Rationing Health Care

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: G-politik in Industrieländern 1

Abstract

Based on the report released in 1991 by the Dunning Committee, the Dutch government adopted a rationing policy to relieve the financial burden of the social insurance system and to ensure necessary health care for all. The Committee also formulated some basic principles for health care delivery, which up to today serve as socially agreed and accepted criteria for rationing decisions.

Purpose of health policy or idea

Whereas health care reform in the Netherlands is closely connected with the Dekker Report (1987), the policymaking of rationing health care is linked to the Dunning Report (1991) and the reactions that it generated about its main policy proposals: assessing the basis package, admitting (new) technologies, stimulating appropriate use of health care and regulating the waiting lists.

Rationing health care is not related to one single government policy, it is distributed over these four policy domains.

Forced by the expected fiscal crisis of the national health care system new policies are recently proposed and developed on all these four approaches.

The main objectives and expected outcomes of these rationing policies are aimed at relieving the financial burden of the social insurance system, ensuring necessary health care for all (and preventing that in the end just a proportion of the population have access to all conceivable medical facilities). Basic in the approach is also the making of explicit and publicly accountable choices (as opposed to the traditional covert rationing decisions).

The most involved party, government itself, does in the end not have much more incentives for these policies than a firm legitimation and connected political support in society. As history learns this support is definitely not obvious, it should be deserved in painful processes without the guaranty that it will succeed. For the most involved parties in the field, i.e. service providers and health care insurers, there are not many (positive) incentives connected to these rationing policies, other than a perspective on more freedom of choice (insurers), financial support and stimulations to be innovative, professional and entrepreneurial. The party that is mostly affected by the rationing policies, the citizens/ patients, has to pay and will probably experience a growing personal (financial) freedom in their choices of health care, more efficiency and a better quality of services.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

From the mid-1960s onwards, limitations of medicine became clear. Moral objections against the unbridled expansion of medical technology. Slower economic growth in prosperity created funding problems. Hence, apart from quality and accessibility, macro-effectiveness became a third responsibility of government in health care. Rationing, distribution and pricing of health care were not without results. However, rationing resulted in a health care gap where provision lagged further behind rising demand.

Review of the regulatory system of health care was needed: Dekker-committee.

Dunning-committee: Priorities need to be set, scarcity in health care is inevitable. Dunning-committee added a further question: must everything that is possible in health care in fact be offered and, if so, to what extent must all this be publicly funded?

At least two domains of rationing policies are increasingly affected by international relations and regulations: the policies aimed at waiting lists and the admission of (new) technologies.

National policies to contain the supply of services with the acceptance of waiting lists are confronted with EU regulations for the free movement of persons and capital. Till now there is no clear national (nor international) policy reaction on these new dynamics.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The Dunning-committee outlined a framework involving four sieves or filters: necessary; effective, efficient, personal responsibility. Dunning Committee argued that interpretations of cases should be made from the community's point of view, the professional point of view and from the individual's point of view. The community interpretation of necessary care should predominate.

Dunning-committee added a further question: must everything that is possible in health care in fact be offered and, if so, to what extent must all this be publicly funded? Basic principles according to Dunning:

• Fairer to ensure necessary health care for all than all health care for just a small proportion of population
• Explicit and publicly accountable choices are better than covert rationing
• In setting priorities in health care, social values must be combined with professional and expert opinion as to what is valuable medical treatment and what is not.

Necessity: health is defined as the ability to function normally and a need for health care is related to a restriction in functioning.

Effectiveness: the degree in which a service is confirmed and documented as effective

Efficiency: the degree if cost-effectiveness of a service

Individual payment: the degree in which the service can be left to individual (financial) responsibility

The Dunning approach is characterized by: a frame of reference as a foundation for the application of the strategies and assumption of responsibilities derived from the system of managed competition; a mix of strategies to be used simultaneously at different levels of the health care system; a mix of responsibilities: national government for determining the basic package and introduction of medical technologies; health care providers and professionals to ensure appropriate use of the care in the basic package.

Stakeholder positions

Assessment of basic package

The initial strategy and the criteria to be used (Dunning's funnel) ran into severe criticism after the publication of the report. But matters did not end there.

Even before the Dunning Report was published a 'black list' was circulating in political circles in The Hague of services that should be deleted from the package. The latter did not however prove particularly successful; apart from the substantive criteria of the Dunning Committee, financial considerations (i.e. the need for spending cuts and the anticipated return of the measure in question) and political pressure (from political parties and interest groups) were major factors. Efforts to remove the pill from the package, for example, failed. The same applied to IVF, long-term psychotherapy, transportation by taxi, speech therapy and home-help after an ordinary confinement. But there were also successes. Medically unnecessary cosmetic surgery had already been deleted from the package before the publication of the Dunning Report. Homeopathic remedies, spectacles and lenses were dropped from the package in 1993. Pharmaceutical items followed in 1994 and in 1995 a number of ineffective drugs were deleted from the package. The first really radical excision took place in 1995, when dentistry for adults was dropped from the package. The dentists gave this their support, because they (rightly, as it turned out) anticipated that the demand for their services would not fall as a result. Long-term physiotherapy followed in 1996 and, in response to severe budgetary pressure, the provision of incontinence pads, colostomy bags and hearing aids were heavily rationed early 1999. In addition the Dunning Committee criteria were applied with some success to the admission of new drugs and other services.

It proved difficult but not impossible to eliminate existing services from the package with the aid of the Dunning Committee criteria. The most successful variant consisted not of eliminating the entire service but of curtailing it. The technical criteria (effectiveness, efficiency, affordability) have the upper hand. There is little support for a normative debate and value-based selection.

So, there is a basis for new initiatives, like the recent proposal (February 2003) of the ministries of Health and of Finances to remove a couple of services from the basic package (including the General Practitioners!) leading to a reduction of the collective burden of € 930 million in 2007.

Admitting new technologies and appropriate use

Dutch government has developed only limited control over the admission of new technologies. Little has so far come of international co-operation in this field. There is no question whatever of a technology policy along European lines. On the other hand, the government has embraced the assessments of existing medical technologies and the incorporation of the results into guidelines for medical treatment. This approach has become closely interwoven with the policy with respect to appropriate use.

The policy aimed at improving the efficiency of medical treatment has much in common with the strategy put forward by the Dunning Committee to promote appropriate use. This policy has proved successful with respect to the input of health service professionals, the development of guidelines and the use of those guidelines in practice. But, apart from a few noteworthy exceptions, the involvement of the other partners (care insurers, patients/clients) has been less pronounced.

In fact is the system for deciding on the use of new health technologies very loose. First of all, there is no central direction on which technologies are targeted for HTA. Dunning's first criteria, 'necessary care', did not lead to any obvious exclusions. There was the list of 126 of the Health Insurance Council, which is by itself just a list to which other organizations may or may not orient themselves, and which has itself been regrouped and renewed in different ways. The Health Insurance's Investigative Medicine Fund has in fact recently been taken over by Dutch Health Research and Development Council, which has several research and implementation programs running alongside of this one. In addition, there are many other local and national initiatives, funded through different routes, which do HTA studies or set up trials. The Health Council of the Netherlands (Gezondheidsraad), for example, issues HTA reports on a regular basis. With the Investigative Medicine Fund as a major source for funding and with policy makers being interested in the results, HTA has developed as a research field in the academic community (notably, all eight academic hospitals have by now some sort of HTA unit). The boundaries with fields such as medical decision making, clinical epidemiology, quality of care research, implementation research, public health research, health services research, the Dutch Cochrane Centre and the overall movement of evidence-based medicine, however, are blurred.

Waiting lists

The government managed to keep the thorny question of waiting lists off the political agenda for several years after the publication of the Dunning Committee Report. Although there were waiting lists, the fact that the waiting lists and waiting periods were not properly and uniformly recorded and that opinions as to the causes and consequences diverged meant that the scale of the problem could not be clearly determined. Two developments, however, served to spotlight the issue:

• services were offered on top of the compulsory package, open to private insurance or out-of-pocket payments;
• priority access was given for services in the compulsory package to a specific, eligible population, with extra funding.

The first development was a form of privatisation outside the mainstream circuit (i.e. paid through social insurance via earmarked payroll taxes), especially applied to nursing and home care and private outpatient clinics. These offer facilities outside mainstream health care for those able and willing to pay for it individually or via private insurance. This development has become a highly controversial one. Nevertheless privatisation is still continuing in this area. A system of private home nursing is arising which is used not just by the well-off but, notably, by mainstream health care in order to ease the pressures on the system.

A second development was a form of privatisation inside the social insurance package. A reform of the Dutch social insurance system in 1996 acted as the trigger, in that this reform placed the financial risk of long-term sickness absence with the employer. This gave employers a very real incentive to return their employees to good health. It then rapidly became clear that the waiting lists constituted an obstacle. In the case of psychiatric care - psychological disorders such as stress are responsible for roughly half of all sickness absence - the average waiting period in 1990 was for example 63 days, a period that had risen by 1998 to 87 days. A similar waiting period applied to the treatment of the other major cause of sickness absence, namely orthopaedic complaints.

This transfer gave employers a financial interest in effective and, in particular, swift health care. The incentive on the part of employers set in train a stream of initiatives to by-pass the waiting lists in mainstream health care. The most prominent of these have been the outpatient clinics, where the employees of a particular firm can receive swift treatment in return for payment and so can return to work quickly.

These initiatives on the part of businesses and hospitals to get round the waiting-list problem sparked off a fundamental political and public debate, in which the preferential treatment for employees (ahead of those not in employment) came in for criticism. Company outpatient departments, although still of negligible importance in practical terms, evolved into the leading symbol of the threatened bifurcation of Dutch health care. Fundamental values of equity and solidarity were seen as being at issue. And as had happened previously in the case of home care, the possible practical benefits were overruled by the threat of legislation banning hospitals from giving preferential treatment to employees.

In 1998 there was a provisional pause when the governing political parties and the health care organisations reached agreement on a plan of approach. This plan provided for a financial injection, a number of structural measures and agreement that employees were not to be given priority. Hospitals were to receive money to alleviate the worst bottlenecks, on condition that they submitted a properly worked out proposal and undertook to co-operate in the structural measures to reduce waiting lists. If they later fail to come up with results the money tap will be turned off. The structural measures, which are intended for the entire curative sector, consist of the uniform recording of waiting lists, clear-cut medical and urgency indicators, encouragement of co-operation between health care institutions, the rearrangement of care processes and longer working hours.

Influences in policy making and legislation

As argued above the processes are, again, highly incremental. So, there are no clear pieces of legislation that formalise these policies.

Adoption and implementation

See above policy paper and stakeholder positions.

Monitoring and evaluation

see above

Expected outcome

Setting priorities systematically by excluding services, as proposed by Dunning, posed severe political problems in the Netherlands. Hence, the government had to withdraw various proposals to exclude services from the insurance package. It has been easier to limit the extent to which the service is covered. Next to this, priority setting has been reached through guidelines that are developed by professional associations, based on evidence from research (clinical guidelines). Priority setting shifted towards the micro level, urging clinicians to use resources in a way that is consistent with the national framework set out by Dunning. Particular emphasis has been placed on the role of professional bodies and specialist associations in encouraging the use if cost-effectiveness of health technologies.

Neglected issue so far has been the role of patients in priority setting. Providing them with information about the risks as well as the benefits of treatments may moderate their demands for health care.

References

Author/s and/or contributors to this survey

Tom van der Grinten

Empfohlene Zitierweise für diesen Online-Artikel:

Tom van der Grinten. "Rationing Health Care". Health Policy Monitor, May 2003. Available at http://www.hpm.org/survey/nl/b1/2