Urgent need for innovation
Jan Van Emelen has worked as a doctor in the tropics, he was the healthcare advisor in the Belgian Prime Minister’s cabinet and he’s currently innovation director at one of the country’s main sickness funds. As such, Van Emelen is well placed to say a thing or two about the Belgian healthcare system. In this interview, Van Emelen doesn’t mince his words. As a system we’re not tackling the core challenges and we’re inherently resistant to innovation. Nevertheless, a new consortium of healthcare stakeholders is taking action.
Roots in the tropics
I’m a physician by training. After doing research at the Antwerp Institute for Tropical Medicine I spent 13 years working in tropical countries. Those were fantastic years and I do miss them. When I returned to Belgium I started work in the field of occupational health. From there I landed up in the Cabinet of Premier Guy Verhofstadt—again a very stimulating time. Since 2003 I’m Director of Innovation and Research at the Independent Sickness Funds. As you can see, I’ve got a pretty diverse background: from fighting AIDS in Africa to occupational health and politics in Belgium—all of which have informed my view on the state of healthcare today.
A sober analysis
The independent sickness fund is the third largest in Belgium. What’s unique about us is that we’re politically independent. We only do insurance. We have no vested interests in hospitals or pharmacy chains. Our goal is quite simply to strive for an optimal healthcare system that keeps our members healthy. And that’s the problem—we’re running behind in Belgium. In our research with the Itinera Institute, for example, we’ve had to conclude that this country is not tackling the challenge of the ageing population. We have several interrelated challenges in healthcare today. The demographic profile of the population is changing which means that we are going to see a lot more demand for healthcare in the coming years, especially for chronic illnesses such as cancer, diabetes, depression, Alzheimer’s, etc. This will place increasing pressure on healthcare budgets. And simultaneously we’re experiencing an increasing shortage of people—especially nurses—to perform the actual healthcare.
There is urgent need for innovation in the way we organize healthcare in this country but we’re not doing anything, and that is mainly because we don’t have all the stakeholders in the system onboard. If you want to accomplish anything in terms of innovation then it is critical that you have everyone—the doctors, the sickness funds, the government—involved. The ideas exist but they need executing.
In Israel they introduced the electronic health record in 1988! In Belgium we’re still talking about it. In the 1990s they introduced electronic prescriptions. In 2010 we have a pilot project on the go. Countries like Israel are innovating at a tremendous pace. Unfortunately in Belgium we have a system that slows everything down. Due to the lengthy decision-making procedures involving numerous committees it takes at least five years before a new technology can be put to use in our hospitals. And at any stage of such decisions, a single stakeholder can stall the entire process. For example, hospital based kidney dialysis could be replaced in part by home dialysis machines. It is used in Africa and it could work in Belgium too in the right context. Here’s a way to reduce healthcare costs but politically it is impossible to push through. The problem is that we have too many large hospitals, too many kidney dialysis centers. Our system has overcapacity in highly specialized care but we’re not willing to experiment with alternative home-based treatments. It is political suicide to touch the hospitals. Another example: thrombosis patients need weekly controls of their blood. In the Netherlands there are 80,000 such patients and 50,000 are in a system where they do the controls themselves at home via a simple device. In Belgium that procedure isn’t refunded. Why?!
I’m painting a negative picture I realize, but there are opportunities for moving forward. The main opportunities for more effective and efficient treatment of chronic illness lie in telemedicine and in nanotechnology. In the pharmaceutical industry also amazing work is being done—in Belgium by the likes of Paul Stoffels and his work on AIDS. Basically these are techniques that allow for much more personalized care that is based on understanding the individual illness characteristics and sensitivity to specific drugs. Already we’re seeing that cancer patients who are treated in smaller hospitals have poorer survival rates than patients treated at larger hospitals and that’s because these larger institutes are far more specialized. The problem is that the financing system doesn’t follow these innovations. In Belgium everybody with a common disease gets refunded equally but that doesn’t fit with today’s science anymore. We know that some patients are not helped by chemo while others are; but the financing system lumps them all together. A changing medical paradigm needs to be supported by a chancing financial paradigm, but that isn’t happening yet.
In the Post-War period there was a tremendous boom in the building of regional hospitals for short-term acute care. Today we have a totally different context that is marked by a much higher prevalence of chronic illnesses. Today we need multidisciplinary care and a lot more cooperation among the various stakeholders in the system. Patients too need to be empowered and we need to make a lot more use of home-based care.
To address these challenges we’ve built a consortium involving four technology companies, two health insurance funds (the independent and the neutral health insurance funds) and two major care provider associations (the pharmacists and the doctors). It is a new initiative and strikingly, it is a private initiative. Our goal is to create structures and procedures for enabling innovation. At present we’re looking at four areas:
The enrollment of patients with a chronic condition can be done much more systematically. At present we’re only reacting when people get really ill—that’s when the system kicks into gear. We should be identifying people on the basis of risk factors. Also, we need to capture the masses of data that is currently being generated and use that to proactively assess people at risk. At present all the data is used simply for administrative purposes or to create retroactive reports.
Patient empowerment is an urgent priority, at different levels. There is tremendous opportunity to involve patients with chronic conditions in their treatment, especially via educational and coaching tools. For example, with the right coaching it is possible for early stage diabetes patients to delay medication for years. Our communication at present is totally inadequate. We make beautiful brochures but who reads those? We’re preaching to the converted. Those who read the brochures already have information. But a large analphabetic group we’re not reaching at all.
Communication between healthcare providers is a catastrophe. The electronic medical records are simple translations of the paper records and they’re not designed to be used by care providers. Doctors are being paid to have electronic records, not to use them. A recent survey showed that only 4% of doctors in Brussels use an electronic record system appropriately. The useful data in those systems just isn’t getting through—and it isn’t the doctors’ fault. The software is designed wrong; it offers no intelligence for doctors. And yet, the technology is available to support doctors in their clinical decision making, systems that are based on evidence-based medicine.
Finally, we need to improve assessment, the measurement of quality and outcomes. Patient satisfaction is particularly high in Belgium, but that is mainly because we have a system where patients are free to choose their provider. We can shop around. But that says nothing about the quality of care.
Optimistic about change
These are our priorities at present. We have a consensus among a broad group of stakeholders, including the Flemish government. At a Flemish level we have made headway with preventative strategies. People are smoking less and exercising more. But there is potential for so much more. We need to expand our scope beyond disease management to risk management. That’s a much more proactive approach to healthcare. Our life expectancy is 83 years, but our healthy life expectancy is only 73 years; that’s quite a gap to fill. I’m reasonably optimistic. Solutions do exist. What’s lacking is leadership.
About Jan Van Emelen
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