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In Netherlands, Insurers Compete Over Quality of Care

October 6, 2009 at 12:00 AM EST
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In the first of a series on health care abroad, Ray Suarez looks at how the Netherlands achieved a massive health care overhaul four years ago.
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JIM LEHRER: Next tonight, our global health unit begins a series of reports on the ways other countries are delivering health care. Ray Suarez has the first of two stories on the Netherlands, where the government recently shook up health care.

RAY SUAREZ: Every September, Queen Beatrix of the Netherlands travels in a gilded coach from her palace to the Dutch parliament a few blocks away. The streets of the capital are packed with her subjects, dressed to honor the country’s royal House of Orange.

By world standards, the Dutch are wealthy and healthy, but the country’s changing. With each year, it’s home to more Dutch elderly and more young immigrants from the developing world.

The queen opened a parliament once again wrestling over health care, still trying to contain costs after a massive overhaul designed four years ago.

Abraham Klink is the Dutch minister of health.

DR. ABRAHAM KLINK, minister of health, Netherlands: Health care had to be accessible and affordable to everyone, but on the other hand, there had to be competition. What we did the last years is to make — to create an infrastructure in which the insurance companies can make a difference and make a difference on the side of quality and the side of prices.

RAY SUAREZ: What the Netherlands did is require everyone to buy health insurance and hand over what was a system of public-private health care coverage to private insurance companies.

When the Netherlands redesigned its national health care system in 2006, there were three main goals: continue universal coverage, unleash competition between private insurers, and keep down costs for the long run.

Every citizen is required to buy a basic package that typically costs about $160 a month. The insurance companies are required to offer the same prices to all customers, regardless of age or medical history. Low-income residents have their premiums subsidized. Health care shoppers can choose to pay more for coverage, for things like dentistry, cosmetic surgery, or physiotherapy.

RINA NOPPEN: You always can choose for a basic health care, and one star, two star, three stars, four stars. If you choose for four stars, everything is…

RAY SUAREZ: Covered?

RINA NOPPEN: Everything’s covered.

No discrimination

Roger Van Boxtel
CEO, Menzis
There can be no discrimination if you're ill or old or young. We have to accept everybody. And I think that is one of the big differences with the United States. We have a level playing field, and we have to compete.

RAY SUAREZ: The government challenged the insurance business. The thinking goes, since they can no longer compete on price, the companies will have to fight to keep customers based on the quality of care. Roger van Boxtel is CEO for Menzis, one of the Netherlands' biggest insurers.

ROGER VAN BOXTEL: There can be no discrimination if you're ill or old or young. We have to accept everybody. And I think that is one of the big differences with the United States. We have a level playing field, and we have to compete. We have to do our best to have good prevention programs, to innovate, and to buy health care with the providers, the GPs, the hospitals, the physical therapists. We make contracts with them every year, and we're seeking for the highest quality and the most efficient price.

RAY SUAREZ: In fact, Menzis now offers a ranking on top hospitals and doctors for its customers, which is exactly what the government was hoping for.

DR. ABRAHAM KLINK: I see so many people who want to know that, if they have to go to the hospitals, for example, for heart diseases or heart failure, they want to know what quality is. And only those people, which are in the inner crowd of the hospitals or the policy making, they know what the quality differences are. And what I want them to know, all the people, I mean, is what hospital is the best and which general practitioner is best.

RAY SUAREZ: Since expensive-to-treat patients can't be turned away by insurance companies, what if one company ends up with way more diabetics, cancer patients, Alzheimer's suffers? The government runs what's called a "risk equalization fund," which reimburses insurance companies for each high-risk patient it takes on.

Anne-Marie Bigby is one such patient. In May, Bigby was diagnosed with breast cancer. She had recently switched her insurance to the cheapest basic coverage package. Still, she says, her treatments have been fully paid for and began as soon as she discovered a problem.

ANNE MARIE BIGBY: The total span of when I discovered the lump, went to my G.P. on Monday. I was in here on Thursday. And within, I think, 7 to 10 days from that, I was receiving my first chemo.

Americans seek refuge abroad

Barry Van Driel
We were extremely worried about money and our finances in the United States, and that created a lot of stress. I don't have that concern anymore. There are other concerns, but not that.

RAY SUAREZ: So far, Bigby is pleased with her coverage, but if for some reason she decides to switch companies, no insurance companies could turn her down or charge her extra for her illness.

Coverage for expensive therapies is so attractive, it's lured some to take up residence in the Netherlands. Five-year-old Tilo van Driel's parents moved from the United States. Tilo has autism.

Like most with the disorder, Tilo has trouble communicating with others. His ongoing, lifelong therapies are extremely expensive. Here, at the autism center in the Hague, Tilo is taught to better react to his environment.

DORRIT ONTROP, Centrum Autisme: It's best to have a very intensive program for these children. Most of the time, they get, like, an hour or two hours in a week treatment at the center, but we also focus on teaching parents how they can practice skills with their children, so they can do that in daily life.

RAY SUAREZ: Tilo's parents, Barry and Fiona, moved to the Netherlands so they could afford Tilo's care. Barry is Dutch; Fiona is American. The couple was living in the United States when they began to suspect Tilo was autistic.

BARRY VAN DRIEL: We didn't feel we had a choice. We felt we had our backs against the wall financially. We felt that we did have some money in savings, but not very much, and we felt that we were one treatment away from being bankrupt there.

We were extremely worried about money and our finances in the United States, and that created a lot of stress. I don't have that concern anymore. There are other concerns, but not that.

RAY SUAREZ: Because they have dual citizenship, the family qualified for coverage. Not only are Tilo's intensive therapies covered, the family also gets support at home and cash for babysitters.

FIONA PASSANTINO: We basically have this personal budget, which would cover up to 8 hours a week of somebody coming into the house and helping us out with day-to-day things, getting him dressed, getting him, you know, on the potty, helping watch him while we take care of business and so on, and then we can go out, and we can go out for overnights, and that's all covered by the government, essentially.

New system breeds bureaucracy

Dr. Else Borst
Dutch Cancer Federation
From the patient's point of view, you're always in a hurry. If there is a new treatment for breast cancer, you want it tomorrow for all breast cancer patients in this country, and not within half a year.

RAY SUAREZ: The architect of Netherlands' new health care system, former Health Minister Dr. Elsa Borst, says she's pleased with the way the new system has unfolded, but she has some concerns. She's now head of the Dutch Cancer Patients Federation.

Borst worries about whether Dutch patients are quickly getting the latest cancer drugs. New treatments have to be approved by the government not only as good medicine, but as cost-effective treatment.

DR. ELSE BORST: It's just that there is such a lot of big bureaucracy always, because drugs only are reimbursed in our new health care insurance system when they have been proved to be effective and also cost-effective.

And, well, there are some people looking at that and they take their time. And from the patient's point of view, you're always in a hurry. If there is a new treatment for breast cancer, you want it tomorrow for all breast cancer patients in this country, and not within half a year.

RAY SUAREZ: Even with universal coverage, the Netherlands spends less than half what the United States spends per person on health care. While spending half the money, the Netherlands gets better results. The Dutch have longer life expectancy and lower infant mortality. The average Dutch citizen spends about 7 percent of income on health care, and they seem satisfied with the system. The annual Euro Health Consumer Index puts the Netherlands in first place in a survey of patient satisfaction across Europe.

JIM LEHRER: Ray's next report looks at efforts to contain health care costs in the Netherlands. There's also a comparison of health care systems in five countries -- the Netherlands, but also Japan, Canada, Mexico, and the United States -- on our Web site, newshour.pbs.org.