Lessons from Abroad: The Dutch Health Care System, Part 2
In my last blog post, I looked at the structure of the Dutch health system following reforms undertaken in 2006, which were studied by many of the architects of the Affordable Care Act. Like Americans, the Dutch have a public–private system, albeit one that is more heavily regulated and subsidized by the government than the U.S. health system will be even after all reforms are implemented.
Today, Dutch residents are required to purchase private health insurance. The government pays for half of all premium costs through payroll taxes, as well as additional sliding-scale subsidies for about 40 percent of the population to help them cover their portion of the premium. Long-term care insurance is provided by the government and financed separately.
As a result, health insurance in the Netherlands is nearly universal and health care in the Netherlands is both affordable and accessible. The quality of care itself also measures up well. Health care in the Netherlands has always been based heavily on primary care. Even by European standards, doctor–patient relationships seem to be long-lasting; in the 2008 Commonwealth Fund survey, Dutch patients were both most likely to have a primary care physician and most likely (along with German patients) to have had that primary care physician for at least five years. In the U.S., responses to both questions were lower—although, in fairness, it's not clear how much of that reflects greater geographic mobility (and larger geographic expanse) in the U.S.
One consequence of strong primary care may be the high rates of participation in basic screening and prevention programs. According to the latest government data, 82 percent of Dutch women get breast cancer screenings while 66 percent get cervical cancer screenings, and 95 percent of all citizens get a full complement of vaccinations. All children have contact with preventive care within the first year of life; nearly 80 percent have maintained that contact by age five.
The close relationship that Dutch patients have with their primary care physicians may also help explain why the Dutch score well on many measures of chronic care. In the Commonwealth Fund survey, 59 percent of respondents from the Netherlands reported getting recommended services for diabetes, second only to the United Kingdom (where the response was 67 percent). In the U.S., just 43 percent of respondents reported getting the recommended services. In addition, patients in the Netherlands were least likely among the eight populations surveyed to experience care coordination problems, such as duplicate tests or physicians not having records at time of a consultation. Just 14 percent of Dutch respondents said they'd had such experiences, compared with 34 percent of Americans. The Dutch are way ahead of Americans—not to mention most other countries—when it comes to the integration of information technology into medical practice. Surveys show that virtually every Dutch physician now uses electronic medical records, although coordination between doctors and hospitals remains a work-in-progress.
The focus on primary care has raised a few concerns, as well. Dutch health care has long operated on a "gatekeeper" model: Patients only saw specialists when a primary care physician referred them. And this is still the case today. But recently the government has become concerned that primary care physicians may be too "reluctant" to refer to specialists even when specialty care is appropriate. Also of concern to government officials is whether GPs are providing sufficient guidance about healthy lifestyles. In the Commonwealth Fund survey, Dutch patients were least likely to report getting such advice from their primary care physicians. Americans, by contrast, were most likely.
Outcomes in the Netherlands compare well with other developed countries, including the U.S. According to data from the Organization for Economic Cooperation and Development, the 30-day mortality rate for acute myocardial infarction—i.e., heart attacks—is now down to 8.4 percent, which is lower than the OECD average. To be sure, health care results in the Netherlands are not uniformly stronger than those in the U.S. Cancer survival rates, for example, are generally lower in the Netherlands, although it's not clear how much that reflects cultural differences about hospitalization and the treatment of advanced disease. (Among the signs that the Dutch tend to be more wary of aggressive medical care: At-home births remain quite common, accounting for about a quarter of all births, even though both the government and medical societies now recommend hospital deliveries.) But the Dutch consistently fare better than Americans on broad indicators like "potential years of life lost," "disability adjusted life years," and "mortality amenable to health care"—statistics designed to capture the overall effects of a country's health care system. And this is despite the fact that Americans spend almost 50 percent more on health care (17.4 percent of gross domestic product) than the Dutch do (12 percent of gross domestic product). Perhaps not coincidentally, in surveys the Dutch consistently express more satisfaction with their health care system than Americans do with theirs.
Indeed, at this point, the issues that most preoccupy Dutch officials and experts are the same ones that concern their counterparts around the world: The fact that coordination of chronic care and overall quality of care—even if generally good by international standards—could be better. A major goal of the reforms that passed in 2003 was to improve performance in these areas, while simultaneously restraining the rising cost of medical care in the Netherlands. Increased competition for business, it was widely believed, would both improve quality and reduce costs.
It's not yet clear whether that is happening. In 2006, the first year of the reforms' implementation, 18 percent of people switched insurers. But the very next year, just 4 percent changed plans. (Some critics had suggested this is evidence that competition is minimal; government officials, however, point out that consumers seem more aware of the possibility of switching and simply seem disinclined to do so in large numbers.) Working closely with consumer groups, medical societies, and the hospital industry, the government has collected—and is disseminating—far more data about the quality of care than ever before. Today, people in the Netherlands can go to a Web site called www.kiesbeter.nl to see how providers and insurers are performing on a range of measures, although surveys suggest only a small percentage of people make use of the new data. ("Kiesbeter" translates roughly as "better choice.") The government has also kept a close watch on insurers, to see what sorts of innovations they are undertaking.
So far, according to the 2009 annual report by the Ministry of Health, Welfare, and Sport, insurers seem to be competing for new business primarily based on price—that is, their ability to reduce reimbursement rates for providers and to offer lower premiums to consumers—rather than based on quality. Government officials say they want to push insurers to focus more on quality, but it's not yet clear how they will do that—or whether they will succeed.
Today, the evidence of the impact of the reforms on quality and costs appears mixed. Still, change takes time and the reforms are not yet six years old. And there is anecdotal evidence of the types of changes reformers envisioned. Menzis, the country's fourth-largest insurer, has started to establish multispecialty clinics—modeled loosely on the more successful group practices in the U.S.—as a way to provide more coordinated and sustained patient care at lower prices. Groups representing different types of patients, chief among them diabetics, have completed the task of developing quality guidelines and have begun to provide members with information on which insurers meet them.
The government-sponsored consumer Web site (www.kiesbeter.nl) now carries a rudimentary three-star rating system showing hospital performance on a handful of diseases, based on statistics like readmissions and 30-day mortality rates. Tertiary facilities are starting to develop common protocols for tests and treatments, so that referring physicians and facilities can reduce duplication of services and improve quality of care. Some insurers have experimented with offering bonus payments to providers who meet quality guidelines or offer enhanced care for chronic disease, while others have set up their own pharmacies. (In a related development, insurers in 2008 were also able to negotiate significant new discounts with generic drug makers. Drug prices were already quite low, with the most commonly prescribed drugs in 2006–07 costing only 45 percent as much as they would in the U.S.)
Insofar as American policymakers hope that competition can improve the quality of health care while reducing (or at least restraining) its cost, the future of the Dutch reforms are certainly worth watching. But Americans hoping to recreate the Dutch experience must be mindful of the Netherlands' strong commitment to the principles of social insurance. Even after the Affordable Care Act is fully implemented, medical care in the U.S. is likely to remain far less affordable: According to official government projections, around 5 percent of legal residents and 9 percent of the population overall will remain without insurance; out-of-pocket expenses will remain burdensome even for many people with insurance. Improving primary care in the U.S. will require many more primary care providers than the U.S. currently has. The Affordable Care Act addresses this problem, by (among other things) boosting payment for primary care. But experts predict the resulting improvement will be modest, leaving the U.S. still well behind the Dutch. The legislative debate about enacting health care reform in the U.S. may be over, but the Netherlands still offers many lessons worth learning.