title: Integrating care by implementation of bundled payments: results from a national survey on the experience of Dutch dietitians.
abstract: BACKGROUND
  In the Netherlands, bundled payments were introduced as part of a strategy to redesign chronic care delivery. Under this strategy new entities of health care providers in primary care are negotiating with health insurers about the price for a bundle of services for several chronic conditions. This study evaluates the level of involvement of primary health care dietitians in these entities and the experienced advantages and disadvantages.
  
  
  METHODS
  In August 2011, a random sample of 800 Dutch dietitians were invited by email to complete an online questionnaire (net response rate 34%).
  
  
  RESULTS
  Two-thirds participated in a diabetes disease management programme, mostly for diabetes care, financed by bundled payments (n=130). Positive experiences of working in these programmes were an increase in: multidisciplinary collaboration (68%), efficiency of health care (40%) and transparency of health care quality (25%). Negative aspects were an increase in administrative tasks (61%), absence of payment for patients with comorbidity (38%) and concerns about substitution of care (32%).
  
  
  CONCLUSIONS
  Attention is needed for payment of patients with co- or multi-morbidity within the bundled fee. Substitution of dietary care by other disciplines needs to be further examined since it may negatively affect the quality of treatment. Task delegation and substitution of care may require other competencies from dietitians. Further development of coaching and negotiation skills may help dietitians prepare for the future.
authors.affiliation: NIVEL (Netherlands Institute for Health Services Research), The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: Tol
authors.affiliation: NIVEL, The Netherlands.
authors.forename: I C S
authors.initials: IC
authors.lastname: Swinkels
authors.affiliation: RIVM (National Institute of Public Health and Environment), The Netherlands.
authors.forename: J N
authors.initials: JN
authors.lastname: Struijs
authors.affiliation: NIVEL, The Netherlands.
authors.forename: C
authors.initials: C
authors.lastname: Veenhof
authors.affiliation: NIVEL, The Netherlands\TRANZO (Tilburg University, Scientific Centre for Transformation in Care and Welfare), P.O. Box 90153, 5000 LE Tilburg, The Netherlands.
authors.forename: D H
authors.initials: DH
authors.lastname: de Bakker
keywords: bundled payment; dietetics; disease management; integrated care; payment reform; primary care