Government keeps tight fists around health care budget in the Netherlands

The Netherlands needs more doctors and more money to address the backlog of patients waiting for surgery.

In order to control the amount of money spent on health care, the government in the Netherlands has prearranged a set number of medical specialists permitted to practice in the country. Health care providers worry that not increasing the number of doctors to match the growing rate of the population will result in detrimental effects on the way health care procedures are performed and will limit access to health care. Long waiting lists for needed procedures are already a problem here, with some cataract patients having to wait up to a year for surgery.

Shortage of providers

A chief issue currently affecting the Netherlands is that a serious shortage of health care professionals, nurses included, is likely to occur. A number of socioeconomic developments, some of them reaching back 30 years, are having a serious effect on health care now and will continue to do so in the not-too-distant future.

According to Peter J. Ringens, MD, PhD, a retinal surgeon and president of the Dutch Ophthalmological Society, starting in the early 1970s the number of medical students enrolled in medical schools in the Netherlands was limited. This policy has continued. “As a consequence, the number of possible candidates for family medicine or for medical specialties has decreased seriously,” Dr. Ringens told Ocular Surgery News. “And because of a lack of trainees in medicine, the number of possible candidates for ophthalmology is much lower.”

In the early 1990s, according to Dr. Ringens, it was decided that in order to control the growth of spending in health care, the number of available positions for medical specialists would be fixed. This was achieved by freezing the budget for each specialty. This meant for ophthalmology that the annual budget for the 450 practicing ophthalmologists would be US$50 million.

“Health care in the Netherlands is suffering from stringent budgets and a tremendous bureaucracy,” Prof. August F. Deutman, MD, a medical retina and vitreoretinal surgeon, told Ocular Surgery News. “An ophthalmologist can only do the exact amount of consultations and surgeries he did the previous year since budgets usually stay the same. Our income is fixed.”

Increased demand

Now more than ever there is a high demand for medical providers, due in part to the growth of the population and changes in the country’s demographics. However, the budget has not been adjusted to sufficiently accommodate these changes. Even after the Dutch Ophthalmological Society pointed out back in 1991 that there would be shortage problems by the late 1990s, there was no expansion of the number of positions for ophthalmologists.

“As a consequence of the increase in demand within the same budget, the amount of work increased and the reimbursement decreased proportionally for the practicing ophthalmologist,” Dr. Ringens said. “This again has led to the point where ophthalmology has become a specialty with little status. Medical students feel that they should not choose ophthalmology because they need to work too hard.”

In Dr. Ringens’ department, with 18 ophthalmologists plus 10 residents, approximately 140,000 patients are seen in the outpatient clinic. The physicians perform 10,000 surgeries, 5,000 of which are cataract procedures, on an annual basis.

In recent years, burnout has increased enormously amongst health care professionals, Dr. Ringens said.

It is not only ophthalmology that has lost its appeal, according to Dr. Ringens. This is true for all specialties as students now predominantly opt for legal or economic professions. In the future, 65 medical professionals will be produced out of 100 enrolled medical students, he predicted.

The major health care issue in the near future is that access to care will become more and more difficult. There will be an ever-increasing problem finding a doctor. The problem for doctors is it will mean that they will not be able to face the growing demand for health care.

Waiting lists

There is also a major shortage of registered nurses. This has led to many surgical sessions canceled by hospitals, despite the enormous demand and long waiting lists. Waiting lists are a common phenomenon, according to Dr. Ringens and Prof. Deutman, and they rank high among the priorities of political debates. At the end of 2000, there were regions in the Netherlands where the waiting period for cataract surgery had increased to 10 or 12 months. Even a consultation with an ophthalmologist has a waiting period of up to 6 months.

“There are long waiting lists for certain procedures, depending on the area of the country,” Prof. Deutman said. “In some places there are waiting lists of more than a year for cataract or elective surgery.”

The government has been made aware of the increasing problem, and large amounts of money have been reserved to handle waiting lists. However, these are temporary solutions, Dr. Ringens said.

“These are temporary solutions, but we need to search for infrastructural improvements, which will not be easy to find,” Dr. Ringens said. “We do not believe that we will be able to change the popularity of a career in medicine within a couple of years. Also, medical schools now have permission to train 200 additional medical students, but universities have already indicated that this is not an easy task for them, since their infrastructure has dwindled since the early 1970s.”

Reimbursement and insurance

In the Netherlands, it is mandatory that every citizen should be covered for health care. About 65% of the population is covered by a number of health care insurance policies either through their employers or through the state. The remaining 35% pays for its own insurance. This difference between the groups is roughly based on the annual income.

All insurance companies cover necessary care. The total budget for this type of care is US$29.15 billion. Apart from this there is elective care, which is not covered by regular insurance policies, such as cosmetic or refractive surgery.

Because this type of care, which patients pay for themselves, is not budgeted and reimbursements can be decided by professionals, it is not unrealistic to assume that more and more professionals are going to invest less time in necessary health care, such as cataract surgery, Dr. Ringens said.

According to Prof. Deutman, since the health care budgets are inadequately funded, it is next to impossible to start using new therapy modalities, and innovative medical equipment is difficult to obtain.

Cataract surgery is covered by all insurance policies in the Netherlands; therefore, the patient doesn’t incur any immediate costs other than insurance fees. Without insurance, a cataract procedure costs approximately US$2,000, 5% of which, or about US$125, is the doctor’s fee. This percentage is similar for other procedures such as retinal detachments, vitrectomy or glaucoma surgery. For a vitrectomy an individual is charged US$3,500, of which the doctor’s fee is US$190. Because of the strict budget system, it is not possible for surgeons to request a higher fee for care covered by regular insurance. These figures can be different depending on the place where the procedure is performed.

In the Netherlands about 80,000 cataract extractions are performed per year. There are roughly 450 ophthalmologists for 16 million people.

Refractive surgery

Refractive surgery has become increasingly popular in the Netherlands, Dr. Ringens said. Waiting time for these procedures is up to 6 months. Patients pay between US$1,500 and US$2,100 per eye for excimer laser surgery. LASIK costs between US$1,700 and US$2,100 per eye. Implantation of an Artisan lens costs the same as LASIK. The doctor’s fee is US$300 for an excimer laser procedure and US$700 for all other refractive surgery procedures.

For Your Information:

• Prof. August F. Deutman, MD, can be reached at Radboud west, Philips van Leydenlaan 15, Postbus 9101, 6500 HB Nijmegen, Netherlands; +(31) 024 3613138; fax: +(31) 02403540522;
• Peter J. Ringens, MD, PhD, can be reached at Eye Hospital, Schiedamse Vest 180, Rotterdam, 3011, BH, Netherlands; +(31) 10-401-7777; +(31) 10-213-1352