Centraal Bureau voor de Statistiek (Statistics Netherlands)

Team Health and Care

Health care expenditure quantifies the economic resources dedicated to health functions, excluding capital investment. Healthcare expenditure concerns itself primarily with healthcare goods and services that are consumed by resident units, irrespective of where that consumption takes place (it may be in the rest of the world) or who is paying for it. As such, exports of healthcare goods and services (to non-resident units) are excluded, whereas imports of healthcare goods and services for final use are included.
Health care expenditure data provide information on expenditure in the functionally defined area of health distinct by provider category (e.g. hospitals, general practitioners), function category (e.g. services of curative care, rehabilitative care, clinical laboratory, patient transport, prescribed medicines) and financing scheme (e.g. social security, private insurance company, household). For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA sets out an integrated system of comprehensive and internationally comparable accounts and provides a uniform framework of basic accounting rules and a set of standard tables for reporting health expenditure data. The System of Health Accounts - SHA 2011 is a statistical reference manual giving a comprehensive description of the financial flows in health care. It provides a set of revised classifications of health care functions, providers of health care goods and services and financing schemes. The SHA is currently used as a basis for a joint data collection by OECD, Eurostat and WHO on health care expenditure. The manual sets out in more detail the boundaries, the definitions and the concepts of health accounting – responding to health care systems around the globe with very different organisational and financing arrangements.

Accounting period: Health expenditure and financing data pertain to the calendar year (1 January to 31 December).

The time coverage of this Quality report is 2014 to 2016 reference years.

Healthcare expenditure is recorded in relation to the international classification for health accounts (ICHA) defining:

• healthcare expenditure by financing schemes (ICHA-HF) — which classifies the types of financing arrangements through which people obtain health services; health care financing schemes include direct payments by households for services and goods and third-party financing arrangements;
• healthcare expenditure by function (ICHA-HC) — which details the split in healthcare expenditure following the purpose of healthcare activities — such as, curative care, rehabilitative care, long-term care, or preventive care;
• healthcare expenditure by provider (ICHA-HP) — which classifies units contributing to the provision of healthcare goods and services — such as hospitals, residential facilities, ambulatory health care services, ancillary services or retailers of medical goods.

1. Household individual consumption on health, including the collective consumption with two exceptions:
i. Occupational health care (intermediate consumption within establishments) minus an estimated share of occupational health in health providers’ and other medical industries net administration;
ii.“Remunerated” unpaid household production in the form of transfer payments (social benefits in cash) for home care of sick, disabled and elderly persons provided by family members.
SHA 2011 Manual recommends following the standard System of National Account (SNA) rules for drawing the production boundary of health care services, albeit with two notable exceptions:
- Occupational health care is included in the national totals of health care spending. In SNA, this item is recorded as ancillary services and part of intermediate production of enterprises,
- Part of the cash transfers to private households for care givers of home care for the sick and disabled are treated as the paid household production of health care.
2. Health care financing schemes: HF1 Government schemes and compulsory contributory health care financing schemes; HF2 -voluntary health care payment schemes;
HF3 - Household out-of-pocket payment; HF4 - rest of the world financing schemes.
3. NACE rev. 2, section Q, human health and social work activities.

4. Parts of NACE rev.2:
4711 - with regard to sale of over the counter pharmaceuticals
4773 - pharmacies
4774 - Retail sale of medical and orthopaedic goods in specialised stores (includes also sale of OTC pharmaceuticals)
4932 - Taxi operation, with regard to patient transportation
6512 - Non-life insurance, with regard to health insurers for private supplementary health insurance, and operation of compulsory health insurance
8412 - Regulation of the activities of providing health care, education, cultural services and other social services, excluding social security, with regard to the ministry of public health, welfare and sports
8422 - Defence activities, with regard to health care for defence personnel
8423 - Justice and judicial activities, with regard to health care provided by the Justice department, e.g. prison hospital

SHA concept is the consumption of health care goods and services.
Health care statistics describe the process of providing and financing health care in countries by referring to health care goods and services, its providers and financing. For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA is a tri-axial system in which the financing, provision and consumption dimensions are covered by the ICHA (International Classification for Health Accounts): Health Care Functions (HC), Health Care Providers (HP), Health Care Financing Schemes (HF).
Data are presented in 3 summary (one-dimensional) tables and 3 cross-classification tables (2-dimensional tables).

Summary tables provide data on:

• Current expenditure by provider (ICHA-HP)
• Current expenditure by function (ICHA-HC)
• Current expenditure by financing scheme (ICHA-HF)

Cross-classification tables refer to:

• HC x HP: Health care expenditure by function and provider: data on which type of health care goods and services are supplied by which health care provider;
• HC x HF: Health care expenditure by function and by financing scheme: data on how are the different types of services and goods financed;
• HP x HF: Health care expenditure by provider and by financing scheme: data on from which health care provider and under which particular financing scheme are the services and goods purchased.

Commission Regulation 2015/359 concerns the collection of data on "current expenditure on healthcare" which is defined as the "final consumption expenditure of resident units on health care goods and services".
There is a very close relationship between the concept of "final consumption expenditure" as defined in the System of Health Accounts (SHA) and in National Account and, as a consequence, also between the underlying economic transactions as recorded in the two accounting frameworks.
In National Accounts there are two types of statistical units: institutional units and local kind-of-activity units (KAU). A local KAU groups all the parts of an institutional unit in its capacity as producer which are located in a single site. A local KAU belongs to one and only one institutional unit.
SHA uses the same two types of units for data compilation.
Local KAUs operating as providers of healthcare goods and services to resident units are statistical units in SHA.
Also transactions by institutional units are recorded in SHA, in which framework institutional units are also referred to as "financing agents". More precisely, SHA financing agents are institutional units that manage one or more financing schemes. The transactions are executed by the financing agents, according to the rules of the financing schemes.
Financing agents serve as key statistical units in producing national health accounts. While financing schemes are the key units for analysing how the consumption of health care goods and services is financed, the data concerning the relevant transactions are collected either from the financing agents that operate the different financing schemes or from the providers.
The concept of "healthcare financing schemes" in SHA is an application and extension of the concept of "social protection schemes" defined by the European System of Social PROtection Statistics (ESSPROS):  "a distinct body of rules, supported by one or more institutional units, governing the provision of social protection benefits and their financing ...". The social protection scheme is the statistical unit in ESSPROS. It is an analytical unit that allows describing the complete structure of the social protection financing system:  expenditure and receipts.
According to SHA Manual 2011, "the key concepts for describing the structure of the health care financing system are based on measuring: (a) the expenditure of health care financing schemes, under which goods and services are purchased directly from health care providers, on the one hand, and (b) the types of revenues of health care financing schemes, on the other hand.  
Commission Regulation 2015/359 limits its scope to the collection of data on the expenditure of health care financing schemes.

SHA focuses on the consumption of health care goods and services by the resident population irrespective of where this takes place. This implies the inclusion of imports (from non-resident providers) and the exclusion of exports (health care goods and services provided to non-residents).

The data aims at providing a complete overview of expenditure on health care goods and services consumption of services and goods by the resident population on the national territory of a country.

1998-2017.

Not applicable.

Several data sources are used:

-          Surveys/census: 1

-          Public administrative records: 1

-          Financial reports: 2

-          Other: 2

Surveys/censuses

Public administrative records

Financial reports

Other

Annual.

Data are collected through the joint health accounts questionnaire (JHAQ) that countries submit to Eurostat during the annual data collection exercise. There is a voluntary deadline to send the JHAQ questionnaire for the calendar year T by the 31st of March T+2. The joint health accounts questionnaire (JHAQ) is coordinated in agreement with the World Health Organisation (WHO) and the Organization of Economic Co-operation and Development (OECD). These three international organisations are known collectively as the International Health Accounts Team (IHAT). Countries submit data to Eurostat on the basis of Commission Regulation (EU) 2015/359 of 4 March 2015 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council as regards statistics on healthcare expenditure and financing.

The 2018 JHAQ includes a number of features which allow national data correspondents to perform various quality checks before submitting the data. The embedded programmes allow the verification of:

1- Consistency of the data between tables,
This step checks if the marginal totals reported in each table of the JHAQ are consistent across all tables. For example, for each function (HC), the total across all financing schemes (HF) in the HCxHF table has to be equal to the total across all providers (HP) in the HCxHP table, i.e. the values in the column “All HF” in the HCxHF table have to be equal to the values in the column “All HP” in the HCxHP table. Any detected differences are flagged up in the corresponding row or column in the relevant tables and all inconsistencies are listed in the “Report” worksheet by variable code together with the amount by which the respective variable differs between the two compared tables. A positive value indicates that the first listed table has a higher value for the same variable, and vice versa.

2- Consistency of the data within tables,
Any detected inconsistencies are listed by variable code together with an indication of which total is not equal to the sum of its subcomponents as well as the numerical difference. A positive figure indicates that the total is greater than the reported sub-components, and vice versa.

• The presence of negative values,

Entries in the tables cannot be negative as they refer to the consumption of goods and services.
If an individual data table is checked for internal consistency, the negative values check is performed for the relevant table and then any negative values are highlighted red and crossed out.

• The presence of atypical entries,

The atypical entries check provides information whether the data tables contain values in cells which are – if at all – only reported by very few countries and are thus atypical for health accounting.
If an individual data table is checked for internal consistency, the atypical entries check is performed for the relevant table. In the data tables, any cell containing an atypical entry will be highlighted for national data providers.
Should any atypical entries be identified, compilers should scrutinize in detail the transactions that led to entries in those cells and assess whether the accounting rules of SHA have been correctly applied. If they come to the conclusion that the transactions are recorded in the correct categories of the ICHA classifications, then the corresponding atypical entries represent unique – and correctly accounted for – features of the country’s health system. In this case a short description of the nature of the transactions should be included in the accompanying Metadata file under “II.3. Atypical entries”.
If, on the other hand, compilers come to the conclusion that the transactions are not recorded correctly, then they need to make adjustments in the concerned tables. In case the transactions recorded in a cell do not belong to the boundaries of SHA (e.g. they refer to intermediate consumption) the value of the respective cell should be deleted (and all cells that are affected by this change adjusted accordingly). In case the transactions are misreported and another category of the ICHA classification is more appropriate, the value of the cell should be transferred to the correct cell of the table.

3- The growth rates against the previous year and the magnitude of revisions as compared to previously submitted data. Results are grouped into three different categories:

• Breaks in series (the current questionnaire shows no data for an item that is not null in the other file)
• Newly reported (the current questionnaire contains data for an item that is empty in the other file)
• Differences (all other types of differences)

Several methods are normally used for estimations:

• Balancing item/Residual method: For example, if data are available from the financing side, which permit accurate estimation of the flows to a provider or function, then an acceptable estimation method is to subtract these expenditure flows from the total revenues, and derive the expenditure flows from the unmeasured financing scheme as a residual.
• Pro-rating/Utilisation key: Typically in the absence of direct spending data, a utilisation key linked to the proportion of resources used can be constructed in order to distribute e.g. aggregate provider spending across functions. For every key a fraction of total utilisation within the cost-unit is assigned: fractions in the key must add up to 100% of all care delivered by the cost-unit. Examples of utilisation keys are admissions, bed-days, contacts, staffing, etc.
• Interpolation/Extrapolation: In the absence of data for the period in question, missing values can be estimated using known data points.
• Or other

Main sources

Statistics Netherlands: surveys of health and social care providers; National Accounts; price and tariff data.
External sources: financing data (National Health Care Institute, the former health insurance fund); budget data (Ministry of Health, Welfare and Sports); tariff information (Dutch Health Authority), Vektis (health care data of the health insurers), annual reports.

See also Health care institutions, Health care practices, Production statistics.

Structure of integration framework

The figures on health and social care and those on health care according to SHA use the system for integration of statistics: the health and social care accounts. The production of the figures according to the System of Health Accounts is integrated in the production process. Information is collected for groups of providers, called actors (e.g. physiotherapists, general hospitals, internal occupational health agencies); this is done for around 80 actors. For each actor (e.g. mental health care institutes) expenditure on specific types of care (e.g. psychiatric care) is allocated to financing schemes (e.g. private health insurance) and to the functions of the types of care (e.g. inpatient curative care). Each actor is mapped to a category of the Health Care Providers classification of the System of Health Accounts.

Provisional figures for the previous year, published in May, are based on external sources and supplementary estimates. Revised provisional and final figures are based on internal sources of Statistics Netherlands and some external sources.

Authorities responsible for SHA data collection are working to ensure that the statistical practices used to compile national health accounts are in compliance with SHA methodological requirements and that good practices in the field are being followed, according to the methodology underlined in the SHA 2011 Manual and European Statistics Code of Practice respecting professional independence of the statistical authorities. Procedures are in place to plan and monitor the quality of the health care expenditure statistical production process.

Checks are carried out for completeness, internal and external consistency and plausibility of the collected internal and external data. Where necessary, corrections are applied.

The sequential comparability of provisional data and final data shows that usually the difference is small for the aggregates (less than 1 %) and bigger for data that are disaggregated.

The comparability with SNA aggregates shows that after correcting for differences in definitions and scope, the data are reasonably good reconcilable, see e.g.

Health expenditure data for policy: Health accounts, national accounts or both? (https://doi.org/10.1016/j.healthpol.2018.06.004 )

Main users :

- RIVM (Institute for Public Health and the Environment); usage for Cost-of-illness studies. RIVM receives detailed tables per year that are further processed with data on population and illnesses; including breakdown according to the budget of the Ministry of Health.

- CPB (Netherlands Bureau for Economic Policy Analysis; usage for their medium-term forecasts.

- Ministry of Health and Welfare; usage for main indicators; CBS produces linkages tables from Care accounts to the Health budget.

- General public, including media like newspapers, magazines, independent journalists.

CBS has regularly meetings with the Ministry of health and welfare, and RIVM. With CPB we have a meeting once every two years, and several contacts during the year. Several tailor made answers to questions have been produced.

Data are complete as far as the Commission regulation is applicable.

100%

As the SHA tables are the result of an integration process, as well as of estimation of details within the SHA framework, the character of the figures is inevitably not 100% accurate. The final figures derived from the Digimv source cover around 60 per cent of all expenditure, and are a solid source (missing less than 1% of annual reports). The integration process itself ensures a better accuracy, as we compare at least two sources whenever possible: Digimv and the sources on financing. Direct out of pocket expenditure is based on estimates, of which around 50% is a direct estimate and 50% a residual, with some minor expenditure figures based on an initial estimate and development. Some of the data on providers are also based on estimates like TCAM providers.

Not applicable.

Not applicable.

See also coherence and comparability in this case of integrative statistics.

Coverage error in the case of this integrative statistics apply to the coverage of health care providers.

Not applicable; the statistics are the result of an integration process.

Not applicable; the statistics are the result of an integration process.

Not applicable.

Not applicable; the statistics are the result of an integration process.

Not applicable; the statistics are the result of an integration process.

Not applicable; the statistics are the result of an integration process.

Not applicable; the statistics are the result of an integration process.

Not applicable; the statistics are the result of an integration process.

Not applicable; the statistics are the result of an integration process. See statistical processing for remarks.

Not applicable.

General publication strategy: In year t: Provisional figures for year t-1, revised provisional figures for year t-2 and definite figures for year t-3 are published in May of year t. Revised provisional figures for year t-1 and t-2 are published in November or December of year t.
Big scale revisions, in which we apply all new insights, methods and sources are carried out approximately every 5 years. In 2015 this coincided with the provision of SHA 2011 figures.

Revisions

The system of health and social care accounts will be revised once every five to ten years. All actors are checked in terms of completeness, validity and reliability. New actors are created if necessary; actors can also be merged.

In 2016-2018 the team health and care has revised the whole system of Care Accounts, partly aligning with the revision of National Accounts that was going on in the same period. Several estimates of providers have been re-assessed (e.g. hospitals (downward), TCAM providers (downward), pharmaceuticals providers (downward), GP's (upward), Psychologists (upward), care for the handicapped (upward)). Overall, the revision has been downward in total. New data sources have been used for this, as well as for other providers and for structural information. For instance, the income statements of the large institutions have now a better breakdown according to type of (health) care service and from 2015 onwards, also a breakdown according to financing scheme. This has led to significant changes in the structure of financing and the structure of products, and for SHA, the structure of functions.
The total amount of deductibles in the compulsory health insurance is now almost fully based on the information of health insurers instead of information of the ministry of health, the difference being that the former refers to actually paid cost-sharing, while the latter refers to the supposedly (nominal) paid cost-sharing (which is higher than the one actually paid as insurers have some choice to offer exemptions from cost sharing).
As far as curative care is concerned, there is a better estimation of the expenditure on hospitals (lower) vs. expenditure on independent treatment centres (daycare mostly) (higher); there is also a new estimation on the distribution between in-patient, daycare and outpatient treatment for hospitals (general, university, special) and for independent treatment centres. E.g. for university hospitals the first estimate was 49% share of inpatient treatment in 2015, it is now 44.2%. The estimates are based on an analysis of the expenditure on diagnosis treatment combinations.
The old figure of NIPSH financing schemes was related to much of double-counting, which has been removed as far as possible. However, part of the financing of e.g. hospitals comes out of NPISH, but the team does not know how much. This is an omission for which the team health had up till now no real good data. This is one of the many items that the team health and care still has for a new revision of the Care accounts.

The adjustment due to the revision was for SHA -0.6%; due to the usual new data becoming available during the year, the normal adjustment would have been -0.4%. This has resulted in a total adjustment compared with the transmitted data in 2017 of -1.0% for the total current expenditure according to SHA.

Member States are required to transmit their data to Eurostat in compliance with the Commission Regulation 359/2015 transmission deadlines.
Data and reference metadata for the reference year T should be transmitted to Eurostat by 30 April T+2.

Provisional figures for year t-1 are published in May/June of year t.

Definite figures for year t-3 are published in May/June of year t.

Transmission of data was on time, on 31 March and April in year t for figures on year t-2.

Transmission to Eurostat : 30 April in year t for figures on year t-2.

Not applicable at national level.

Not applicable.

The figures of the Health Accounts are comparable sequentially, due to the fact that the used definitions and concepts are univocal and guide the process of integration. The sequential comparability applies both to levels and changes. However, if a choice has to be made between them, the level is preferable for data in current prices.

Breaks in time series resulting from methodological changes

1998-2017.

The SHA figures can be reconciled with figures from Business statistics (as they are an important source for the care accounts of which the SHA figures are a subset); with ESSPROS as far as ESSPROS covers the SHA figures or the figures of the care accounts.

Not applicable.

The figures on health and social care expenditure for each actor are used by and discussed with National Accounts. SHA is a subset of health and social care expenditure.

In May/June of each year CBS publishes a news release on care expenditure of the previous year; it includes also the SHA indicator current expenditure as percentage of GDP.

On the revision of the care accounts, including SHA figures: https://www.cbs.nl/nl-nl/onze-diensten/methoden/onderzoeksomschrijvingen/aanvullende%20onderzoeksbeschrijvingen/revisie-zorgrekeningen-2015 (in Dutch).

News release 2018: https://www.cbs.nl/nl-nl/nieuws/2018/22/zorguitgaven-stijgen-in-2017-met-2-1-procent   (in Dutch)

Data are published as open data and are accessible using the CBS Statline app.

https://opendata.cbs.nl/statline/#/CBS/en/navigatieScherm/thema?themaNr=82765

With the three core tables:

https://opendata.cbs.nl/statline/#/CBS/en/dataset/84043ENG/table?dl=C78F

https://opendata.cbs.nl/statline/#/CBS/en/dataset/84078ENG/table?dl=C792

https://opendata.cbs.nl/statline/#/CBS/en/dataset/84035ENG/table?dl=C793

On the site in Dutch, more options are available: https://opendata.cbs.nl/statline/#/CBS/nl/navigatieScherm/thema?themaNr=82175

In 2018, 5393 unique page views have been made pertaining to all tables in the Dutch language derived from the care accounts; of which 799 were for the tables with SHA figures. The tables covered both revised and non-revised figures (covering the 1998-2016 period).

Not applicable.

None.

The metadata are enclosed in the tables. General descriptions of the method: https://www.cbs.nl/en-gb/our-services/methods/surveys/korte-onderzoeksbeschrijvingen/health-expenditure ; https://www.cbs.nl/nl-nl/onze-diensten/methoden/onderzoeksomschrijvingen/korte-onderzoeksbeschrijvingen/zorguitgaven

on the revision: https://www.cbs.nl/nl-nl/onze-diensten/methoden/onderzoeksomschrijvingen/aanvullende%20onderzoeksbeschrijvingen/revisie-zorgrekeningen-2015

Quality reports are based on self-assessment for the process.

In the past 12 months no corrections have been made on published results  (https://www.cbs.nl/nl-nl/cijfers/statline/correcties-en-revisies-in-statline )

Not available.

Not available.

The statistics are secondary, the burden on data providers or respondents is the one from the sources. Additional: specific tables from Zorginstituut Nederland, that serve also National accounts and Government finance departments of CBS.

The Regulation (EC) No 223/2009 on European statistics (recitals 23-27, 31-32 and Articles 20-26) applies.

Disclosure of data on specific healthcare providers is suppressed by including them in a larger group of health care providers.

None.