Tilburg University, Scientific centre for care and welfare (TRANZO), LE Tilburg, The Netherlands.
Health Policy. 2011 Apr;100(1):60-70. doi: 10.1016/j.healthpol.2010.11.014. Epub 2010 Dec 24.
In the past decades fixed budgets for hospitals were replaced by reimbursement based on outputs in several countries in order to bring down waiting lists. This was also the case in the Netherlands where fixed global budgets were replaced by budgets that are to a large extent volume based and in practice open-ended. The objective of this study was to examine the effectiveness of this Dutch policy measure, which was implemented in 2001. We carried out a statistical analysis and interpretation of trends in Dutch hospital admission rates. We observed a significant turn in the development of in-patient admission rates after the abolition of budget caps in 2001: decreasing admission rates turned into an internationally exceptional increase of more than 3% per year. Day care admissions had already been rising explosively for two decades, but the pace increased after 2001. The increase in the number of admissions includes a broad range of patient categories that were not in the first place associated with long waiting times. The growth was attributable for a large part to admissions for observation of the patient and the evaluation of symptoms, not resulting in a definite medical diagnosis. We considered several factors, other than the availability of more resources, to explain the growth: the ageing of the population, making up for waiting list arrears, ditto for "under consumption" of unplanned care and, as to the growth of day care, substitution for inpatient care. However, these factors were all found to fall short as an explanation. Although waiting times have dropped since the change in the budget system, they continue to be long for several procedures. Our study indicates that making available more resources to admit patients, or otherwise an increase in hospital activity, do not in itself lead to equilibrium between demand and supply because the volume and composition of demand are partly induced by supply. We conclude that abolishing budget caps to solve waiting list problems is not efficient. Instead of a generic measure, a more focused approach is necessary. We suggest ingredients for such an approach.
在过去的几十年中，为了减少等候名单，有几个国家已经用基于产出的报销取代了对医院的固定预算。荷兰也是如此，其固定的全球预算已被在很大程度上基于数量且实际上无限制的预算所取代。本研究的目的是检验 2001 年实施的荷兰政策措施的效果。我们对荷兰医院入院率的趋势进行了统计分析和解释。我们观察到，2001 年取消预算上限后，住院入院率的发展出现了显著变化：入院率下降转变为每年超过 3%的国际异常增长。日间护理入院率在过去二十年中已经呈爆炸式增长，但 2001 年后增长速度加快。入院人数的增加包括广泛的患者类别，这些患者类别最初与长时间等候无关。增长在很大程度上归因于对患者的观察和症状评估的入院，而不是导致明确的医学诊断。我们考虑了除资源增加之外的其他几个因素来解释这种增长：人口老龄化，弥补等候名单的积压，同样适用于“未充分利用”计划外护理的情况，以及日间护理的增长，替代住院护理。然而，这些因素都被认为不足以解释这种增长。尽管自预算制度改变以来，等候时间有所缩短，但对几个程序来说，等候时间仍然很长。我们的研究表明，提供更多资源来接纳患者，或者增加医院活动本身并不能在需求和供应之间实现平衡，因为需求的数量和构成部分是由供应引起的。我们的结论是，取消预算上限以解决等候名单问题是无效的。与其采取通用措施，不如采取更有针对性的方法。我们建议采取这种方法的要素。
