Should the US look to the Dutch healthcare system as a model?
Tuesday, November 14, 2017
Because of its sheer size, California has been a harbinger of many trends in the United States. That now includes healthcare. For instance, 13 million Californians (about 1 in 3) receive Medicaid (called Medi-Cal) — that's more than the entire population of Pennsylvania.
While the Trump administration and the Republican-led Congress still seek to unravel the Affordable Care Act, legislators in Sacramento are seeking solutions to maintain what is now 93 percent healthcare coverage of its residents.
Physician/Assemblyman Dr. Joaquin Arambula recently convened an informational presentation by the Commonwealth Fund at the statehouse to compare the U.S. to 10 other healthcare systems of member-nations in the Organization for Economic Cooperation and Development (OECD). The Commonwealth Fund's Robin Osborn made the case for the Netherlands' approach to universal care, based on their recent report, titled "Mirror, Mirror 2017."
Osborn noted that the study focused upon access, care process/quality of care, equity, efficiency and outcomes. The U.S. came in dead last in each category except for quality of care, where it was slightly above average.
"The U.S. tends to excel on measures that involve the doctor-patient relationship, performing relatively better on wellness counseling related to healthy behaviors, shared decision-making with primary care and specialist providers, chronic disease management, and end-of-life discussions," according to the report. "The U.S. also performs above the 11-country average on preventive measures like mammography screening and older adult influenza immunization rates.
"However, the U.S. performs poorly on several coordination measures, including information flows between primary care providers and specialist and social service providers. The U.S. also lags other countries on avoidable hospital admissions.”
Osborn added that the U.S. does well in chronic care and remains tops in healthcare innovation.
However, while comparable countries spend 9 to 11 percent of their gross domestic product on healthcare, U.S. expenditures exceed 16 percent of GDP. In California, it's about 14 percent of GDP. About 1 in 4 U.S. immigrants lives in the Golden State, and failure to provide basic services to this population sector creates a public health crisis.
Although the Netherlands requires immigrants to pay for their own healthcare, noncitizens are covered for many services anyway.
"Apart from acute care, long-term care and obstetric care, undocumented immigrants have to pay for most healthcare themselves (they cannot take out health insurance). However, some mechanisms are in place to reimburse costs that undocumented immigrants are unable to pay," the report states.
"For asylum-seekers, a separate set of policies has been developed. Permanent residents (for more than three months) are obliged to purchase private insurance coverage. Visitors are required to purchase insurance for the duration of their visit if they are not covered through their home country."
If there were a healthcare Olympics, Osborn remarked, the U.S. would win gold medals in poor outcomes, number of avoidable deaths and excessive spending. Her colleague, economist Sarah Collins, noted that due to high and unaffordable healthcare costs, 1 in 3 Americans don't receive care.
California and New York lead the nation in health insurance coverage at about 93 percent, whereas Florida and Texas only cover about 60 percent of their residents. And 1 in 3 Americans use their local emergency department because they are unable to get treatment at a routine clinic.
And this is where the Dutch really shine. Their strong primary care system includes after-hours care, whereby physicians cover each other on a rotating basis from 5 p.m. to 9 a.m. Also, 88 percent of Dutch doctors visit patients in their homes through general practitioner-led cooperatives, and 70 percent of these visits are tracked by an electronic medical records system, which results in terrific care coordination between healthcare providers.
Primary care providers in the Netherlands receive bundled payments each year, with an emphasis on patient care, not specialty care. Expenditures for Dutch primary care are twice those of specialty care — the reverse is true in the U.S. Consistent with this trend, social services spending in Scandinavia is twice that of healthcare expenses — again, the opposite is true in the U.S.
Osborn conjectured that Dutch (and Scandinavian) public health policy — mandating spending at the front end of preventive health and human services — could explain the lower expenditures for acute and long-term care costs. For example, controlling asthma or diabetes while ensuring adequate housing as a protective gesture of the state exposes itself to fewer acute health events, thereby reducing costly consequences.
Once taxes, premiums and outcomes for health are measured, the Dutch spend as much as we do, but in inversely different proportions and with disparate results. It appears the Dutch have appropriated an aphorism from one of our own, Benjamin Franklin: An ounce of prevention is worth a pound of cure.
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