit, on the basis of protocols.

The Court also recommends that the Care Supervisory Board investigate the extent to which and the way in which health insurance funds commission suppliers to carry out their monitoring tasks, and how the funds themselves monitor the work of the suppliers.

4. Responses and the Court's afterword

The Minister of Health, Welfare and Sport believes that the Court of Audit's investigation as reflected in this report is incomplete and premature. She believes that some of the terms used (such as integrated policy) were not clearly explained and the main aim of policy was incorrectly described. She does not agree with the limiting of the investigation to the period 1996-1999. She is of the opinion that the Court pays too little attention to the historical context of medical appliances provision and developments that have occurred since 1999. The Court has commented on the nine points in the Minister's response, and both the response and the comments can be found in appendix 4.

The Minister does however observe that the Court's recommendations tie in with the policy she has already launched with the aim of simplifying the Regulations and making individual insurers responsible for directing policy on medical appliances. The Court agrees, but would draw the Minister's attention to the position of other parties in the field, such as medical practitioners, patients and suppliers. The parties concerned could collectively convert a set of framework regulations into protocols and guidelines.

The Court believes that more systematic attention should also be paid to autonomous factors such as ageing. Account should be taken of the links and any convergence between policy on providing medical appliances for use in the home in the public health field and developments in related areas such as services for the disabled.

The Care Insurance Board (CVZ) looks at the results of the Working Group on Deregulation and Instruments, whose proposals for the simplification of the regulations would give individual insurers control. The CVZ believes that the Court's proposal that all parties be involved ties in better with its own ideas. It agrees that it is unclear what the Court means by integrated policy.

The Care Supervisory Board (CTZ) looks at the method developed over the years whereby health insurance funds delegate tasks to suppliers. It believes that the regularity of the expenditure could be established if the records of suppliers were examined. The Court shares the CTZ's opinion that it should remain possible for health insurance funds to contract out tasks under certain conditions. These conditions - which mainly concern monitoring and control, but also protection of privacy - should be outlined in the statutory regulations and in future protocols and guidelines.