Klink goes to America

[Cees Binkhorst]

REPLY TO: D66 at nic.surfnet.nl

http://www.nytimes.com/2009/11/10/health/10conv.html
November 10, 2009
A Conversation With Ab Klink
Dutch View of Choice in U.S. Care: It’s Limited
By GARDINER HARRIS
WASHINGTON — The health system in the United States may be twice as
expensive as those in Europe, and the population may be less healthy,
but at least Americans have access to many more choices of doctors and
insurers. Right?

No, says Ab Klink, the Dutch health minister.

Mr. Klink was in Washington last week to attend an annual meeting
sponsored by the Commonwealth Fund, a private health care research
foundation, and swap ideas with counterparts from other countries. At
the meeting, the foundation released the results of a survey of doctors
from 11 countries that reflected poorly on the United States.

For instance, just 29 percent of primary care doctors in the United
States reported making arrangements for patients to see a doctor or
nurse after hours, compared with 97 percent in the Netherlands and 89
percent in Britain. And doctors in the United States were many times as
likely than doctors elsewhere to report that restrictions in insurance
coverage caused major problems with the time that they or their staff
were able to spend providing needed medication or treatment.

Between meetings, Mr. Klink sat down with The New York Times. The Dutch
are in the midst of a significant health overhaul to inject greater
competition into the nation’s insurance and hospital markets, but Mr.
Klink also offered some pointed observations of the health system in the
United States.

His first official visit to the United States as health minister came in
2007, and he came with the usual European preconceptions that this
country had a wide open and fiercely competitive health insurance market
with a myriad choices.

“And what struck me,” he said, “is actually the lack of competition you
have.”

Mr. Klink pointed out that nearly 40 percent of the nation’s population
gets care from Medicare, Medicaid and Veterans Affairs, all of which
have significant restrictions on the choices available to patients. “We
don’t have these kind of public insurance groups in our country,” he
said.

And even among those in the United States who get insurance from their
work, he went on, “it’s the employer who is making the choices of the
health plans from which you can choose.”

In the Netherlands, everyone chooses from a list of 10 or so insurers
who offer a standardized health plan that can be enriched with other
options. Those who cannot afford the premiums are given subsidies;
premiums are based on the benefits offered, not on a person’s age,
health status or sex.

The government once set prices for nearly all medical services, but to
inject some competition into the system, the government last year
allowed prices to vary for about one-third of medical services. Next
year that share will increase to half.

Here is an edited transcript of the conversation:

Q. HAVE PRICES SOARED?

A. All the prices that we have liberated have on average gone down or
stayed the same. This was quite a success. We are just beginning to have
this competition, and the health insurance companies are only beginning
to bargain prices.

Q. CAN YOU GIVE US SOME EXAMPLES OF SERVICES WHOSE PRICES YOU LIBERATED?

A. Knee and hip replacement operations, diabetes care and cardiovascular
management, eye operations, etc.

Q. AND HOW DO YOU ENSURE HIGH QUALITY?

A. For about 80 percent of health care provisions, we are creating
quality indicators. It’s a problem we want to finish by 2011. Many, many
people are interested in quality indicators for hospitals. We all have
family and friends, and people call us when they have to go to the
hospital and ask us, “Which one is the best one?” And I think it’s quite
important to have this double movement of liberalizing prices and having
complete transparency on quality.

Q. AND ARE YOUR QUALITY INDICATORS BASED ON MEDICAL PROCESSES OR ON
PATIENTS’ OUTCOMES?

A. A combination. For instance, one indicator for diabetes care might be
the level of glucose in patients, and the level of referrals to
hospitals and the complications from patients — such as infections or
how many people had to come back to the hospital within 30 days.

Q. DOCTORS HERE COMPLAIN THAT SUCH COMPARISONS FAIL TO ACCOUNT FOR THE
SICKNESS OF PATIENTS.

A. Yes, we are controlling for that.

Q. YOU HAVE ELECTRONIC MEDICAL RECORDS FOR PATIENTS. HOW ARE THOSE
PLAYING A ROLE IN YOUR REFORMS?

A. We are trying to make sure that no one receives health care that is
not coordinated. And that the general practitioners cannot negotiate any
longer with insurance companies unless they are part of a coherent group
that is offering coherent care. That is a change that we will implement
in the coming years, and electronic medical records are critical for
this.

Q. THERE SEEMS LITTLE DOUBT THAT POOR PEOPLE GET BETTER CARE IN THE
NETHERLANDS THAN HERE. BUT DO THE MIDDLE-CLASS AND RICH IN THE UNITED
STATES GET BETTER CARE?

A. The Dutch health care system offers top quality. We have some famous
institutions in our country. So I do think we have a high standard of
quality, and it’s open for everyone. And if there is a fear that the
rationing of care would lower quality, what I have tried to indicate is
that we are not rationing anymore. It’s all negotiable. And I’m quite
sure that if someone could offer a high standard of quality which is
even better than we have at this moment, the insurance companies would,
if needed, pay more.

Q. YOU ARE VISITING THE MAYO CLINIC, WHICH IS CONSIDERED A MODEL THE
WORLD OVER. WOULD WE LOSE OUR EDGE IN TOP-FLIGHT MEDICINE IF WE ADOPTED
A SYSTEM LIKE YOURS?

A. I cannot tell you that Dutch hospitals are better than the Mayo
Clinic or Johns Hopkins. Probably it’s the other way around. That’s why
we’re visiting them. But it’s not because this kind of quality would not
be allowed in our system. We would love the Mayo to open a hospital in
the Netherlands.

Q. BUT IS THERE SOME QUALITY IN THE UNITED STATES THAT HAS LED TO THE
CREATION OF SUCH TOP-FLIGHT HOSPITALS?

A. If you look at Kaiser Permanente or the Mayo Clinic, it’s important
to note that they were both started by people who really cared about
patients and instilled a culture to offer the best health care possible,
and they were able to keep this culture for many decades. And as far as
I’m informed, prices in these institutions are not that different than
those in other institutions or those in Holland. So I don’t think the
fundamental aspect of these institutions has to do with the liberal
climate in your country.

Q. HOW CAN YOU ENCOURAGE THE CREATION OF SUCH PLACES?

A. What I do not want is the rationing of care and what we call
budgeting. So that hospitals get a certain amount of money, and there is
no incentive for them to innovate. Because the aging of our society is a
major threat for health systems in the future. Many people will want and
receive health care, but if there is a shortage of labor, and demand
will rise, so prices will go up enormously.

That’s the main reason we tried to change the system and why innovation
is so important. Without it, there won’t be enough doctors or nurses,
because competing parts of the economy will pay more.

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