The grass is not greener

A comparison of the regulation of the statutory healthcare package in Western Europe

SiRM investigated – on behalf of the Dutch Ministries of Finance and Health, Welfare and Sport – types of ‘restrictive’ statutory healthcare packages in Western European countries and their possibilities for sustainable healthcare expenditure. We conclude that no definitively ‘restrictive’ healthcare system exists and observed no correlation between ‘restrictiveness’ and lower curative-care spending.

In the government's response to the Scientific Council for Government Policy's (WRR's) 'Choosing sustainable care' report, the ministers for Health, Welfare and Sport (VWS) and Finance established a technical working group to examine options for optimising macro-level healthcare spending. Among other things, this working group is investigating whether more government control over the content of the basic statutory healthcare package by assessment-based inclusion of all new treatments and care types, can improve control of collective healthcare spending. Currently, aside from outpatient care, expensive inpatient medicines and physiotherapy, the Netherlands' predominantly non-restrictive basic healthcare package automatically includes new treatments and care types. The Ministry of VWS's Macroeconomic Issues and Labour Market Directorate (MEVA) directorate asked SiRM to examine restrictive healthcare systems operating in Western European countries and the concomitant possibilities for controlling macro healthcare expenditure, particularly curative care. Based on extensive desk research and 25 interviews with experts from the comparison countries, we conclude that 'the grass is not greener' in Belgium, Germany, England, France or Sweden than in the Netherlands.

First, a wholly and definitively 'restrictive' basic healthcare package does not exist. How and to what extent a healthcare package is 'restrictive' varies across countries and care types. Moreover, 'restrictiveness' may reflect a system's focus on removing existing treatment or care types from the basic healthcare package. A system that gives more attention to care reassessment to determine its continued inclusion or subsequent exclusion is de facto more 'restrictive'. Furthermore, the role of effectiveness assessments in determining the inclusion or exclusion of care types from the basic healthcare package differs between countries. In the Netherlands, the Dutch Health Care Institute’s effectiveness evaluations officially inform such decisions about inclusions and exclusions from the healthcare package. Thus, a care type that receives a negative assessment is removed from the basic healthcare package without the Ministry of Health’s intervention, giving the Health Care Institute considerable power compared to other countries and a more restrictive package than its open entry suggests. How much care is still available outside the basic healthcare package also varies. In France, population-wide complementary insurance reimburses care types not fully covered by the statutory healthcare package.

Second, more restrictive packages do not imply lower curative-care spending. Our results show no association between a country's reimbursement of 34 examined treatments/devices and its basic healthcare package's restrictiveness, with other countries generally reimbursing the same care types as the Netherlands. However, countries with more 'restrictive' systems reimburse care types not reimbursed in the Netherlands and often reimburse more care in practice than their coverage regulations indicate due to culture, politics or monitoring difficulties of individual care. Moreover, curative care expenditures in the Netherlands are the lowest among all the countries examined despite its relatively non-restrictive healthcare package.

Despite its non-restrictive package, current Dutch initiatives appear to be at the forefront of basic healthcare regulation. However, national price negotiations in France offer an interesting option, particularly for extramural medical devices. Whether or not this approach suits the Dutch context warrants further investigation.

Downloads and links

Written by