Following the revision, CBS is for the first time publishing a detailed breakdown of expenditure by care type. Care types are combinations of activities which are homogenous in terms of content and/or target group, such as home care, shelter care, medical specialist care, care for the mentally disabled and mental health care. This new care type classification establishes a third dimension, alongside the existing dimensions of healthcare providers and financing schemes. This gives users a better insight into which types of care are supplied by which providers and how they are financed. 

Zvw and Wlz claims are an essential source for the new care type classification in healthcare and long-term care. Vektis has also provided CBS with claims amounts per provider for care financed under supplementary insurance schemes. However, there is an important limitation: dental care and physiotherapy claims in particular tend to be submitted by factoring companies instead of by the healthcare providers themselves. This means that those claims cannot be linked to the CBS business register. Claims submitted by factoring companies are grouped proportionally with claims which have the same delivery codes and are linked to the business register. The same method is used for other claims which cannot be directly linked to the business register, for example due to an incorrect AGB code. 

CBS does not (yet) have access to iWmo and iJeugd claims, but hopes to be able to make use of these in the future. As a result, opportunities for breaking down the figures for care financed under the Child and Youth Act and the Wmo by care type are currently limited. The same is even more true of social welfare activities, for which our sources (fiscal data, CBS surveys) contain little or no information about care types. Sometimes, the care type is necessarily assigned on the basis of the classification of the providers: providers of children's day care (subclass 8891) are assumed to only provide children's day care; providers of occupational health & safety support and reintegration (subclass 86923) are assumed to focus exclusively on those activities. This means that if those providers do also provide other forms of care, it will be incorrectly allocated to the ‘principal care type’. Such assumptions are only made for provider categories which, as far as we are aware, provide few if any care types other than those corresponding to their classification.

5.1 Identifying care types

The classification by care type was developed in consultation with various experts and relevant organisations from the section. The care type classification is hybrid: in some cases, the classification is based on target groups (such as care for the mentally disabled), whereas in other cases it is determined by the nature of that care (for example, in the case of palliative care). 

The availability of data from different financing sources largely determines the level of detail to which the care types can be broken down. For example, it is currently not possible to further subdivide mental health care into more specific care types such as addiction care because the Care Performance Model (introduced in 2022) no longer explicitly differentiates within the data. This represents a potential risk for the continuity of the new tables and published care types.

Moreover, medicaments which are part of a broader treatment are not recorded separately as expenditure for the ‘medicaments’ care type. Similarly, preventive care which forms part of a treatment is not explicitly recognised and recorded as such.

In the system used to generate the figures, 62 care subtypes are currently used. The care subtypes are grouped according to the 26 care types listed in the StatLine tables, which are shown in the table below. Annex 2 contains a list of all 62 care subtypes and their allocation to care types.

In defining these 26 care types, CBS has sought to strike a good balance between their value in monetary terms, the wishes of the consulted users and the quality of the data. It is not desirable to have very small care types, given that they will be intersected with providers and financing. Aspects of the quality of the data include the extent to which all care of the relevant type is covered and whether the amounts can be accurately allocated to the correct provider categories. Based on the latter requirement, the figures for Wmo home care and youth care, for example, have not been broken down. Although it is generally known how much money goes to specific groups of providers under the Wmo or Child and Youth Act, insight into the care types within these categories is lacking. This means that, although a good estimate is available for national expenditure on, for example, home care and support, it cannot be allocated to specific provider categories. Both forms of care have therefore been allocated to the ‘Nursing and care at home’ care type. 

For a number of care types, somewhat different criteria have been used, as explained below. 

5.1.1 Care type(s): Medical specialist care

CBS and the experts it has approached have discussed at length how to break down the very large figure for expenditure on medical specialist care (after separating off expensive medicinal products, see previous point). A two-stage approach has been chosen:
Step 1: medical specialist care is a very broad field that partially overlaps with some more specific types of care. As far as possible, those overlaps have been removed by isolating the relevant parts of medical specialist care and allocating them to the more specific care types. Specifically:

1. Population screening (i.e. diagnostics following a positive screening test, for example internal intestinal examination after a positive stool test for colorectal cancer screening);
2. First line diagnostics and other laboratory activities;
3. Perinatal care;
4. Geriatric rehabilitation;
5. Other rehabilitation;
6. Palliative care;
7. Oral and maxillofacial surgery;
8. Psychiatry;
9. Radiotherapy (as a care subtype).

Step 2: By isolating these care types, around €3.8 billion of the total medical specialist care costs can be separated off for 2021. The remaining share of medical specialist care is still very large and heterogenous. That part is therefore differentiated further on the basis of the ‘highest’ setting of the care provided (inpatient, day treatment, outpatient). The setting is inferred from the care activities (such as nursing days) delivered within a Diagnosis Treatment Combination (DTC), in some cases from the treating specialism (for some specialisms, such as audiology, it is assumed that only outpatient care takes place) and, for DTCs for which no setting can be inferred from care activities and specialism, an imputation. DTC subprogrammes that remain without a setting are allocated to the outpatient setting. This classification by setting is also used in the individual statistics on medical specialist care.

For ‘Other Care Products’, no setting is inferred. That care is therefore allocated to the ‘Other Medical Specialist Care’ care type, along with radiotherapy. The same applies to the portion of the expenditure on medical specialist care that is not reimbursed under basic or supplementary insurance.

5.1.2 Care type: Mental health care

The care type ‘Mental health care’ covers treatment and assistance care for people with psychiatric disorders and psychological problems, ranging from short-term help with mild symptoms to long-term, intensive treatments (and inpatient care) for serious conditions. It also includes addiction treatment and care delivered by healthcare assistants attached to GP practices for mental health care.

The following sources are used for the classification of ‘Mental health care’:

• Claims under the Healthcare Insurance Act, Long-term care Act (Wlz) and supplementary insurance, based on delivery codes:
• Delivery code list for ‘GP care’: POH-GGZ
• Delivery code list for ‘Curative mental health care’
• Delivery code list for ‘Medical specialist care’ (psychiatry specialism)
• Wlz deliveries which belong to the GGZ-B care profile

• Expenditure on Wmo care at mental health care institutions
• Expenditure on psychological assistance care (uninsured)
• Expenditure on forensic care

5.1.3 Care type: Preventive care

The ‘Preventive care’ care type covers care and activities focused on preventing disease and health issues. This includes vaccinations, screening programmes, health information provision and lifestyle interventions. It also includes specific preventive services such as dental check-ups, oral hygiene, dietary advice, youth healthcare and occupational health & safety services. Preventive care which is part of a broader treatment is not included in this category, because it is not explicitly recorded as such. This implies that the figure recorded for expenditure on prevention is far from complete. It has nevertheless been decided to publish this figure, because it is informative, even if it only relates to earmarked preventive care.

Various sources have been used for the classification of the care type ‘Preventive care’, for example:

• Claims under the Healthcare Insurance Act and supplementary insurance, based on delivery codes:
• Delivery code list for ‘GP care’: vaccinations, smear test, stopping smoking, fall risk assessment
• Delivery code list for ‘Paramedical’: fall prevention and fall risk assessment
• Delivery code list for ‘Dental care’: consultation and diagnosis, making and evaluating images and preventive care
• Delivery code list for ‘Medical specialist care’: follow-up on population screenings.
• Expenditure on care by dieticians, oral hygienists and occupational health & safety services.
• Government spending, such as the national vaccination programme and municipal health services (‘GGD’).
• Population screening financed by the national government.

5.1.4 Care type: Palliative care

The ‘Palliative care’ care type comprises care aimed at improving the quality of life for patients with incurable diseases. This includes services such as pain management, symptom management, psychological support and guidance with end-of-life decisions. As with ‘Prevention’, palliative care that is part of a broader treatment is not recorded separately.

The classification of ‘Palliative care’ is based on claims under the Healthcare Insurance Act and the Long-term care Act (Wlz):

• Delivery code list for ‘GP care’: euthanasia, euthanasia consultation, palliative consultations.
• Delivery code list for ‘Primary residential care’: palliative terminal care and residential care in the final phase of life.
• Delivery code list for ‘District nurse services’: palliative terminal care.
• Delivery code list for ‘Medical specialist care’: palliative care and support and symptom relief.
• Wlz services which fall under the VV10 care profile.

5.1.5 Care type: Sheltered accommodation

The care type ‘Sheltered accommodation’ comprises care combined with accommodation for individuals with psychological or psychosocial problems who cannot live independently (temporarily or otherwise), with support for their daily activities, personal development and recovery. This is not the same as assisted living.

The ‘Sheltered accommodation’ classification is made up of the following components:

• Sheltered accommodation under the Wmo: this is based on the total expenditure on Wmo tailored provisions for ‘Residential care and shelter’, as reported in the Municipal Social Domain Monitor (GMSD). The distribution between ‘Sheltered accommodation’ and ‘Other shelter care’ is estimated using information from the municipal fund’s May circular. The Wmo expenditure on ‘Sheltered accommodation’ is proportionally allocated to the provider categories based on the out-of-pocket payments they receive for Wmo residential care, for which the AGB code is known.
• Sheltered accommodation under the Long-term care Act (Wlz): this is based on claims for residential mental health care under the Wlz.

5.1.6 Care type: Medicaments

The ‘Medicaments’ care type comprises the provision of medicinal products and consumables (such as bandages) for the prevention, treatment or management of diseases and symptoms. This includes both medicinal products available on prescription and over-the-counter medicaments (available without a prescription). The so-called expensive medicinal products (care subtype) provided as part of medical specialist care also fall under this care type. What does not fall under this care type are the ‘ordinary’ medicinal products provided as part of a hospital treatment or residential care in a nursing home. The reason for this is that their cost cannot be distilled from our data. Also not included under this care type and in fact completely absent from the Health and Social Care Accounts are medicinal products sold without a prescription on the internet.

5.1.7 Care types: Integrated care

This care type is an odd one out because the demarcation is based not on the content of care but on the method of financing. Integrated care is multidisciplinary coordinated care for chronic conditions (diabetes type 2, COPD, cardiovascular risk management), provided under the Healthcare Insurance Act, with different care providers and organisations working together to integrate the care for a patient. 

It is made up of GP care, physiotherapy, medical specialist care, etc. Ideally, integrated care would be broken down further, but it is not possible to distribute the amount spent on integrated care between underlying care types. For this reason, it has been decided to include integrated care as a separate care type. In the table showing the intersection of care types with provider categories, this care type is listed under the provider that submits the claim rather than the providers that deliver the care.

5.1.8 Care type: Shelter care

The ‘Shelter care’ care type comprises care and support for persons temporarily without accommodation or in a crisis situation – e.g. homeless shelters, women's shelters, asylum seekers shelters and other provisions.

5.1.9 Care types: Training and R&D

The ‘Training’ care type comprises only expenditure for further medical training under the Zvw and Wlz. Because this training takes place ‘on the job’ at care institutions, the costs are included in the Health and Social Care Accounts. The ‘R&D’ care type comprises only R&D carried out by UMCs.