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The health care system of the Netherlands is based on the Bismarckian model introduced almost 100 years ago of universal coverage through compulsory social insurance. Unusual for Europe, however, almost 75% of Dutch hospitals are private, not-for-profit establishments run by the Protestant or Catholic churches, and almost all primary care physicians also are independent.In a further departure from the European norm, the health care insurance system in the Netherlands also is mixed. Two-thirds of the population are compulsarily enrolled in one of the country's health care insurance funds, while the remaining third with incomes over a preset level are insured privately. As a further complication, the whole population also is covered by insurance for long-term "catastrophic" care.

Over the past 15 years, the Netherlands has been one of the international leaders in efforts to introduce "managed competition" into health care. Patients can change between insurers and/or health care funds once a year, and insurance organizations are not permitted to limit exposure to bad risks by turning anybody down. Insurers are encouraged to contract with physicians and hospitals of their choice. The idea was that there should be enough competition between both insurers and health care providers to gradually change the entire system from being supply-driven and subject to central cost control into a system that would be demand-led and driven by patient choice — but still able to provide universal coverage at comparatively low prices.

So what has been the result? The Netherlands has achieved enviable results in terms of quality of care and health outcomes, even though it spends less proportionally than France or Germany in Europe or the U.S. But continuing tight cost controls by the Dutch finance ministry, combined with shortages of physicians, has contributed to both substantial waiting lists and unsatisfied demand. Spending on health care as a proportion of GDP has fallen slightly to around 8% in recent years, and is regarded by many as too low.

The original Dekker commission report of 1978, which proposed greater reliance on market forces rather than central regulation and cost control, has been implemented only in part. In particular, central regulation has been retained and even increased. Plans to abolish the distinction between health care funds and private insurers, allowing everyone to make their own choice among all insurers, to relax central control and to permit competition between hospitals and physicians alike, are ready for implementation, but currently on hold following the recent Dutch parliamentary elections, which will mean significant changes in the representation of various political parties in the new coalition government.

One point of controversy, for example, is that the Labor party wants the premium paid to health insurers to be income-related, to help the poor. But that would negate an essential component of competition, on price. It might be better to help lower income groups through the tax system rather than by interfering with the health care market.

If the Dutch reforms are pursued with enough vigor, said Professor Wynand van der Ven of Erasmus University in Rotterdam, the Netherlands might get closer than any other country has to solving the world's big health care conundrum: How to improve service delivery and provide universal coverage, while using the market rather than the government to hold down total health care spending.

Nordic health care needs more money too

The Norwegian health care sector can be characterized as being high quality, providing universal care and with well-qualified professionals. In order to keep step with increasing demands, $2.6 billion has been spent in the primary and elderly-care sectors over the past four years. The hospital sector is currently undergoing major reforms that involve a change to governmental ownership for all hospitals, including those previously operated by not-for-profit charities.

Hospitals are now organized into five regional public enterprises, with the hospitals being independent subsidiaries. Investment in new hospitals and renovation of older ones is planned over the next 10 years under a budget of $6 billion.

Because of long distances and scattered populations, especially in the north, telemedicine already is widespread in Norway. The Norwegian Center for Telemedicine at University Hospital (Tromso, Norway) provides telemedicine services throughout the Artic region of the country with a staff of 80.

In Denmark, increasing shortages of qualified health care professionals are causing concern. A task force has been appointed by the government to assess current and future trends in the demand for manpower in the health care/medical device sectors, and the findings will be used to form the government's education policy.

The Copenhagen County Authority, which controls all hospitals in and around Copenhagen, has allocated approximately $7 million for the acquisition of new equipment for its hospitals. In particular a decision has been taken to switch over to digital X-ray to allow electronic storage of images and their transmission between hospitals and departments.

A recent report from the Danish Ministry of Health shows that there has been only a modest uptake in the use of telemedicine in Danish hospitals and that they had only given limited consideration to the potential changes in procedures planning that it will allow. Hospitals have focused on the opportunities offered for better treatment, rather than on possibilities of effecting economies by reducing patient transportation and by utilizing physicians more effectively.

New German laws change reimbursements

The latest amended version to the diagnosis-related groups (DRG) law on reimbursement sets a fixed level of reimbursement for each medical procedure and introduces an obligatory regulation for reimbursing innovative technologies. Under the new amendments, the hospital and the health insurance fund (Krankenkasse) now will be obliged to agree to DRG reimbursement rates for any innovative examination or treatment method. In the case of inability to agree, an arbitration board can be invoked.

Stricter regulations for reprocessing single-use devices came into force at the beginning of this year with the second amendment of the German Medical Devices Act. The act also deregulates medical device advertising and opens the way for using qualified recommendations and patients' testimonies, as well as simplifying the provision of patient-oriented information via the Internet. The German medical device industry association, BVMed (Berlin, Germany), is pushing for much stronger monitoring of hospitals and other device reprocessors in the future.

More financial problems in Japan

Reform of Japan's health care system, with annual costs of around $235 billion, is urgently needed. With Japan's prolonged recession, income from health insurance premiums has stagnated while benefits and costs have continued to rise. The government-managed health insurance system is expected to use up its reserves by the middle of this year.

To prevent this from happening, the health ministry has proposed to raise patients' costs and to increase insurance premiums, but the plan faces opposition not only from entrenched interests in both the LDP governing party and the health ministry itself, but also those concerned that a rise in health care costs and insurance and insurance premium rates under the current economic situation, is equivalent to raising taxes.

The argument centers on a plan to raise the share of medical costs paid by salaried workers from 20% to 30%. Family members already pay the 30% level. The Japanese prime minister, Junchiro Koizumi, wants the increase to come into effect in April 2003, but there is strong opposition from the medical affairs committee of the LDP, whose members fear that a rise in medical costs would put further strain on the Japanese health industry.

Philips and Siemens launch new C-arms

The LithoDiagnost ME urology and lithotripsy system from Philips Medical Systems (Eindhoven, the Netherlands) has been improved, with an enhanced image quality and DICOM compatibility using the BV Endura and BVPulsera C-arms. Using improved imaging, stones can be located more precisely and speedily, the company says, and the NewTrode Twin shockwave electrode has double the usage life of the previous model.

Siemens Medical Solutions (Erlangen, Germany) has launched its new Axiom Artis MP multi-purpose digital C-arm system, which allows direct viewing of both CT and MR images on the Multi-Modality Display.

Shaped-beam surgery for tumors

BrainLab (Munich, Germany) has developed the Novalis shaped-beam surgery system, which expands the capabilities of intensity modulated radiation therapy (IMRT) with highly accurate patient positioning so that radiosurgery can be used in sensitive locations such as neck, spine and liver, where there are other critical structures near the tumor.

The Novalis system includes radiation planning and delivery software and a modified micromultileaf linear accelerator. Since this system needs no incision, complications should be minimized, with the procedure taking only 30 minutes on an ambulatory surgery basis, with the patient returning home the same day.

One of the first U.S, sites offering the Novalis system is the M.D. Anderson Cancer Center (Houston, Texas) where Dr. Wayne Jenkins, radiation oncologist and medical director, said, "a shaped beam is the highest degree of precision, so we know we're reaching every part of the tumor from every angle. As the tumor changes shape and size during treatment, so does the treatment beam."

Asthma inhaler developments

A problem with many conventional asthma inhalation devices is that only a fraction of the inhaled medication reaches the lower airways where it can have a therapeutic effect. This is largely due to particle size, with monodisperse 2.8 bronchodilator particles being optimal in terms of efficacy.

Researchers at the Delft University of Technology (Delft, the Netherlands) and University Hospital Utrecht (Utrecht, the Netherlands) have developed a new technique called electrohydrodynamic atomization to produce monodisperse droplets of a defined size in the micrometer range. They claim that the use of an aerosol generator employing electrical fields instead of compressed air could lead to a revolution in inhalation therapy.

GlaxoSmithKline (London) has developed an alternative tochlorofluorocarbon (CFC) as the propellant gas in asthma inhalation aerosol medication. CFCs have been banned in developed countries since 1996, but use in inhaled treatments for asthma has been excluded from the ban. The new propellant is hydrofluoroalkane and is used by GlaxoSmithKline in association with Ventolin (albuterol sulfate) in an inhalation aerosol device as a short-acting bronchodilator which relieves sudden symptoms associated with bronchoconstriction during asthma attacks.

Profile Therapeutics (Bognor Regis, UK) and Omron (Tokyo) are collaborating to develop a miniature "intelligent" inhaler system. The project aims to develop an inhaler combining Omron's proprietary electronic mesh-based aerosolization technology with Profile Therapeutics' Adaptive Aerosol Delivery technology, which provides controlled dosing into patients breathing patterns. Under the terms of the deal, Omron will manufacture and supply the miniature Inhalers for exclusive commercialization by Profile Therapeutics.

Post-operative scarring in glaucoma

Cambridge Antibody Technology (CAT; Cambridge, UK) has successfully completed Phase II trials on the use of its CAT-152 lerdelimumab human monoclonal antibody in patients undergoing surgery for glaucoma and cataract. CAT-152 has been developed to help prevent excessive scarring, which is a major reason why glaucoma surgery can fail to lower intraocular pressure in the long term.

Intraocular pressure (IOP) was successfully lowered by surgery in both patient groups, receiving CAT-152 or a matching placebo, but six months later, the achieved IOP was lower in patients receiving CAT-152 compared to those receiving placebo. Resumption of long-term topical IOP lowering medications was needed in 8% of CAT-152 patients compared to 15% of the patients on placebo. Of this second untreated group, three patients subsequently underwent repeat trabeculectomy to control IOP.

Rapid noninvasive Helicobacter test

Current testing options for Helicobacter pylori, associated in particular with peptic ulcers, include a radiolabeled C13 or C14 urea breath test, a serological blood test or an endoscopic biopsy tissue sample of the stomach lining or a combination of these. Each of these tests includes a feature limiting its use in extensive screening, including cost, reliability, use of radioactive materials, invasive surgery or unpleasantness for the patient.

Hyperlyser (Sheffield, UK) acquired in 2000 from Hypoguard (Woodbridge, UK) rights to a device similar to the breathalyzers used to detect alcohol but which detects ammonia produced by H. pylori. The prototype device, which is breath-actuated, uses an ammonia-detection sensor based on a patented conducting polymer sensor material developed at the University of the West of England (Bristol, UK).

Although preclinical trials have been encouraging, Philip Drury, medical director at Hyperlyser, says that further work is required to develop an optimum protocol and to move clinical trials forward.

The potential cost savings from the introduction of an accurate rapid and noninvasive physician's office test for H. pylori are substantial. For example, it has been estimated that only 25% of peptic ulcer patients in Britain are treated with H. pylori eradication therapy, although 90% may be infected. If H. pylori was eradicated from this 90%, the estimated savings to the National Health Service in medicines alone would be $340 million to $440 million over six years.

Insomnia monitoring

Oxford BioSignals (Oxford, UK) has launched what the company says is the first ambulatory monitoring system to bring the expertise of a sleep lab to the primary care level. BioSomnia analyzes a single channel of EEG data overnight in real time, using Oxford BioSignals' patented neural network technology, and then downloads the results to a standard PC for review. Insomnia is a problem affecting up to half the population and effective management requires good diagnosis. The company said that the BioSomnia system is designed to quantify at home a patient's sleeping habits and to help evaluate the effectiveness of treatments.

Antibiotic-resistant infections

Infections with oxacillin-resistant Staphylococcus aureus are becoming increasingly common and usually are resistant to treatment with vancomycin. However, a combination of vancomycin with Synercid injection IV (quinupristin/dalfopristin) from Aventis Pharma (Frankfurt, Germany) has been effective in clearing the infections.

Synercid is the first injectable antibiotic in a distinct class known as streptogramins. It has FDA clearance for treating bloodstream infections due to vancomycin-resistant Enterococcus facium and skin infections caused by methicillin-resistant Staphylococcus aureus or Streptococcus pyogenes.

The Centers for Disease Control and Prevention (CDC; Atlanta, Georgia) recently launched a campaign to target the problem of antimicrobial resistance in health care settings, especially since more than 70% of hospital-acquired infections are resistant to at least one of the commonly used antibiotics.

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