As a healthcare provider, how do you manage your work rosters? And how do you arrange for more hands at the bedside in times of staff shortages? Such questions keep many healthcare managers awake at night. This is nothing new: administrative burdens have been a thorn in the side of healthcare providers for years. Healthcare purchasers, the Netherlands Healthcare Authority (NZa) and the Ministry of Health, Welfare and Sport (the Ministry) have now also realised that the administrative burden in the healthcare sector needs to be reduced. But that aim has nevertheless not yet been achieved, and healthcare procurement regularly increases that burden.
But why can’t and shouldn’t this issue be raised? Administrative burdens lead to more work pressure and less job satisfaction for care workers. Above all, time spent on administrative tasks cannot be spent on the patient. All of this leads to an increased outflow of care workers, which care providers and healthcare purchasers cannot afford, given their duty of care and care procurement duty. Indeed, reducing the administrative burden to an acceptable level is considered an important measure to future-proof the job market. And that is crucial if healthcare purchasers wish to comply with their duty of care and care procurement duty.
So how can a healthcare provider strike at the roots of increased administrative burdens in a timely and effective manner? In this blog, we explain the practical steps that healthcare providers, trade associations and professional associations can take. We provide an overview of agreements on the basis of which healthcare purchasers can easily be called to account and demonstrate how that has been successful done in case law.
Reducing the administrative burden: [Ont]Regel de Zorg (ORDZ)
The Ministry has attempted to reduce the administrative regulatory burden in the healthcare sector. The [Ont]Regel de Zorg (ORDZ) programme aims to create more job satisfaction for professionals and more time to provide care. The objective of the programme is to prevent an increase in the regulatory burden and to simplify or scrap existing laws and regulations where possible. According to the Ministry, all the parties involved, including healthcare purchasers, must “contribute to this joint task”. In a parliamentary letter of July 2023, the Ministry reported, among other things, that financiers (and regulators) must ensure that their information requests are more in keeping with practice.
But the Ministry has nevertheless found that, despite all the positive developments, the administrative burden remains a persistent problem. So there’s work to be done. The new approach in ORDZ 2022-2025 envisages, among other things, picking up on national themes, such as the standardisation of procurement and accountability requirements. Currently, the requirements, registration obligations and contracts tend to differ from one health insurer to another. Standardising these requirements should lead to time savings, lower costs and a reduced administrative burden. The application process for medical aids, for instance, should be improved. The Model Performance Codes for Youth should also make it easier to claim youth care.
Reducing the administrative burden: use of IZA
The Comprehensive Care Agreement (IZA) is also relevant to the reduction of the administrative burden. In the IZA, the parties involved agreed that rules should be tested against the “sensible and radically simple” principle. It was also agreed that the parties would work towards reducing the administrative time spent by 5 percentage points by 2025. The IZA was signed by Zorgverzekeraars Nederland (ZN), the trade association of health insurers, and care administration offices, among others. The Association of Netherlands Municipalities (VNG) also signed the IZA. Healthcare purchasers can be called to account for compliance with these IZA obligations – and that is already being done successfully: see here and here.
In the summer of 2023, the District Court of The Hague ruled in favour of a number of mental health organisations in preliminary relief proceedings against CZ Zorgkantoor. The court cancelled the care administration office’s policy requiring healthcare providers to enter into subcontracts with numerous primary healthcare providers in the short term. This gave rise to a high administrative burden. The court found that that burden was disproportionate and expressly noted that the increased administrative burden was incompatible with the IZA, since the very principle formulated in the IZA is that parties should strive to reduce the administrative burden.
Healthcare purchasers are jointly responsible for reducing the administrative burden
The need to permanently strive to reduce the administrative burden is indeed recognised by (i) health insurers, (ii) care administration offices and (iii) municipalities. A few examples of points on which these purchasers may be called to account are listed below.
Health insurers purchase care covered by the Zorgverzekeringswet (Health Insurance Act). Health insurers work together in trade association ZN. ZN states that its guiding principles are “certainty, minimum administrative burden and crystal-clear information”. Individual health insurers furthermore emphasise the value they place on reducing the administrative burden.
- Zilveren Kruis, for instance, states in its 2023-2024 district nursing procurement policy that it will further reduce the administrative burden for healthcare providers.
- VGZ reports making an “active contribution” to reducing the administrative burden in oral care practices.
- Menzis says it endorses “the aim to reduce unnecessary bureaucracy”.
- DSW regards a low administrative burden as one of its core concepts.
Care administration offices purchase care covered by the Wet langdurige zorg (Long-Term Care Act). Like health insurers, care administration offices work together in trade association ZN. The administrative burden under the Long-Term Care Act is too high. Both ZN and the NZa recognise this.
- The NZa recently reported that it was conducting a new experiment to reduce the administrative burden in long-term mental healthcare and in nursing and care. With the new Beleidsregel Experiment zinnig en simpel verantwoorden Wlz, the NZa wishes to explore an alternative interpretation of the subsequent costing process and the subsequent costing statement.
- The NZa has conducted a similar experiment in disability care in the past.
- iWlz, the care registration system under the Long-Term Care Act, is intended to reduce the administrative burden.
- CZ Zorgkantoor will enter into a partnership with care provider Philadelphia with the aim of reducing the administrative burden, among other things.
- To avoid a high administrative burden, Menzis Zorgkantoor uses a formula that allows care providers with a higher budget ratio to provide less information.
The social domain consists of care covered by Wet maatschappelijke ondersteuning (Social Support Act) and the Jeugdwet (Youth Act). Municipalities purchase care covered by those Acts. Compared to the Health Insurance Act and the Long-Term Care Act, less information is available on the administrative and regulatory burden within the social domain. However, it is apparent from a survey by Movisie that the administrative and regulatory burden is high. This is due to the fact that many care providers work for several municipalities. As a result, they face different requirements for tenders, decisions and registration needs. Municipalities wish to keep a grip on finances, which means that care providers must focus on accountability. Nevertheless, also municipalities appear to recognise that the administrative burden in the sector is too high:
- VNG, for instance, has signed the Covenant on Stopping Time Registration.
- In the i-Sociaal Domein Steering Group, several individual municipalities are working together with VNG, healthcare providers and the Ministry to reduce the administrative burden under the Social Support Act and the Youth Act.
- VNG has set standards for non-key provisions in contracts, such as suitability requirements, certification requirements and corporate liability insurance.
- Reducing the administrative burden by simplifying and standardising implementation is also an important element of the Youth Reform Agenda, in which VNG is involved.
NZa rightly points to the duty of care/care procurement duty with regard to the increased administrative burden for care administration offices
The NZa is also increasingly critical of healthcare purchasers that pass on their administrative and other duties to care providers. In its 2022-2023 Summary Report on the Implementation of the Long-Term Care Act, the NZa drew attention to the fact that care administration offices are outsourcing the monitoring of the client’s health status to the preferred provider. The NZa reported that “the care administration offices disproportionally pass on this responsibility, which is part of their duty of care, to the care provider, while they themselves do too little to adequately live up to their own responsibility”. The NZa expressly noted that this is an “administrative burden that is inevitably detrimental to the provision of care” and that is being passed on to healthcare providers. The NZa hits the nail on the head there: now more than ever, given the labour market shortage and their duty of care/care procurement duty, healthcare purchasers must be careful not to bear their administrative burden themselves. It is a good development that the NZa is notifying care administration offices that they cannot simply pass on their own administrative duties to care providers. In our view, this principle equally applies to health insurers and municipalities. The effective fulfilment of the duty of care/care procurement duty of these healthcare purchasers is also not served by care providers having to spend even more of their time on administrative tasks, since that time cannot be spent on patient care. That is detrimental to the fulfilment of the duty of care/care procurement duty, which is increasingly under pressure.
Practical tips to enforce agreements on reduction of the administrative burden
While courts have already ruled that healthcare purchasers (partly in light of the IZA) may not simply increase the administrative burden for healthcare providers, the question presents itself what providers can do if they find that healthcare purchasers are in fact increasing their administrative burden. Care providers and their trade associations or professional associations can take the following steps in that case:
1. Write to healthcare purchasers: proactively write to healthcare purchasers to ensure full compliance with earlier agreements on reducing the administrative burden. Draw their attention to the agreements in the IZA, the court’s ruling, the objectives of the ORDZ, and undertakings previously given by the care purchaser (or its trade association) regarding reduction of the administrative burden. Request care purchasers to expressly state (in writing) how the care purchaser takes into account the need to reduce the administrative burden. If a care purchaser believes that an increase in the administrative burden is indeed proportionate, then also request that care purchasers to explain why that is the case. If a care administration office or other care purchaser outsources the monitoring of the client’s health status to care providers, point out to that care purchaser that the NZa believes that that is the care purchaser’s responsibility, in light of its duty of care.
- Object: formally object at the care purchaser against any procurement policy that foreseeably and disproportionately increases the administrative burden, and request that it cease and desist from such policies.
- Litigate: where necessary, institute proceedings against any care purchaser that violates agreements made on reduction of the administrative burden. Healthcare providers are well-advised immediately to notify their professional or trade associations of any violations of agreements not to increase the administrative burden. A professional or trade association – whether or not together with its members – may write to the care purchaser in that context and, where necessary, take legal action.
- Contract the NZa/Ministry: where necessary, disproportionate administrative burden increases resulting from care procurement may be reported to NZa and/or the Ministry, in addition to points 2 and 3. Notify the Ministry in the context of the supervision of the implementation of the IZA, and the NZa in the context of the IZA and its duty of care/ care procurement duty, and request them to act in that regard.
In sum: at an individual, organisational and societal level, it has been acknowledged for many years that the negative impact of the regulatory burden in the healthcare sector is too great. Healthcare providers and their trade associations or professional associations can reduce the administrative burden by calling care purchasers to account in good time to comply with agreements already made in that context. It is also possible to ask care purchasers, as part of their core task and their duty of care/care procurement duty, to resume their administrative tasks and not to outsource them to healthcare providers.
More information on the rights of healthcare providers and their professional and trade associations, and the duties of healthcare purchasers in healthcare sales, can be found at www.zorgcontractering.com.
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