The dreaded ‘care infarction’ has already arrived. Who will be affected? That’s a matter of chance

Health care is ‘finished’, there is no longer any room for improvement. 120,000 Dutch people are waiting longer than usual for an operation, according to the NZa regulator. There are 80,000 health care workers too few. Emergency departments sometimes close their doors a few times a day because they are full.

Nurses, carers, general practitioners, specialists, psychologists – many healthcare workers walk on their gums. The demand for their services is endless, so are the obligations and workload. Some call in sick, some can be hired (on their own terms) as a self-employed person, and some leave the care altogether. The rest have to work harder as a result.

The ‘care infarction’ that has been warned about for years is not imminent – ​​it is already here. Who will be affected by it is a matter of chance. For example, you live in a village where there is no longer a GP. The nursing home nearby may not have room. Your ambulance has left with sirens blaring, but has to wait an hour in front of the hospital door.

A year ago, the Scientific Council for Government Policy warned that ‘scarcity’ in healthcare was imminent. Politicians, wrote the Council, must quickly prepare citizens for the need to make choices. Informal care – from family and friends – will no longer be the exception, but will be the norm.

But politicians made no choices. She does not dare to deliver that hard message, a Tilburg hospital director complained Fidelity. Because when it comes to hard choices in healthcare, there is an immediate uproar. Seriously ill patients are allowed to join talk shows when the ministry spends a long time negotiating the price of a new, expensive drug. Or there is commotion when another emergency post closes, such as when council members from Lelystad considered blocking the A6 because of the imminent closure of the emergency department in the city.

The fact that no action is being taken despite all the warnings was reason for the Dutch Healthcare Authority (NZa) and the Health and Youth Care Inspectorate to make an urgent appeal to The Hague in October: Public Health must prepare the public for a painful new reality – too little care. And the ministry must quickly make policy to help doctors and nurses in times of scarcity.

The big question is: what care do you provide and especially not in situations of sudden shortage? The point at which doctors have to choose is “much closer[bij] than many people think”, according to the NZa.

This month, a large insurer dared to say the same. Eliminating waiting lists is no longer possible and the limits of the healthcare system have been reached, chairman Joep de Groot said The Telegraph.

“I cannot guarantee that healthcare will always be accessible to everyone. In fact, I think I can almost guarantee that it is not the case.”

How did it come to this?

The problems in healthcare have been dormant for a long time. Due to population growth and aging, there are more patients. Personnel shortages are persistent: many recent graduates – discouraged by work pressure and changing shifts – quickly leave the healthcare sector. And the increased medical possibilities are great, but as a result people live longer, often as chronic patients.

The patient also presents himself as a consumer much more often than before. He wants another conversation, another check-up, would like a second opinion. The patient who is on average heavier and older than before. Who wants and can get new joints.

Experts have been saying it for years – the system would crash. In the end, the coronavirus pushed hospitals under water. And now the care sector is no longer able to make up for the major arrears.

A market?

It is tempting to blame ‘the market’ for all the problems. After all: in 2006 the health insurance funds disappeared and ‘market forces’ were introduced. But healthcare did not become a market; it would have been if patients chose and paid for their own treatment – ​​like a car. And if doctors only sold cost-effective treatments to patients who could afford them.

That is not true. The Netherlands has a system of solidarity: everyone receives everything that is available and necessary for the treatment of their illness. Operations in the hospital, chemotherapy and radiation for cancer, general practitioner care, birth care, check-ups, ambulance transport, emergency care and diagnostics, an ICU bed if you are on the verge of death.

In the Netherlands, healthy people pay compulsory taxes and premiums for unhealthy people. You don’t have to sell your house, like in the United States, if you have to undergo expensive medical treatment.

Efficiency and distrust

And yet. Because the system is so solidary and everyone is entitled to everything, health insurers must constantly monitor costs. That’s their job. Their problem, in turn, is that they do not trust hospitals and doctors to always prescribe and declare appropriately. The insurers assume a certain nonchalance, because patient and doctor together spend other people’s money. The whole system is based on distrust.

So more than a decade ago, insurers started imposing ‘budget caps’ on healthcare providers: one pot of money for the whole year. The following often applies: the most efficient hospitals and other institutions receive a larger sum and are therefore allowed to treat more patients per year than the least efficient. At one hospital the ceiling was already reached in July, at the other only at the end of December. This is how you send masses of patients to the cheapest hospitals.

Because hospitals compete with each other, if they have waiting lists, they are not inclined to refer the patient to another hospital. Patients are sales.

Due to the pressure of the insurer, hospitals do have a strong incentive to deal efficiently with the patient. That usually happens. The patient is sent home very quickly after major surgery. Only if there is no one there to take care of him or her – a partner, child, home care – can the patient stay in the expensive hospital bed for a while. The costs are staggering: 24 hours in a normal hospital bed costs an average of 1,000 euros. Sometimes the patient is there a day too long, sometimes a week, sometimes even longer.

Meanwhile, insurers require doctors, nurses, and paramedics to write down just about every act; from injection to infusion, from follow-up to order. Because imagine if they declared something superfluous or too expensive. That administration costs a lot of time, irritation – and also money.

Guidelines

Then there are the guidelines. These are drawn up by the scientific associations for each specialism, based on the latest medical insights. They are recommendations, not laws. But if you, as a doctor, adhere to the guideline, you will not have any hassle afterwards with your boss, the Inspectorate, the health insurer or, worst of all, the disciplinary tribunal.

The guidelines are packed with medical caution: any risk must be ruled out. Having someone come for follow-up after an operation for years, before you-know-but-never, even if it has long been clear that the patient is doing well. A brain scan for anyone who falls hard on their head; whether they are 28 years old or 88, fell off their bicycle or down the stairs. One ICU nurse on one and a half ICU beds and not on two, let alone three ICU patients – because that could turn out to be risky. The schedule of the operating room must perfectly match that of the anaesthetists, the nurses, the recovery room, the ward – otherwise it will not work. Because there would only be one person somewhere too few.

And there are plenty of ‘perverse incentives’. Physiotherapy is not always reimbursed because the result is difficult to measure. Patients with shop window legs (narrowed blood vessels that cause a lot of pain) often prefer quick vascular surgery to weeks of exercise and physiotherapy.

Doesn’t anyone pull the brakes? Yes. The Dutch Healthcare Authority and sometimes a brave doctor. Like oncologist/epidemiologist Gabe Sonke, who explained in his inaugural lecture in Amsterdam at the end of September that all cancer drugs of the past decades had mainly benefited the pharmaceutical companies and much less the cancer patient. “Over the past ten years, the five-year survival rate for cancer patients has increased by 8 percent. But the costs of expensive medicines have increased tenfold in the same period to almost 3 billion euros per year,” he concluded.

Choices

What is the answer? Make choices. The scientific societies will have to choose which treatments can be shorter or less expensive.

At an individual level, doctors and patients will have to opt for ‘appropriate care’. A treatment is then only prescribed (or undergone) if it really adds something. So: do not continue to treat the elderly unnecessarily, do not let people come by if it is also possible by telephone, do not prescribe medicines that have little effect. And tell people clearly that if they want to prevent a heart attack, they better stop smoking than asking for a pill.

A comment from a urologist still echoes in the head of Marian Kaljouw, the head of the NZa. She recently spoke to him at a conference and asked: “How many people do you see in the outpatient clinic, physically, where you think: there was no need for that?” He replied, “50 percent.”

According to Kaljouw, some people go to their GP up to thirty times because of underlying problems such as stress or a bad lifestyle. Finally, they are sent to the hospital. Especially in the elderly, something is usually found. “Before you know it, someone is being treated for something that never bothered them.”

Shout ‘appropriate care’ – and everyone in the industry starts nodding. It’s been for years buzzword – and in the years before the slogan ‘sensible care’ was in vogue. But they find it difficult to really push through. In 2020, the Court of Audit issued a punitive judgment on the Zinnige Zorg program of the Zorginstituut, which advises the minister on which reimbursed care should be included in the basic insurance. It would provide advice on ‘inappropriate’ care, and the promise was that this would save hundreds of millions annually. But in reality, the institute was “not helping to control health care spending.” It did give advice, but doctors reacted critically and hardly put it into practice. The Zorginstituut had no strategy to force changes.

The NZa itself is not free either. This institute is about the level of the reimbursements and not all incentives work well. An operation generates a lot of money for the hospital, while preventive advice about a good lifestyle hardly anything.

According to Kaljouw, healthcare is now facing a revolution that is greater than the abolition of the health insurance funds. “It is a complete change in thinking. We will have to say to people: what you can do yourself, you will have to do yourself. What the people in your network can do, they will have to do. That leaves one group for which we have to formulate an answer. It’s going to be that scarce. It’s going to be that hard.”

Correction 30-11: An earlier version of this article stated that physiotherapy is not reimbursed for patients with shop window legs. That is incorrect. Since 2018, 37 physiotherapy treatments, with supervised gait therapy, are reimbursed for those patients. We regret this mistake.