The Combined Lifestyle Intervention is a Dutch example of health insurance funding to finance health promotion and disease prevention. Read more about this approach in insurance funds.
The main goal of Combined Lifestyle Interventions (CLI) is to initiate and sustain a healthy lifestyle of the population. These interventions include advice and guidance on forming healthy eating habits, healthy exercise pattern, and how to deal with factors impacting health, such as stress and lack of sleep. Lasting two years, these programme areimplemented at the national level and includes a one-year treatment programme and a one-year programme ensuring the sustainability of results achieved.
People with elevated weight-related health risks are eligible for reimbursement for these interventions. The indicative criteria for this can be found in the Guideline for Obesity by the Dutch College of Practitioners and in the Standard of Care for Obesity. The CLI is reimbursed from the basic health insurance package, which is compulsory to everyone in the Netherlands. The National Health Care Institute of the Netherlands, together with the Ministry of Health, Welfare and Sport played an important role ensuring that the CLI is included in the basic healthcare package that is covered by insurance.
How the Combined Lifestyle Intervention came to being
There was no specific window of opportunity allowing for the development of these preventive services. Instead, it took more than ten years from the publication of a report on how prevention could fit into the healthcare system in 2006 to the inclusion of such interventions in basic insurance packages in 2018.
In 2008, following the prevention report, the National Institute for Public Health and the Environment (RIVM) published a report showing the cost-effectiveness of the CLI. Two years later, after reviewing all scientific data and practical findings, the Dutch Healthcare Institute concluded that CLIs would be an effective intervention to tackle overweight and obesity, and that it could fit within the basic health insurance package. In response to that, the Ministry decided to run various pilot projects to find out how the CLIs could be implemented in practice.
As part of the preparation, RIVM carried out a budget-impact analysis of the CLI to estimate the required costs. The Dutch Healthcare Authority established a policy, including rates and the conditions for financing the intervention. The RIVM assessed the quality, effectiveness and feasibility of the interventions that were available and in 2018 recognised three of them. In consultation with the Association of Dutch Healthcare Insurers, the Dutch Healthcare Institute decided which interventions that were assessed by RIVM would be included in the basic health insurance package. The Dutch Healthcare Authority developed a description of costs and performance specifications under the Dutch Healthcare Market Regulation Act, after which health insurers included available interventions in their insurance packages. RIVM monitors the implementation of the CLI on behalf of the Ministry of Health, Welfare and Sport.
Deciding which interventions to include
RIVM assesses candidate Combines Lifestyle Intervention (CLI) programmes in terms of their quality, effectiveness and feasibility. If programme measurements show effect on weight loss, physical activity, determinants of behaviour and quality of life, it will be recognised as having first indications for effectiveness. After the assessment, RIVM offers advice to the Ministry of Health, Welfare and Sport on which types of treatment and intervention should be covered by the basic healthcare package. The final decision is taken by the Minister after consulting the Lower House of the Dutch Parliament.
Currently, there are three CLIs accepted for inclusion in the basic insurance package. These have been evaluated in terms of both process and impact. All interventions have at least one pre- and one post-measurement of results after the treatment phase (year 1) and after the assessment phase (year 2). All interventions show weight loss, improvement of risk factors such as blood glucose and blood pressure, and improved physical activity levels. All health insurers have included one or more CLIs in their health insurance packages.
All three programmes have an intervention owner who provides training to professionals who want to offer the programme in question. This training is mandatory. In addition, all programmes come with a manual, and various materials are available for programme implementation.
Prior to the implementation of a CLI, the professional must:
- Register as a professional qualified to offer the CLI
- Attend a training course on carrying out the relevant programme
- Obtain a license to carry out the intervention
- Conclude a contract with the healthcare insurer
- Collaborate with general practitioners and/or specialists who can refer the patient to them
RIVM is developing and conducting a monitoring and evaluation process to determine how efficient and cost-effective CLIs are within the basic insurance package. Data on weight loss and quality of life, and the rate of engagement of participants are among the factors monitored.
CLIs’ impact on health equity
It is expected that CLIs have a positive impact on health equity, as participants are not required to make a financial contribution and there are no costs associated with taking part. However, if the results show that the CLI is not cost-effective, the Ministry can decide to cancel reimbursement of the intervention from the basic health insurance package.
Because CLIs are reimbursable under the basic insurance package, the government has ensured equitable distribution of the service across different sectors of the population. The basic insurance package is compulsory for every resident, so the programme is available to every adult who meets the inclusion criteria. Participation is not deducted from the participant’s excess and literally does not costs participants anything, promoting access to preventive measures for all residents of the Netherlands. Instead of charging the participant, health insurers directly pay the lifestyle coaches and health care professionals who organise the interventions. This is needed, as people from low-income groups are more likely to be overweight and diabetic, but they have less money to participate in preventive activities. Inclusion in the basic package means that this offer will be available to a group of people who normally cannot participate.
€ 9 million was reserved for the implementation of the service on an ongoing basis, starting in 2020. For 2019, € 6.5 million had been set aside.