The mental health care system in the United States follows a managed health care model, established in the 1980’s (managed care plans are health insurance plans that contract with medical facilities and health care professionals to deliver health care services to members at reduced costs). It intended to provide greater efficiency and cost-effectiveness (Lepolstat, Goldbeck, Kostelnik, Mandyam, Montero, & Brown, 2009). It was also the belief that health care coverage would become more affordable for more Americans, as a result of a decrease in health care costs. However, health care costs have continued to rise, and as of 2001, 41 million American adults and children had no coverage (Davis & Schoen, 2003). According to Lepolstat et al. (2009), the cost of health care in the United States is increasing as accessibility to services is decreasing.
A major change resulting from the transition to managed health care includes the requirement of permission from a primary care physician to access specialty services. Limits are placed as to which providers patients can choose from. An additional change resulting from the transition to managed health care is that providers’ caseloads are too large, resulting in a compromise in consumer care (Lepolstat et al., 2009). The larger a providers caseload, the less time the provider can dedicate to each consumer.
Managed health care uses prior authorization and utilization management to lower costs. These methods often deprive specific special populations. Interestingly, a lower socioeconomic status (SES) is generally associated with an increased prevalence of unhealthy behaviors, such as overeating, smoking, and promiscuity (Lepolstat et al., 2009). According to Figueira-McDonough (1993), universal health care (similar to that of the Netherlands) may resolve some of these public health concerns because health care could be provided to anyone regardless of income.
According to Zhu (2004), many individuals who are ineligible for Medicaid as a result of their income being above that of program eligibility are not able to afford supplemental health care coverage. Kane and Kane (2005) noted the elderly is the only population that qualifies for universal federal health insurance (Medicare). According to national public opinion polls conducted from 1991 to 2006, 61 percent of managed care organization (MCO) members felt that their health plan was less concerned with providing consumers with the best treatment, and more concerned with minimizing costs. This is compared to 34 percent of consumers enrolled in traditional health plans (Miller, 2006). Also, this poll found that almost one-third of participants surveyed had to delay medical treatment due to cost, and that over ten percent of Americans reported their quality of health care as poor. Most European countries provide universal health care, making health care not a privilege, but an entitlement (Lepolstat et al., 2009).
Dutch Mental Health System
Mental healthcare in the Netherlands has drastically changed since the 1970’s, a time when services depended on large psychiatric hospitals that provided long-term admission. There was little continuity with community mental health centers. The Dutch government reorganized a provision-based system to a need-based system by stimulating provider competition. At present, in Dutch mental health care, there is no systematic quality control like in commercial services and industry, where consumers are supplied with specifications for products, tolerances, and procedural standards used to maintain product quality (Van Os, Hilwig, & Delespaul, 2004).
Health care reform in the Netherlands aimed to better serve mentally ill consumers in economic and social activities while maintaining continuity of care (Pijl & Sytema, 2004). Community care for consumers with severe mental illness remains inadequate (Van Os, Hilwig, & Delespaul, 2004). According to Ravelli (2006), regional mental health care centers are taking over the admission function of hospitals, which will lead to a significant percentage of the old-fashioned admission wards to be destroyed or emptied. According to Ravelli, the formation of regional mental health care centers have been focusing too much on reducing the amount of space in psychiatric hospitals, the refurbishing of old buildings, and the need for new facilities. This has resulted in a rapid decline in psychiatric beds, and consumers with severe mental illness not being provided with appropriate treatment options.
According to a study by Pijl, Kluiter, and Wiersma (2000), all theories that predict community care attracting a new, and less mentally ill population of consumers should be rejected. This study supports the opinion that current innovations in mental health care in the Netherlands differ from those of other countries historically. In the Netherlands, there has been no distinct period of deinstitutionalization; the system changed gradually and the changes were mostly the responsibility of existing mental health care providers. Pijl and Sytema (2004) explored whether or not the time between hospital discharge and first subsequent community-based care decreased during the transition to community-based mental health care. The results of this study are that an increase in aftercare and a transition from in-patient care to more intensive day and home treatment indicate an improvement in the delivery of mental health care services in the Netherlands.
Comparison of Dutch and United States Mental Health Systems
Differences. Less money is spent on medical research in the Netherlands than in the United States. Only a few universities have made researching mental health one of their top research priorities. Unlike the United States, there is not much collaboration with other agencies and providers of mental health services (Van Os, Hilwig, & Delespaul, 2004). This lack of a collaborative approach weakens the overall effectiveness of providing support to consumers, and results in less treatment options and referrals. However, unlike in the United States, consumers do not require preliminary authorization from their primary care physician, which increases access to specialized care (Lepolstat et al. (2009). In addition, the Netherlands does not hold a primary focus on mental health research, resulting in a lack of evidence-based policy development (Pijl & Sytema, 2004).
Similarities. According to Menzel & Light (2006), treating the uninsured population in the United States is a financial burden for all citizens. This is also the case in the Netherlands because government funding provides health care services. Menzel & Light (2006) also state that treatment options are limited by managed health care on the basis of cost in the United States. In the Netherlands, treatment options are limited due to a lack of research to develop empirically tested, new treatments. Health care plans that limit treatment options can result in a lack of more effective and appropriate treatment for both American and Dutch consumers (Van Os, Hilwig, & Delespaul, 2004).
In the Netherlands, regions may differ in availability of mental health services. This is especially the case in rural areas (Pijl, Kluiter, & Wiersma, 2000). In the United States, consumers in rural areas also may lack availability of mental health services. This can be a result of inaccessibility to public transportation, population size, or not enough need for a specific service in an area with a small population. This can also be a result of many rural areas in the United States belonging to agricultural communities, where individuals are less likely to have the ability to afford health care and to be offered health care by their employers.
What This Writer Observed
It is the opinion of this writer that consumers in the Netherlands appeared to hold more accountability for their behaviors and greater psychoeducational awareness of their conditions. This writer observed more informal rapport between consumers and providers, and more consumer freedom. This writer feels that these differences encourage consumers to have greater responsibility and accountability in their recovery, and allows them to become more autonomous, productive members of society. It is the opinion of this writer that consumers in the Netherlands are encouraged to further their education more so than in the United States. This writer also believes that there is more of a focus on rehabilitation, recovery, and integration into the community in the Netherlands, with the exception of the Personalized Recovery Oriented Services (PROS) model. The writer of this paper is currently serving as an intern in a PROS facility. The PROS movement in the United States follows a rehabilitation model, where consumers are reintegrated into the community, as opposed to a clinical model, which focuses on the treatment of mental health disorders and management of psychotic symptoms.
This writer also noted a greater presence of peer counselors in the Netherlands, and greater consumer independence, even when formally institutionalized. Many consumers were afforded their own housing units with minimal staff interference. Consumers appeared more honest about their activities, with little fear of legal intervention. When this writer asked a peer counselor why providers do not report illegal activities that are not life-threatening, the counselor stated that it was the responsibility of the legal authorities and not the counselors. It is believed that this policy serves to enhance trust in the therapeutic relationship.
Strengths of the Dutch System That the United States Can Adapt or Change to Strengthen Their Own Mental Health System
According to Figueira-McDonough (1993), individuals living in poverty often do not receive health care. Universal health care may resolve this issue because everyone would receive health care regardless of SES. According to Menzel and Light (2006), universal health care could alleviate cost pressures placed on MCOs and traditional private insurance plans. When the uninsured population’s health conditions become critical and hospitalization is required, all citizens share the financial burden. Therefore, it can be assumed that if the United States were to adapt a social policy that required all citizens to be insured, individuals who belong to MCOs and private insurance plans, as opposed to a public option for health insurance, would in return pay lower premiums.
In the Netherlands, the unit costs of community-based health care are lower than those of inpatient care (Pijl & Sytema, 2004). It is possible that the costs of mental health services in the United States could decrease if there was a greater focus on community-based care, and less psychiatric hospital admissions; it may only be necessary for dangerous individuals to be hospitalized.
Studies show that the shorter the interval between consumers’ release from hospitalization to their introduction to community-based health care reduces the risk of suicide following hospital discharge (Motto & Bostrom, 2001). The United States should improve the time in which it takes to enroll an individual to community-based treatment to reduce the risk of suicide in vulnerable consumers. According to a study by Pijl, Kluiter, and Wiersma (2000), the Dutch enactment of community care increased accessibility of mental health care services. This study provides evidence that the current reform in the Dutch mental health system improved consumers’ access to health care services. If the United States were to adapt its current policy so that community-based treatments were more popular, access to health care services could improve for individuals who do not qualify for Medicaid and cannot afford to purchase a managed health care plan or in-patient hospitalization.
Strengths of the United States System That the Dutch Can Adapt or Change to Strengthen Their Own Mental Health System
According to a study by Ravelli (2006), a more integrative approach to mental health care in the Netherlands would be beneficial. A multidisciplinary approach, like that which is common in the United States, could enhance treatment options and improve results in the Netherlands by including a team of professionals from various disciplines to work together. Managed care, like that in the United States, is typically better at providing preventative services (Landon, Zaslavsky, Bernard, Cioffi, & Cleary, 2004). If the Dutch mental health care system studied the differences between how preventative services are accessed and provided in the United States, the Dutch may strengthen their already improved access to mental health care services.
A strength of the United States mental health care system that the Dutch could adapt is dedicating more money to universities and other institutions for research (Van Os, Hilwig, & Delespaul, 2004). This would enable advances in the Dutch system by improving and increasing treatment options. This would allow the Dutch to make a greater contribution to the scientific knowledge base of mental illness. According to Van Os, Hilwig, and Delespaul (2004), only a few Dutch universities have made mental health a top research priority, and the Netherlands spend less money on medical research than other industrialized countries.
Less money is spent on medical research in the Netherlands than in the United States (Pijl & Sytema, 2004), and unlike in the United States, there is not much collaboration with other providers (Van Os, Hilwig, & Delespaul, 2004). A lack of research results in a lack of evidence-based policy and scientific contribution to the field of mental health for the Dutch. Collaborating with other providers is considered an integral part of the mental health care system in the United States, and results in more effective treatment and more treatment options for consumers.
In both the Dutch and the United States health care systems, treatment options are limited, but for different reasons. In the United States, treatment options are limited by managed treatment plans. In the Netherlands, treatment options are limited as a result of a lack of research to develop new treatment strategies (Menzel & Light, 2006). In both systems, rural areas are typically restricted in their availability of services (Pijl, Kluiter, & Wiersma, 2000).
The United States could benefit from adapting some Dutch mental health care policies. Universal healthcare in the United States could alleviate cost pressures placed on MCO’s by lowering premiums (Menzel and Light, 2006). It is possible that the cost of mental health care services in the United States could decline if there were more community-based care options and less psychiatric admissions. In the Netherlands, unit costs of community-based healthcare are less than that of inpatient care (Pijl & Sytema, 2004). The Dutch mental health care system could also benefit from adapting some of the health care policies of the United States. For example, a more integrative approach like that which is common in the United States could enhance treatment options for consumers (Ravelli, 2006). The Dutch system of mental health care could benefit by dedicating more money to research facilities to develop and improve treatment options. This places the Netherlands at a disadvantage, for they are not contributing research to the field of mental health. This may result in a reduction of new, evidence-based mental health treatments for consumers worldwide.
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