With these effective strategies, you can successfully create regulatory space for new MGZ payment titles

An example of a new form of collaboration is the payment title 'Care Trajectory for Vulnerable Patients', which was partly developed following the initiative Multidisciplinary Primary Elderly Care with a Specialist in Elderly Medicine (MESO) by Ester Bertholet. MESO is one of the initiatives working in this way to create regulatory space in policy and is therefore used in this article to illustrate the movement.

After a few years of temporary funding and research into its effectiveness, the Dutch Healthcare Authority (NZa) made structural funding possible as of January 1, 2025, for the deployment of geriatric specialists to support independently living older adults with complex care needs. This  article reflects on the effective strategies and the work required to get this off the ground ─ offering lessons for future initiatives.

How trajectory-based financing works

The new funding structure includes:

• A three-month start-up phase by the geriatric specialist,
• Followed by a monthly billable continuation phase.

This broader payment title goes beyond the current consultation fee under the policy rule ‘Medical Care for Specific Patient Groups’ (GZSP), because it funds specialist care for a longer period and also enables integrated care by multiple professionals.

Previously, it was only possible to declare the deployment of the geriatric specialist per hour. This new performance is intended not only to structurally secure the MESO initiative but also to create space for geriatric specialists and broader care teams across the country to take on more care demands in primary care. At the same time, there are still some snags in the implementation. For example, the new payment title cannot be used simultaneously with the existing GZSP. Also, separate agreements must be made with health insurers to use the payment title.

The example of MESO provides insight into the process of (creating) regulatory space. What stands out in the creation of the payment title 'Care Trajectory for Vulnerable Patients' is that the process runs through several steps, with some steps occurring more or less simultaneously.

Process steps

1. Identify bottlenecks in care

A starting point in this development process is clarifying the bottlenecks in the current situation of medical generalist care. In this case, it was the lack of appropriate care arrangements for a growing group of independently living older adults with complex care needs. MESO offers a solution. General practitioners can engage the MESO team, consisting of an geriatric specialist, a geriatric nurse, and a secretary, when care demands become too complex. The MESO team visits the home for diagnostics and treatment and prepares a care plan together with the relatives.

This initiative began in 2011 in Velp, where general practitioners could refer older adults to the Elderly Medicine Practice Bertholet. It was enthusiastically received but was also difficult to secure structurally and scale up due to project-based, temporary funding.

2. Secure room and resources for experimentation

A second step is obtaining experimental room through negotiations with system and field parties. Such a project period of small-scale experimentation with temporary subsidies brings uncertainties. At the same time, experimental room is needed to get started and further demonstrate the added value of an initiative. That the MESO pilots were conducted in three municipalities (Tiel, Zoetermeer, and Rotterdam) with diverse challenges helped in this regard.

3. Work on a convincing story about the added value

The next step in the process is working on a convincing narrative about the initiative’s added value. This ensures recognition and traction with system parties such as the NZa, the Ministry of Health, Welfare and Sport (VWS), health insurers, and professional associations such as Verenso and the National Association of General Practitioners (LHV).

This happens by emphasizing the added value of MESO in the current care landscape and demonstrating that this initiative can be scaled up to other regions. MESO was described as an important part of a broader regional care model with variable forms of specialist deployment. A lot of time and energy was invested in making the initiative visible. Policy conferences and meetings were used, and many documents were prepared to convince system parties of the initiative’s added value. This is how MESO became increasingly known and embraced. Support from health insurers then helped to put the initiative on the NZa’s agenda.

A specific part of developing a convincing story is working on evidence that shows the added value of the initiative. Setting up research in MESO pilots played an important role. This showed that the MESO initiative yields concrete results, such as fewer and delayed nursing home admissions. MESO’s added value was also strengthened through learning networks, where acquired knowledge flows to other locations. Additionally, value was created by participating in projects such as Better at Home with GP and geriatric specialist of Amsterdam UMC, to formulate a generic description of the geriatric specialist’s deployment in primary care.

4. Align with national policy

The MESO example further shows the importance of ensuring the narrative fits with policy shifts over the years. This was done by creating a 'bureaucratic hook' into ongoing policies. MESO had to align itself with many policy programs developed in recent years, such as The Right Care in the Right Place (2018), Appropriate Care (2022), and the Primary Care Vision 2030 (2023). This required translating the story into current policy objectives and allowing it to evolve accordingly - without sacrificing the initiative’s original design. This requires a certain degree of flexibility.

5. Spark a system-level discussion

Ultimately, MESO’s experimentation and proven added value sparked a system-level discussion on the structural financial embedding of this and similar initiatives. Based on existing and ongoing research, the NZa made a value judgment between temporary funding for specific treatments and generic structural embedding. The structural payment title now allows space for other initiatives focused on deploying geriatric specialists in primary care. In making these choices, the NZa considers macro frameworks and tries to keep the consequences relatively manageable.

The steps are interconnected

The above process steps in realizing a new payment title are not isolated. The MESO initiative shows how these steps are interlinked. At several points over the past decade, experimental space was obtained, research was conducted to demonstrate added value, and system parties were engaged (and still are). This shows the process does not end with the creation of a payment title; health insurers must still be convinced to actually purchase the care.

Moreover, the newly acquired payment title calls for further steps. Currently, it only covers care for independently living older adults under the Health Insurance Act (Zvw). What this means for those under the Long-Term Care Act (Wlz) is still being explored. Additionally, insurers are still only partially purchasing trajectory care. This shows that the process does not end with creating a payment title; insurers must be persuaded to actually contract this care.

Regulatory space emerges from interaction between local, regional, and national actors

From the example of MESO, we learn that there is room for regulation for medical generalist care for elderly people living at home in the interaction between local, regional and national parties. On the one hand, it requires courage and perseverance to (dare to) work outside existing frameworks. Healthcare professionals and project coordinators have been creative in finding solutions to obstacles, but also need system parties for this. This requires long-term movement back and forth between healthcare practices, boardrooms and policy tables. At the same time, this process is vulnerable and uncertain, because it requires a lot of staff deployment with no guarantee of a successful outcome. Creating new financial arrangements is therefore not an easy and unambiguous route. However, awareness of the steps to be taken over time makes this process less vague and therefore more manageable.

Reflection by Oemar van der Woerd and Jitse Schuurmans – Erasmus University Rotterdam