Tag: International

Going Dutch for Health Reform Ideas


Every now and then HealthBeat takes a look at health care systems in other countries So far we’ve tackled Germany and China. Next on our list was the Netherlands, but it turns out Health Affairs beat us to the punch. In May, Wynand van de Ven and Frederik T. Schut, two professors at Erasmus University in Rotterdam, authored an excellent profile of the Dutch health care.

Why should we care how they deliver health care in a tiny country most of us will never visit? Few European health care systems have garnered the kind of attention from Americans that the Dutch system has received — especially from folks not known for their Euro-philia, including the Bush Administration. In the fall, the White House sent a delegation to the Netherlands to learn more about the Dutch system.  The Wall Street Journal also has praised the Dutch system for accomplishing “what many in the U.S. hunger to achieve: health insurance for everyone, coupled with a tighter lid on costs.”

What could make conservatives entertain the possibility that we might learn from Europeans? Under the Health Insurance Act of 2006, the Dutch have created a system of universal coverage delivered entirely through private insurers. In this, the Dutch plan is very much like the plan Dr. Ezekiel Emanuel proposes for the U.S.  in his new book Healthcare, Guaranteed. (We wrote about Emanuel’s plan here and here), calling it a “fresh” proposal for reform.)

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The Talking Cure: moving patients to the center of care

The relationship between patients and doctors is fundamentally changing. Transparency in medical records, patients’ accessibility to health information online, and online social media driving patient-to-patient conversations are some forces at the base of the future of health care.

This, according to a thought-provoking report that addresses the evolving nature of patients vis-à-vis physicians in the National Health Service (NHS) in the U.K. These factors are also driving change in health and health care in the U.S.

The Talking Cure: Why Conversation is the Future of Health Care is an essay published in mid-May 2008 by two smart guys at Demos. As the National Health Service in the U.K. approaches its 60th birthday, the Demos research organization launched The Healthy Conversations project (now known as The Talking Cure) to engage stakeholders in and outside of the NHS in a dialogue of how to move patients to the center of health in the U.K.

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Real transparency in a socialist nirvana? UK releases hospital death rates

In yet more evidence that the transparency revolution is worldwide and not merely a product of American capitalism, comes news that in the UK death rates for specific types of surgery at NHS hospitals are to be revealed. Can this be happening in the single-payer government morass that we’ve been warned off for years? Michael Millenson, one of America’s leading experts in patient safety and quality, gives us his reaction.

This is mind-boggling, if, alas, short on some crucial detail: Is this based on claims data (high-school-graduate-coded administrative information) or clinical claims? If the former, it is impressive, if the latter, extraordinary. For those who believe in the superiority of American medicine, here are a few observations.

First, he who pays the piper calls the tune. If NHS decides to
collect this data, it’s done. One also presumes they don’t need an act
of Parliament to do so, thereby avoiding at least some degree of
political interference.Second, a leading physician, who
actually pioneered releasing clinical data to the public, went on to
serve in the Cabinet and continue leading this effort on behalf of the
broader public interest. By comparison, our equivalent of a cardiac
database, the Society of Thoracic Surgeons database, has strict
confidentiality requirements that don’t even allow city-city or
state-state comparisons. The exception: a physician can release his own
information for marketing purposes.Third, and most interesting, are these seemingly innocuous sentences. “There were initially fears
raised that releasing the information would lead to surgeons avoiding
difficult cases which could impact their rates. But agreement was
reached on a method to take into account the difficulty of cases and
mortality rates are released against the number of deaths expected. Sir
Bruce has been working with hospital specialists on a way of rolling out
a similar scheme across all areas of surgery and medicine to help
patients choose where to be treated.”

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INTERNATIONAL: Rational talk about Canadian Health Care

I’m very happy to relate that one of the best pieces ever by me on THCB, Oh Canada, (written when THCB was just finding its feet in 2003) is still as relevant as ever. There are still inordinate amounts of crap talked about the Canadian system by defenders of the current US status quo (not that the far right loonies who dredge this stuff will say that’s what they’re doing). This is dspite the fact that no major US Presidential candidate, with the possible exception of Harry Truman, has ever proposed introducing such a system here.

But over on liberal blog Campaign For America’s Future (the guys who are backing  Jacob Hacker’s work and by the way taking credit for the Edwards, Clinton and some of Obama plan) Sara Robinson—a self described “health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border”—has written a very balanced piece called Mythbusting Canadian Health Care.

I can see the Canadian ex-pat trio of Pipes, Gratzer & Graham going into apoplectic fits even as I type!

POLICY/INTERNATIONAL: The new health care system in the Netherlands

It would be great if we could get the US to a system of health insurers competing over the right things. With a universal individual mandate that worked, risk adjustment between insurers, and social solidarity mixed with market incentives — the best of both worlds. The Dutch (pound for pound) have better football, beer and drug laws than anyone else.  And now a very sensible health care system too.

Here’s a video on the new health care system in the Netherlands.

INTL: Market invisible hand forces Canadian death rate numbers public!

In a valiant effort to stop Canadians storming the borders and leaving their home health care system bereft of their health care dollars, the Canadian government has yielded. It’s made death rate numbers at Canadian hospitals public. The probably futile hope is that Canadian citizens will believe that the competition of transparency will lead to improvements in the current situation in some Canadian hospitals, such as the Scarborough Hospital mentioned in the article, which kills 124 out of every 100 patients admitted.

Now that the Canadian dollar is so strong, buying some 45,000 American Lire to the northern Peso, it’s cheaper for a Canadian to sneak across the border and pay cash for open heart surgery than it is to pay the tax on the Canadian cigarettes that caused the heart disease in the first place.

The combination of renowned treatment from private American hospitals that kill far fewer than 1 in every 1 patient (and sometimes less than that), and the strength of the Northern Peso have now resulted in the desperate situation of empty waiting rooms, and no queues for surgery in America’s northern neighbor.

The collectivist Marxists who run things in Canadian health care from their command center in the bunker of the UBC health care economics department have been horrified at this development. A spokesman who sounded a lot like Morris Barer was (or maybe wasn’t) overheard saying, “it’s our right as Canadian elitists to make the rest of our citizens wait forever for hospital care that will probably kill them if they don’t die waiting in line first. The overwhelming transparency and easily demonstrated quality of the now dirt cheap American health care system is not fair.”

Reports that the WTO was investigating were unconfirmed at time of writing.

Unrepentant free-marketeer Canadian exile David Gratzer was reportedly seen crowing, “See how Adam Smith has kicked those loonies in the ass! The market triumphs again!”

Now can I get a job in the Giuliani administration?

POLICY/INTERNATIONAL: The Dutch–Better than the US at football, drug-laws and health care organization

The Netherlands is a small nation of only 16 million, and yet they have a record in International soccer that’s better than many three times their size. laws about drugs and prostitution that reduce crime, violence and embody toleration, and now they probably have the most advanced health care financing system in the world.

How so? It’s essentially Enthoven’s original managed competition idea in action (circa 1987). Even the Wall Street Journal thinks good things. The key is you need to ban underwriting, and implement risk adjustment (not that it’s easy but it is doable) between plans. Then you have to give the insurer and the insured incentives to realize that the way that population health is managed has ramifications for both the population’s health and its wealth. Then you get rational trade-offs made at a population level.

Can it happen here? I think so, unless you think that Americans cannot handle rational choice. Of course the people who claim to value choice in health care here can’t abide by the concept of the rational structure that the Dutch have put in place which allows choice to be made about the right things. So "choice" here in health care financing means, as the WSJ put it:

In the U.S., competition among insurers often means competition to find
the healthiest customers, especially in the individual market.

But of course if you don’t allow individuals to make the choice of what they spend collectively on a monthly basis to be the point of decision on how much is spent on health care (and put those intermediaries in the middle in the position of benefiting from lowering that amount in the "right" way), then the only other rational allocation is to have the government do it via the tax system.

CODA: I wrote extensively earlier this year on my comparison between the two and how different they both are from typical American notions of competition.


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