PBS had an interesting program about The Netherlands Health system last night. The Netherlands (Dutch), has been on the cutting edge of a number of health care issues over the years, including policies for physician assisted suicide for the terminally ill and allocation of resources for maternity and child care. Recently, the Dutch decided to switch from a single payer health care system to an open market, privately insured system, where every resident has a health care budget. This approach could work for the United States, but a number of changes would have to be made to the insurance regulatory infrastructure. This article addresses those system delivery concerns.
Question of Scale
First of all, lets talk about scale, The Netherlands is a tiny country compared to the United States, with excellent public transportation and health services in place for the entire country. In the USA, if you have a car, transportation is excellent, though costly, but access to healthcare in rural and poor areas is much more limited in America than in The Netherlands. Secondly, the country has the same health care insurance standards for everyone in the country, not fifty different standards like the states.
Health Insurance Regulation
In America, the Insurance Commissioner of each state regulates the health insurance industry and though commissioners have a national organization with some standardization recommendations, each state is free to do what it wants for health insurance regulation. There is very little standardization in health care insurance or service delivery in the United States, which is partly the cause of the incredible disparity in cost of care per capita compared to other industrialized countries. Also, about half of the USA health care system is financed by private employer plans and for those employers who choose to take some risk and self insure their health plans, there is an exemption from most of the insurance commissioner regulatory authority. So, this begs the question, how would you standardize the process? The answer is an amendment to the ERISA law, which created this health insurance loophole in the first place. Though it may be easier just to do the pay or play and provide the allowance/subsidy as needed, than to dictate benefit design to these stakeholders.
Lack of Standardization
It is one thing for The Netherlands to take its existing long established policies on basic care, palliative care, and eldercare and change their financing system, but the USA doesn’t yet have standardized policies for health care services. Also, since the administrative cost for private insurance is about three times that of the largest government run program, Medicare, it is hard to see how administrative savings will be made in this scenario. The government has more control to drive system delivery changes with Medicare than it would have with several hundred insurance companies. I can just see the marketing geniuses working on their differentiation campaigns now.
Potential Applications from Netherlands Style Market Based Health Plan
The Dutch have a few options to select from for health care insurance, from basic, to deluxe, and pay an individual cost accordingly. Dental, vision, and luxury services are in the latter package. The United States health care reform movement should require a minimum level of care for all of its eligible residents, including primary care, hospitalization, and prescription drugs. A secondary plan may include basic dental and vision services, whereas the deluxe plan could include better coverage in those areas. One consequence of providing an individual health care allowance is the individual would have to take more responsibility in accessing and choosing health care. Theoretically this policy would reduce unnecessary services.
Evidence Based Treatment
In The Netherlands, new prescription drug and other treatments are subject to an administrative review to determine medical evidence and efficacy of the intervention before approving the treatment. This concept would also be a sound mechanism to thwart excess profiteering in the U.S. health care system. Though some patients may be concerned that they are not receiving the latest treatment, this does not necessarily mean their treatment isn’t effective. There are many instances in health care where a lower tech treatment is just as effective as the more technological one. For example, in wound care, the individual vacuum devices that are affixed to the patients wound are less costly and often more effective than hyperbaric treatment. U.S. citizens have to learn to access quality data when making health care decisions.
Universal Availability of Health Quality Data
Though alpha health care organizations, like Virginia Mason Medical Center, have been integrating quality reporting into their system for years, there is limited national standardization of quality reporting. The NQA or National Quality Association has good data available, but it has not been integrated into all health care delivery systems. Quality measures are complex, but leading health care organizations, like Seton Family of Hospitals, a division of Ascension Health, have incorporated quality into their program development measures for years. If you look at medical standards nationally, each specialty has its own education group that advocates for certain treatment protocols. Perhaps the start of a national standardization movement for basic health care is to create a roll-up of these separate quality measures and continue to refine the process.
Accountability and Reporting
Again, given the scale of The Netherlands compared to the U.S.A. and the fact they migrated from a standardized program initially, their reporting issues are less problematic than for the U.S. migration into a standardized health program. Reporting simplicity, transparency, and auditing would be crucial to maintaining equity in a national health care program. Given the Unites States recent bouts with criminal banking activities and the usual health care fraud scams, the importance of tracking private insurance payers is even more crucial. Since the banking industry has wanted to get into the health care industry for years, this may be their opening, so beware of the foxes in the hen house.