Reviews | Care does not need insurers for quality

In the discussion of the impending unaffordability and shutdown of our healthcare system, Marjolein Smidt and Mathieu Weggeman suggested the idea of ​​removing insurers from our healthcare system (“Getting insurers out of the health system”, 8/12). They could be replaced by a National Office for the Administration of Care and thus reduce the heavy administrative burden for care providers, while saving a lot of money. An interesting and provocative vision that deserves at least reflection.

The reaction of Wouter Bos on behalf of the health insurer Menzis (“It’s the policy that determines how much money goes to health care, not the insurer”, 12/14), however, was mandatory and meaningless. His point of view: politicians determine how much money goes to health care and the insurer ensures that more quality can be achieved for every euro spent.

This is where the first shoe pinches right away. Most healthcare providers often have no idea what quality insurers are talking about and how insurers’ actions are improving that quality. Smidt and Weggeman argue for a change in the system where professionals are in the driver’s seat again.

And this is where the second shoe pinches, because medical specialists and other health professionals are generally confronted with institutionalized mistrust in the debate on the costs and quality of care. The “inappropriate” or “irrational” care that would be provided (Nederlandse ZorgInstituut), the “susceptibility to perverse production incentives” (Nederlandse Zorgautoriteit), the specialists that should therefore be employed (politicians).

Mistrust

Medical specialists find it difficult to defend themselves against this mistrust. The idea that most healthcare professionals simply want to provide the best care possible is rarely taken for granted. However, many examples prove the opposite. Take, for example, the treatment of uterine prolapse by Dutch gynecologists. This treatment may consist of surgery or fitting a diaphragm, also called conservative treatment. It goes without saying that surgical treatment is more expensive than conservative treatment.

Not all prolapses can be treated conservatively, not all operations are effective. In 2010, research was carried out for the first time on how Dutch gynecologists treat uterine prolapse. There seemed to be a large intervariation that could not be explained by differences in the patient population. This is called practice variation in medical science and is usually a sign of substandard quality. There were hospitals where many more operations were performed than average and the type of operation could also vary. At the other end of the spectrum, there were hospitals where very few operations took place. There was insufficient processing there, another sign of substandard quality. The same variation in practice was seen between university hospitals, where specialists are still employed.

Simple declaration

Insurers and gynecologists had no idea of ​​the right balance between the two treatments: which patients benefit from surgery and which should be treated conservatively?

Recent research, to which I have contributed, shows that Dutch gynecologists have started to treat in a much more similar way in recent years. The same type of operation is also chosen much more often and the absolute number of operations has decreased over 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 true that all gynecologists suddenly started working as employees or that insurers set different quality requirements. The most obvious explanation is simple, namely the publication of a new recommendation, in 2014, for the treatment of prolapse. This guideline includes the results of a large number of (Dutch) studies on the results of different treatments.

The working group of pelvic floor gynecologists ensured the national implementation of the recommendation. This is how things can happen if you give space to medical professionals and invest in scientific research. Many other similar examples can be given. No health insurer played a role in any of them. Not only will they disappear from our healthcare system, but some of the costs we currently pay to insurers could be better spent on scientific research and good healthcare guidelines. It pays more.