6. Approach to double counting
When calculating health and social care expenditure, CBS takes the revenues of care providers from supplying care as its starting point. A drawback of this approach is that instances of double counting can arise when a care provider outsources part of the care to another (possibly independent) care provider. In such cases, the revenues of both the principal provider and the subcontractor may be added together, which can result in the same expenditure being recorded twice, and therefore to an overestimate of total care expenditure.
Further complicating factors are the fact that the principal provider and the subcontractor do not always fall within the same subclass of section Q, and that a care provider can be a principal provider and a subcontractor at the same time. Generally speaking, it is not possible to infer relationships between the principal provider and subcontractors from the available sources, and hard figures about the scale of subcontracting are lacking for much of the care sector. For this reason, it is often necessary to use indirect evidence of subcontracting. In order to better estimate the scale of possible double counting, specific methodologies have been applied. The most significant examples of double counting and methods of correction are explained below.
6.1 Examples of double counting
1. Consolidation within group structures
In their annual corporate social responsibility reports (DigiMV), some care providers issue both a consolidated statement at group level and a statement per underlying unit. CBS maintains a Care Units Register, in which a record is kept of the chamber of commerce numbers (and CBS business units) associated with a conglomerate, in order that we do not count the income from the separate financial statements twice. This has allowed us to effectively prevent this form of potential double counting. (This was already the case before this revision.)
2. Procurement of healthcare and services from other healthcare providers and enterprises
Many healthcare providers purchase supplementary services from healthcare and non-healthcare providers alike, such as laboratory testing or cleaning services. In the case of procurement of care from independent medical laboratories (subclass 86924), which are monitored by means of a separate CBS survey, double counting would occur if no correction were made for these services between providers in the case of laboratories or hospitals (or other procuring healthcare providers). This is because the amount the hospital receives for providing care already includes the fees it charges for laboratory testing. For the procurement of non-care services, such as cleaning or financial administration, no correction is necessary because the income from these providers is not monitored and therefore there is no double counting. Figures for subcontracting and outsourcing often make no distinction between procurement of care services and non-care services.
3. Financing schemes in which the care provider does not submit claims itself.
Within the care sector, it is increasingly common to find examples of care financing in which the party that claims back the costs of care is not the party that provides the care. For instance, multidisciplinary care (also known as integrated care) is claimed by one party, which is then responsible for payment to all the care providers that provided part of the care. The claiming party usually falls within the SBI subclass ‘Umbrella organisations in the field of health care and other support activities for health care’ (86929), while the care may be provided by independent GPs and physiotherapists who fall within their ‘own’ subclasses. The claims are counted as care expenditure and a correction needs to be made on the side of those GPs and physiotherapists in order to prevent double counting. Another example are care farms. Many care farms work together in partnerships. For example, a partnership may act as the contracting partner for local authorities for the delivery of Wmo care on behalf of all the participating care farms. These partnerships are often classified in SBI subclass 86929, as referred to above, whereas the care farms are primarily classified in SBI subclass ‘Residential and day care for mental retardation’ (8720). Other examples of a risk of double counting associated with the method of financing are integrated perinatal care and patient transport.
4. Use of self-employed persons
As stated in the introduction, the number of self-employed persons in the care sector has risen sharply in recent years. Self-employed persons often fall into a different SBI category than the care institution that hires them in. The revenue of the self-employed person is included in the care claimed by the care institution. In order to prevent double counting, we would need to know whether each individual self-employed person is working on behalf of a care institution or not, plus the monetary value of the care provided. After all, self-employed persons can also deliver and invoice care directly to clients.
6.2 Methodology for correcting double counting
The manner in which CBS corrects for double counting depends on the available data sources and the financing structure. Cataloguing all the principal contractor-subcontractor relationships within the care sector would be impossible; the use of one or more generic methods is essential.
1. In SBI subclasses for which an Annual Social Responsibility Document (DigiMV) is compulsory: use of specific variables about subcontracting
For several years now, hospitals and institutions for residential mental healthcare, care for the disabled, shelter care, residential youth care, outpatient youth care and nursing, caregiving and home care have been required to state in their annual accountability statements how much revenue they receive from subcontracting and how much they pay out to subcontractors. The quality of the figures is not yet of a standard that would allow the tracking of year-on-year developments. However, they are used to make a good estimate of the revenues from subcontracting and are deducted from total operating returns in order to prevent double counting. That does not yet solve the problem of self-employed persons hired in by care providers. That potential double counting is addressed on the side of the self-employed persons – see below under point 4.
2. Providers of GP care and dental care: preventing double counting by determining the level of care expenditure from the available financing sources
These SBI subclasses contain thousands of small providers of care, some of which are part of a chain and some of which are not. There are locums, partnerships, chains that submit claims for the participating healthcare providers, chains that only provide services to participating healthcare providers, financing via financial controllers (integrated care, GP services structures). For these categories, the problem of double counting is avoided by not calculating the care expenditure as the sum of the income of the providers but by adding up how much money is spent from the different financing sources. That is to say: an estimate of the amounts patients themselves pay is added to the claims per provider (Zvw and supplementary insurance). While making such an estimate is difficult, it yields a great benefit in terms of preventing the double counting problem. This approach is also used for health centres (subclass 86921) and medical laboratories (subclass 86924).
3. Health care providers surveyed by CBS: Cost of agency staff and other temporary contract workers
For healthcare providers surveyed by CBS, such as children's day care centres, local and social work and occupational health and safety services, the variable ‘Cost of agency staff and other temporary contract workers’ is used. This item is broken down into the cost of agency staff on the one hand and the cost of other temporary contract workers on the other, on the basis of figures from the Care and Welfare Labour Market (AZW) project on numbers of agency staff and self-employed persons hired in. The estimated figure for other temporary contract workers is then used to correct for instances of double counting. This therefore means the correction takes place on the side of the hirer of care staff. This is not a particularly robust method, due to the assumptions which are needed to break down the costs of agency staff and other temporary contract workers, and because it is not known whether those temporary contract workers are actually engaged in care activities and, if they are, which SBI subclass the self-employed persons in question belong in. The implicit assumption is that they fall within the same SBI subclass as the care provider hiring them.
4. Identifying subcontractors (including self-employed persons) who provide insured health care
Whether companies and self-employed persons that provide care which is typically insured are classified as ‘double counters’ or not is based on the following considerations: if those companies do not submit claims themselves, have not submitted an annual corporate social responsibility report, do not provide care financed from personal budgets (cash benefits) and are not listed in the AGB register, they are regarded as double counters. For self-employed persons in a medical profession, such as nurses, an even stricter criterion is used: if they do not submit claims themselves, this is taken to mean that they are hired in on a long-term basis and therefore should be regarded as double counters.
In the domain covered by the Child and Youth Act and Wmo, AGB registration is a virtual requirement in order to be able to submit claims to municipalities, so in this case the assumption is that if a self-employed person or (small) company is not listed in the AGB register, it is a double counter. However, if a self-employed person or company is listed in the AGB register, the revenue in question is counted. This approach may not be strict enough: there will be providers of Wmo care who work for the party which has a contract with the municipality but who are nevertheless AGB-registered. Although we use a great many sources to support our conclusion, it remains a crude method. A refinement of the method has been introduced for the aforementioned care farms: the care farms often submit claims related to personal budgets (cash benefits) themselves and in many cases are also AGB-registered, but they earn the remainder of their income as subcontractors of a party that concludes contracts with municipalities. In such cases, only the personal budget-related revenue of the care farms themselves is counted.
This method does not work for SBI subclasses that provide a lot of uninsured health care or social work. For this reason, there is a lack of instruments to identify double counters within the ‘Other paramedical practitioners’ subclass (excluding the BIG occupations) and the ‘Psychologists’ subclass (excluding those who are BIG-registered), and two subclasses comprising ‘Other providers of care’ (86929 and 88999). These subclasses consist of many thousands of sole proprietorships for which only a name is known that reveals little. As a result, it is not possible to determine whether they have actually delivered care (see the text box on the ‘Human Health and Social Work Activities’ section <link to text box in chapter 2> ). For this reason, there is no correction for double counting in these subclasses. Although this can lead to an overestimate of care expenditure, there are few indications that subcontracting takes place here to any great extent.