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GGZ Nederland is the sector organization of specialist mental health and addiction care providers in the Netherlands.

The aim of GGZ Nederland and its members is to ensure the availability of high quality, accessible, affordable and sustainable mental health care.

In 2013, its 113 members were responsible for a market share of 80.6% in the health insurance market and more than 90% in child and youth care, sheltered housing, addiction care and forensic care

Seated in Amersfoort, its 60 employees represent the interests of its members in an on-going and constructive dialogue with client organizations, health insurers, national and local governments, professional associations and trade unions.

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Dutch health care

Source:

2014Total health care expenditure €67,6 billionPer person €4.297,-Percentage GDP 11,1%Total mental health care expenditure €6,6 billion

38%

10%14%

26%

4%8%

Hospital, medicalspecialistsMental health care

Providers of care for thedisabledProviders of long term carefor elderlyPrimary care practices

Other care providers

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Source: Ministry of Health: State Budget 2015

As of 2015, Dutch mental health care is funded through 5 different sources

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The Dutch health system is for the part “Health Insurance Act” a managed competition

Source: Schäfer W, Kroneman M, Boerma W, van den Berg M, Westert G, Devillé W and van Ginneken E. The Netherlands: Health systemreview. Health Systems in Transition, 2010; 12(1):22

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The critical success factor “transparency”needs four cornerstones on service provider level

Cost effectiveness=

1.Efficiency+

Performance=

2.Safety +

3. Client opinion+

4. Outcomes

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Diagnose Related Group based financial system

• An episode based system operational since 2013• 140 DRG’s for treatment• Provider sends an invoice to

health insurer:– diagnosis (DSM IV)– time spent by professionals– price of services delivered

• Maximum tariffs set by national healthcare authority

• Negotiation between health insurer and provider

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The critical success factor “transparency”needs four cornerstones on service provider level

Cost effectiveness=

1. Efficiency+

Performance=

2.Safety +

3. Client opinion+

4. Outcomes

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Routine Outcome Measurement

• Clients fill in questionnaires at the beginning, during and end of treatment or support.

• Distinction between different domains: – Adults with common mental disorders– Adults with severe mental illness– Children/youth– Elderly– Substance abuse – Forensic care

• Symptom reduction• Daily functioning• Quality of life

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ROM in the Netherlands

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In 2009, the national organisations of patients, professionals and providers developed a shared vision

1. Treatment & Support2. Learning

3. Transparency

4. Research

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In 2010, GGZ Nederland and the national association of health insurers agreed upon a covenant

• Starting up a Third Trusted Party National data collection Safety and privacy Access to data

• Agreement on response rates (%) ROM is used, unless … Pre/post measurements are collected With an annual increase of 10% of clients

• Agreement on what and how to deliver (MDS) Unambiguous data Uniform instruments and measurements Useful reports on outcome

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Accumulation of outcome data to discuss performance

• The Mental Health Benchmark Institute collects outcome data nationwide (pseudonymized)

• Board members:– national platform of clients in mental health (LPGGZ) – health insurers (ZN) – service providers (GGZ Nederland; Meer GGZ)

• Scientific council :– Professional association of psychiatrists (NVvP) – Professional association of psychologists (NIP)

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Accumulation of outcome data to discuss performance… Can we do it?

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It is possible to have meaningful outcome on aggregated level

Clinical recovery(according to RCI)

A B C D

% Recovered 31% 39% 23% 28%% Reliable improved 11% 13% 19% 21%% No change 55% 43% 50% 43%% Reliable aggravated 4% 6% 9% 8%

Results of pilot in 2011 of 4 mental health service providers in long term mental health care on the basis of HONOS questionnaires. Not corrected or standardised for case mix. RCI = Reliable Change Index (RCI).

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Variation in treatment effect (Delta – T)between service providers in the treatment of adults with common mental disorders

Accumulation of outcome data are an opportunityto discuss performance

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Results 2009-20152009-2011• Shared vision of patients, professionals and providers• National standard for questionnaires;• Trusted Third Party to collect and analyze outcome data and to present

reliable benchmarks;• PR-and marketing tools for the implementation of ROM

2011-2015• Several expert groups function as a liaison with daily practise and the

scientific council of SBG• The national and local infrastructure for data-collection is set• Everybody in mental health care knows about ROM and thinks about

ROM • A case-mix model 1.0 has been developed

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And.... A milestone when it comes to response rates

Source: NZa (2014), Marktscan GGZ, deel B.

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Did we accomplish all of our goals?

1. Transparancy2. Learn

3. Treatment & support

4. Research

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There is still some criticism...

From a professional point of view:• The process of data collection does not relate directly to

clinical practice and values;• The registration system is build up from a systems

perspective, not from a clinical perspective; • The system thus disowns health professionals quality

improvement.

From a more scientific point of view:• Post hoc correction of case mix is scientifically not sound.• Too much bias (client/professional/instrument/selection)

for using ROM to make irreversible decisions.• Data collection needs to serve clinical decision making

and continuous improvement.Source: Delaspaul. P h. A.E.G. (2015)., Routine Outcome Measurement in the Netherlands, - a focus on benchmarking.

International Review of Psychiatry (Early edition; 1-9)

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The Dutch system from a New Zealandperspective

Recommendations

• Develop a renewed vision and plan for ROM• Promote ROM as part of a quality improvement

process (not solely as a benchmarking tool)• Reduce the number of measures that are

collected• Continue the relationship with IIMHL and Te Pou• Establish a workforce program to support ROM

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To make the pendulum swing back, a Breakthrough Project for ROM started in 2014

• Aim is to increase use of ROM as an instrument for quality improvement in mental health

• Two national learning networks:• Each consisting of 15 – 20

professional teams • Experiment with implementation

of ROM • Following the “breakthrough

method”• Teams are supported intensively

by experts to learn, analyze and improve the use of ROM

• Investment in the workforce to improve the use of ROM in daily practise

• Development of one outcome measure for recovery• National evaluation of the Mental Health

Benchmark Institute and the goals for ROM; • With specific focus on validity of aggregated

data.• New multi-stakeholder vision on cost effective

mental health care, integrating ROM into quality standards.

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Rising to new heights

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Quality Care Standards

• For 80% of the most common mental disorders• Development between 2014-2017• From a collective point of view: patients,

professionals, providers, health care insurers• Evidence or practice based

• Quality standards describe (at least): • Multidisciplinary treatment protocols/ guidelines• The diagnose and indication• How to organize the care• Which professionals are able to provide the care• The expected duration of the treatment• Participation and patient recovery• Quality indicators/ outcome indicators

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What would be the ideal situation ?

recovery

Future situation

Quality standardFinancial system (DBC)

Treatment 1 Treatment 2

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How to reconcile two legitimate perspectives on quality of care ?

• From the viewpoint of health workers, the limited resources (time) should be directed to instruments that enables them and their clients improve the tangible qualityof care on the spot. That is in the best interest of the client and professional.

• From the viewpoint of society, financial restrictions make it necessary to allocate resources to cost effective interventions. To do so, performance assessment in terms of measurable quality is needed. This is in the best interests of people paying taxes, insurance and out-of-pocket fees.