Published On: Fri, Jan 27th, 2017

“Establish a purchasing agency today”

Wynand van de VenProfessor Van de Ven about National Health Insurance:

“Establish a purchasing agency today”

GREAT BAY – It could take another two to three years before the National Health Insurance is up and running but in the meantime the government can already take swift action to address one issue: the purchase of healthcare service and medication. That is the conclusion from our interview with Professor of Health Insurance Wynand van de Ven, who is on the island this week at the request of Public Health Minister Emil Lee.

Van de Ven addressed a closed door central committee of Parliament meeting on Tuesday and he spoke at a conference about national health insurance yesterday. Today interviewed the professor, who teaches at the Erasmus University in Rotterdam, during a break from a workshop he was giving at the University of St. Martin on Pond Island on Wednesday afternoon.

The first issue to look at is financial sustainability, Van de Ven says. “The system has to remain sustainable in the long term. A National Health Insurance must aim for efficiency, not only as a third-party payer (of medical bills) but also as a third party purchaser of medical care and medication.  The NHI must play an active role and sign contracts with providers. It has to negotiate not only about price and quality of care, but also about issues like customer friendliness and waiting times. This is a very important task for the NHI and I understood that this is new for the island.”

Another aspect that deserves proper attention is the choice between one or several insurers. The last option would bring competition into the mix, and it sounds therefore attractive.

“Unfortunately, I cannot advise this for St. Maarten,” Van de Ven says. “What stands out here is the small scale of the island. The Netherlands implemented a system in 2006 with several healthcare insurers. Clients can make a choice every year; if they are not satisfied they are free to go to another insurer. I have been a proponent of such a system for 35 years and I brought it up for the first time in the eighties. But for meaningful competition you need at least six insurers. The insurers in St. Maarten are third party payers – they pay medical bills but they do not purchase care. For that, you need scale and you need expertise. And expertise costs money.”

What then, would a National Health Insurance institute look like in St. Maarten? “The NHI can be an institute but it can also become the insurer itself. The solvability requirements that apply to private insurance companies do not apply to a public entity; the government can be its guarantor.”

Van de Ven notes that purchasing care is one of the most important functions of health care insurers in the Netherlands.

He repeats that securing financial sustainability is key: “To achieve that, the NHI must behave like an active purchaser of care. It has to sign contracts, also for overseas care; otherwise the sky is the limit. Currently there are no contracts for overseas care.”

Van de Ven emphasizes the importance of working together with surrounding small island nations to overcome the handicap of scale. “If you work together with others in the region that have similar problems your position becomes stronger. You are talking about a higher volume. This does not only apply to care, but also to medication. Against the monopoly of the pharmaceutical industry you have to create your own monopoly. Purchase medication together with other countries. The Netherlands has 17 million inhabitants, but it is doing the same, together with other European countries to get a better price for at times extremely expensive medication.”

Van de Ven advises the government to establish a purchasing agency as soon as possible. “Do it today,” he says. “Before you have set up the organization you are two to three years further down the road. It is a must that there is an effective third party purchaser. So begin with that.”

Another aspect of the NHI is the basic care package: what falls under the insurance and what does not? “To avoid financial disasters, I advise to begin with a limited package,” Van de Ven says. “You can always expand it. Taking something out of the package later on is much more difficult because that will trigger all kinds of protests. Put only cost-effective care in the package. Care you don’t really need should be stopped at the purchase-stage.”

Van de Ven refers to the situation in the Netherlands where dental care for adults and eye glasses are not part of the basic care package. Physiotherapy is only paid by the insurance for clients with specific chronic conditions.

In St. Maarten, 20 percent of adults are uninsured. During the workshop at the university on Wednesday someone remarked that the number of uninsured is therefore much higher, because the percentage does not include the children of these uninsured citizens. That detail is another reason for Van de Ven to advise a limited care package: “If that group gets access to healthcare, it will use the system much more than it does now.”

There is more to think about, Van de Ven says. “Think about a contribution from the insured to cover part of the costs. That is useful to prevent overconsumption and it is also important for the financial sustainability of the system.”

Van de Ven has one more lesson to share: “Do not reinvent the wheel. St. Maarten can learn so much from other countries. The Netherlands has a lot of expertise about the purchase of care. Look at Aruba; it also has a single insurance agency system but it has been around for fifteen years. They too have experience with purchasing care.”

Photo caption: Wynand van de Ven