in English This document describes the Dutch system of long-term care (LTC) for the elderly. An overview of LTC policy is also given. This document is part of the first stage of the European project ANCIEN (Assessing Needs of Care in European Nations), commissioned by the European Commission under the Seventh Framework Programme (FP7). Since the first stage of the project aims to facilitate structured comparisons of the organisation of LTC for the elderly in different countries, comparable

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... ts have been written for most other European countries (including new member states). Future analyses in subsequent work packages within the project will build on these country reports. Abstract in Dutch In dit document wordt een omschrijving gegeven van het Nederlandse systeem van langdurige zorg voor ouderen. Ook het beleid op dit terrein komt aan de orde. Het document is geschreven ten behoeve van een Europees project in opdracht van de Europese Commissie (ANCIEN, Assessing Needs of Care in European Nations), als onderdeel van de eerste fase van het project. De bedoeling is om niet-Nederlanders inzicht te geven in het Nederlandse systeem en om gestructureerde vergelijkingen te kunnen maken tussen de systemen van verschillende Europese landen. Een groot aantal andere Europese landen schrijven namelijk soortgelijke rapporten in het kader van het ANCIEN-project. Deze landenrapporten dienen als basis voor de analyses in de volgende fasen van het ANCIEN-project. Short overview of the LTC system 7 Recent reforms and the current policy debate 53 4.4 Critical appraisal of the LTC system 60 References 64 Appendix A Number of formal long-term care-users 68 5 Preface The ageing of populations has stimulated interest in studying systems of funding and delivering long-term care for the elderly. One way to analyse the optimal design of these systems is to make international comparisons. European countries differ considerably with regard to the way in which long-term care is organised-and therefore also in the expected effects of population ageing. In countries such as the Netherlands, where an extensive system is already in place, the future sustainability of the system is a point to consider. In countries with a much more modest system, or a system that is still being developed, the process of ageing may reveal the need for improvements that have to be made in the system. Furthermore, the current economic crisis has negatively affected the financial situation of governments. Government deficits will also affect the available funding options for long-term care for the elderly. This report describes the current system of long-term care for the elderly in the Netherlands and the Dutch policy with respect to long-term care. It is part of the output of a project under the Seventh Framework Programme (FP7) of the European Commission, called ANCIEN: Assessing Needs of Care in European Nations. ANCIEN is a far-reaching project with the goal of studying long-term care for the elderly in the European Union. Comparable reports have been written for a large number of other European countries (including new member states). The first stage of the project aims to facilitate structured comparisons of the organisation of LTC for the elderly in different countries and to identify clusters of comparable systems. Future analyses in subsequent work packages within the project will build on the country reports and the cluster analysis. Subsequent analyses will explore not only the need for long-term care but also the demand and supply of informal and formal care for the elderly in selected countries. The quality of long-term care and the impact of technological change will be studied in separate work packages. The final stage of the project will focus on drawing conclusions about the optimal characteristics of systems of long-term care. Philosophy and objectives The underlying philosophy of the Dutch system for long-term care is that the state bears the responsibility for the elderly and others who are in need of long-term care. While informal unpaid care given by family members and others does play a role, there is no obligation to provide this care-save for the usual care that members of a household give each other. The general policy goal for LTC was formulated in 2008 as follows: "To ensure that for persons with a long-term or chronic disorder of a physical, intellectual or psychological nature, care of good quality is available and that the cost level of this care is acceptable to society." Structure of the system In the Netherlands, a system of public long-term care insurance has been in place since 1968. Everyone who lives in the Netherlands is insured under the AWBZ (Algemene Wet Bijzondere Ziektekosten; Exceptional Medical Expenses Act). The AWBZ covers not only care for the elderly, but in principle all chronic care, especially concerning large expenses where insurance on a private market would not be feasible. At the moment, this act covers at-home care and care in institutions for the elderly, institutions for the mentally and physically handicapped and institutions for chronic psychiatric patients. Some form of income-dependent cost-sharing exists for practically all LTC services. Moreover, elderly in institutions have to contribute to the costs of their board and lodging. The AWBZ covers a broad package of services: personal care, nursing, assistance, treatment and stay in an institution. Domestic help used to be part of the AWBZ, but in 2007 it was shifted to the Wmo (the Wet Maatschappelijke Ondersteuning; Law on Social Assistance), an act pertaining to social services, which is carried out by the local council. The AWBZ scheme is open-ended in nature: since it is public insurance, everyone who is eligible for long-term care is-in principle-entitled to receive care. However, every new Dutch government determines budgets for healthcare and long-term care for the subsequent four years. If expenditures exceed budgets, then the ministry of Health, Welfare and Sports (VWS) has to formulate a policy to contain the costs (for example, tariff cuts, higher co-payments or a smaller insured package). The tax financed Wmo is not an insurance scheme: the entitlement to social services is affected by the available funds. For home help, in particular, local councils receive a (notearmarked) budget. In this way municipalities have financial incentives to organise home help efficiently. However, to protect the rights of persons with disabilities, municipalities are obliged to compensate for the effects of their limitations in functioning. The local council can do this in the way it sees fit-as long as everyone can participate in society. This obligation that the local 8 authorities have seems to work reasonably well for persons with limitations in running a household-especially for the elderly. Assessment Every request for AWBZ care must be assessed by an independent organisation, the CIZ (Centrum Indicatiestelling Zorg; Centre for Care Assessment). There are no financial incentives for CIZ: its financial position is not affected by its decisions. CIZ's task is to carry out independent, objective and integral assessments. The procedure is the same for care reimbursed in cash and for in-kind care. CIZ adopts certain standards to determine whether an individual is eligible for one or more 'functions' (services) within AWBZ care: assistance, personal care, nursing, treatment and stay in an institution, extended stay for psychiatric reasons. For each of these functions, CIZ determines the amount of care that is necessary. Other persons in the same household are supposed to supply the "usual care" that family members give each other. In other words, this 'usual care' does not fall under AWBZ care. The effect of informal unpaid care that exceeds the usual care is more complicated: this care may diminish an individual's entitlement to AWBZ care-as long as this informal care is voluntarily given and received. Assessment for home help is carried out by the local council, which has a financial incentive to restrict eligibility. If expenditures on home help are lower than the budget, the local council can spend the money on other goals. The local councils exert democratic control. Organisation of care For most of the AWBZ functions, a potential AWBZ user can choose between in-kind care and cash benefits. The cash-reimbursement option is not available for treatment and stay in an institution. The cash is given in the form of personal budgets. Patients who choose the cashreimbursement scheme receive a personal budget that is 25% lower than the costs of in-kind care. The assumption is that they can buy care more efficiently. They are free to choose who should deliver their care: an official institution, an independent care worker, a family member, friend, neighbour etc. For most of the budget, patients are obliged to be able to show that they did spend the money on care. Patients who prefer in-kind care have some say with regard to which care organisation delivers their care. The responsibility for organising and purchasing this care remains with the 'zorgkantoren' (regional care offices). These organisations, which are affiliated with health insurers, run no financial risk on buying long-term care. Although the care costs are paid from the AWBZ fund, the care offices are charged with keeping costs within the national and regional budget and with purchasing care as efficiently as possible. If the performance of a care office is poor, the permission to operate a regional care office may be given to another health insurer. 11 LTC policy Dutch LTC policy aims for quality, accessibility and affordability of care. As trade-offs exist among these goals, policy is continually being fine-tuned in order to find the optimal equilibrium. In 2003, an important reform of Dutch long-term care took place: the 'modernisation' of AWBZ. This reform aimed at increasing the responsiveness of the care system. The distinction between different types of providers and different groups of AWBZ users became less pronounced. The regulation for personal budgets changed, which expanded the role of personal budgets. The modernisation improved the position of care-users, but made it more difficult to stay within the macro budget for AWBZ care. In 2004 and 2005, measures were taken to control costs in the form of higher co-payments and the introduction of regional budgets. At present, the most important problems recognized in policy discussions are as follows: 1. The long-run sustainability of LTC; 2. The lack of incentives for efficiency in the LTC system; 3. Finding sufficient LTC workers to compensate for the expected increase in LTC demand; 4. The quality of care. Extensive discussions have taken place in the course of the last few years about further reforms of the Dutch LTC system. The government wants to give health insurers a larger role in LTC, provided that a number of conditions can be met. The idea is that health insurers, instead of the regional care offices, carry out the AWBZ for the persons who are insured with them. Since meeting the conditions for this reform is by no means trivial, some time has been taken to collect information. The government planned to decide on the organisation of the AWBZ from 2012 on no later than April 1, 2010, but this decision has been delayed by the collapse of the Balkenende IV cabinet. 13