In the discussion about the impending unaffordability and disruption of our health care system, Marjolene Smidt and Matthew Wegemann proposed the idea of removing insurance companies from our health care system (Taking insurance companies out of the health care system8/12). They can be replaced by the Office of the National Administration of Care and thus reduce the significant administrative burden for carers, as well as save a lot of money. An exciting and interesting vision that is worth at least contemplating.
Reaction of Bill Boss on behalf of the health insurance company Menzies (“It’s the policy that determines how much money goes to health care, not the insurance company.”, 14/12), however, were obligatory and meaningless. His point: Politicians determine how much money is spent on health care and the insurer guarantees that more quality can be achieved for every euro spent.
This is where the first boot pinches off right away. Most caregivers often have no idea what quality the insurers are talking about and how the actions of the insurers augment that quality. Smidt and Weggeman argue for a regime change where the professionals take charge again.
And this is where the second shoe kicks in, because medical and other healthcare professionals generally face an institutional mistrust in the discussion about health care costs and quality. The “inadequate” or “irrational” care to be given (Nederlandse ZorgInstituut), the “susceptibility to harmful production incentives” (Nederlandse Zorgautoriteit), the specialists who must therefore be employed (politicians).
Medical professionals find it difficult to defend themselves against this mistrust. The idea that most healthcare professionals want to provide the best possible care is rarely taken for granted. However, there are many examples proving the opposite. Take, for example, the treatment of uterine prolapse by Dutch gynecologists. This treatment may consist of surgery or placement of a diaphragm, also known as conservative treatment. It goes without saying that surgical treatment is more expensive than conventional treatment.
Not every prolapse can be treated conservatively, and not every prolapse is effective. In 2010, research was conducted for the first time on how Dutch gynecologists treat uterine prolapse. There appears to be a large variance that cannot be explained by differences in the number of patients. This difference in practice is called medical science and is usually a sign of poor quality. There have been hospitals where more surgeries have been performed than average and the type of operation can vary as well. At the other end of the spectrum were hospitals where very few operations were performed. There was abuse there, another sign of poor quality. The same difference is found in practice among university hospitals, where specialists are always employed.
Both insurers and gynecologists had no idea about the right balance between the two treatments: Which patients benefit from surgery and who should be treated conservatively?
Recent research, to which I am a contributor, shows that Dutch gynecologists have begun to treat more similarly in recent years. The same type of operation is also chosen more often and the absolute number of operations decreased during this period. Quality has increased, and care has become cheaper (because: less expensive operations).
What led to these major changes? In any case, it is not the case that all gynecologists have suddenly started working as employees or that insurance companies have set different quality requirements. The most obvious explanation is simple, the publication, in 2014, of a new guideline for the treatment of prolapse. This guide includes the results of a large number of (Dutch) studies on the outcomes of different treatments.
The working group of pelvic floor gynecologists ensured the national implementation of the guideline. This is the way things could work if you gave healthcare professionals space and invested in scientific research. Many other similar examples can be given. No health insurance company played a role in any of them. Not only will it disappear from our healthcare system, but a portion of the costs we now pay to insurance companies could be better used for scientific research and good healthcare guidelines. This produces more.
A version of this article also appeared in the January 9, 2023 Journal
“Twitter junkie. Lifelong communicator. Award-winning analyst. Subtly charming internetaholic.”