There are no simple answers to the question of guilt in the health care crisis

Tuesday is the boom, and Thursday the bang. Firstly, two hospitals with more than 2,000 employees and a total turnover of 225 million euros requested a payment deferral. And two days later, they were already bankrupt.

The Amsterdam Slotervaartziekenhuis and IJsselmeer Hospitals in Flevoland are no strangers to the Special Department of Bank Management. Both hospitals have a history of financial difficulties and internal turmoil. And yet, the bankruptcy of most people involved was a surprise, from nurse to shareholder, from general practitioner to patient.

The roar with which hospitals sink can lead to the most incomprehensible. Would not it have been more civilized and more controlled?

The bankruptcy of hospitals is a reminder of how banks sometimes collapse. If trust is gone and everyone withdraws their money at the same time, a bank quickly returns, even a healthy bank. In hospitals, which were not yet successful, suspension of payments immediately resulted in the absence of hired and temporary staff.

And freelancers have proved to be essential, as in many organizations in the Netherlands. This flexibilisation of the labor market creates a new dynamic for organizations in financial difficulty. Asking for a deferral of payment – intended to create peace and solve problems – causes trouble. A lesson for the following candidates for a moratorium: to organize a pot for a "temporary" force to maintain the situation.

The bankruptcies of the hospitals MC Slotervaart and IJsselmeer will certainly not be the last. Find out about this topic: Many hospitals face a budget that is too small

The culprit

The issue of blame is directly at the center of the health care debate. Everything happened this week: abuse of insurers' power, mismanagement of directors, incitement of hospital owners, inevitable consequence of market forces, self-employed who made everything so expensive.

But simple answers are not there. Hospital care is organized in a complex way. The Netherlands has opted for a hybrid system with a lot of regulation and space for entrepreneurship. With a ban on the distribution of profits.

Hospital owners were also members of the board in recent years. Their pay was higher than the legal standards for health care. The Slotervaart Hospital was never founded for ideological reasons, all doctors exercising a salaried activity. Willem de Boer, until recently chairman of the board of directors of both hospitals, had 0.75 FTEs on each payroll for each hospital.

But is this havoc suffered by the hospital? Loek Winter and Willem de Boer are both important creditors. Entrepreneurs lent 9.5 million euros to hospitals, according to the latest available annual reports. In recent years, it was no longer possible to pay him at the expense of ING Bank. According to the owners, there is also a backlog of 1 million euros in interest payments. With their investment at the time, they speak of an "amount of 12.5 million euros"

This recalls the spirit of the man 's d & # 39; business Joep van den Nieuwenhuyzen at its peak

Schimmigheid

There is another side of the story. Hospitals have also been dealing with other companies of hospital owners or managers in recent years. The NRC revealed last summer that the hospitals of Amsterdam and Lelystad paid about 800,000 euros each year to the company Cashcure. One of the founders was also "Finance & Control Manager" of MC Slotervaart and Lelystad Hospital. It turned out that he had entrusted assignments to Cashcure on behalf of the hospitals. In essence, he signed a long-term contract with himself in 2014.

One of Cashcure's shareholders was the commercial partner of De Boer and Winter. Another shareholder worked temporarily for four years at Slotervaart Hospital by sending invoices from his company to a colleague at the hospital who was one of the founders of the company.

Research also showed that Slotervaart Hospital 3, 5 tons were used to pay a loan of 5 million euros not consented to the descendants of land speculator Jan Schram, the entrepreneur who was the owner of the hospital between 2006 and 2012.

In recent years, the hospital business structures remind businessman Joep van den Nieuwenhuyzen at its peak: divisions, mergers, holdings intermediates and continuous changes of trade names in an opaque Christmas tree of BV. Those who did not visit the Chamber of Commerce for a few weeks ended up in a completely transformed jungle.

At MC Slotervaart, a silent partner operated from a holding company in Curacao, at the address of a trust office. Until the end of 2015, Willem de Boer had shares in the Slotervaart hospital housed in a company owned by an anonymous Cypriot company. The Dutch private company, which holds its shares in hospitals, has unclear financial links with companies located in the tax havens of the British Virgin Islands and Guernsey

Insurers

This opacity does not help to strengthen confidence health insurers, major hospital funders. Since 2006, they are the central purchasing office for health care in the Netherlands. Insurers agree budgets with hospitals – somewhat in proportion to the number of insureds who visit hospitals.

Because Zilveren Kruis, a subsidiary of Achmea, has the most insurance in Amsterdam and Flevoland, the health insurer is essential. party for both hospitals. For years.

In 2013, the Slotervaart hospital came into conflict with Achmea when the Amsterdam hospital refused to sign a contract, former CEO Aysel Erbudak saying the insurer did not have a sufficient budget. It was a high match. Hospital budgets are contractually agreed, often every year. In the case of a hospital without a contract, the insured person will have to advance the amount itself. This is unachievable in practice. Achmea advised his policyholders to avoid Slotervaart and quickly won the struggle for power. Erbudak was killed and relations were reestablished.

With the bankruptcy of two hospitals this week, the discussion broke over the market forces in health care. Minister Bruins is clear: he does not want to change the system .

Bureaucrats

Health insurers must buy the best care as cheaply as possible. The most common criticism is that insurers behave like bureaucrats who distribute the cake with premiums and do not want too many problems. According to the contractors' complaint, they fund the established order in place of newcomers in care facilities that work cheaper and more efficiently.

Like Loek Winter. In his eyes, he has been dealing with an unwelcome health insurance company for years. What insurers had attended private meetings in recent weeks had never been shown before. With representatives of the ING Special Management Service, they discussed the future of both hospitals. The owners of the hospital were sometimes present as "listeners". Scandalous cartel training, according to DSW director Chris Oomen. "This is not possible and it is not allowed."

After a deferral of payment in July, a new request for money was presented this month. Zilveren Kruis is shocked by the deterioration of her financial situation and not by financial means to finance structurally deficit hospitals.

Everyone then looked at each other. It was not realistic to invest the extra money themselves because "for the insurers, it was clear that there was no future in health," informed shareholders on request. The insurer looked at the bank and the bank looked out the window. Why would she make money? In recent years, ING has not significantly reduced its loans to hospitals.

The break in the trend was that this time Zilveren Kruis held up. And so, the health insurer has the fate of hospitals. Are insurers too powerful with this? The company has chosen to outsource this task to the insurer. In the past, it was with the government.

But when politicians are visible and directly responsible, the insurer avoids the spotlight. Even this week, the Silver Cross was often invisible and had no clear story that could justify difficult choices. This happens when helpless bourgmestres seek the public arena to share their discontent.

As Ida Adema (VVD), mayor of Lelystad. As captain of the municipalities of Flevoland this week, she was looking in the media for the message that it is "unacceptable" that the IJsselmeer hospital closes permanently. She does not have the means to keep the institution afloat. She puts the pressure on Silver Cross. And the health insurer is vulnerable to imaging. In 2014, Karel Loohuis (PvdA), mayor of Hoogeveen, threatened to call his residents to a boycott if the insurer made no effort to maintain the local hospital.

There is no doubt that the Silver Cross would have preferred a gradual remedy rather than two notorious bankruptcies. In the meantime, insurers are applying a classic industrial policy: the hospitals of Amstelveen and Zaanstad have insufficient income and benefit from the bankruptcy of Mr C. Slotervaart. The hospitals of Zwolle, Sneek, Hoorn and Harderwijk can also very well use the extra turnover generated by Flevoland.

Do we now see market forces or their failure? The insurer refuses to maintain health care in Amsterdam West and Flevoland, but believes there are enough alternatives. But the Silver Cross itself does not have much to choose from. Zilveren Kruis will soon have the choice between two giants in the healthcare sector in Amsterdam. The risk: rising rates and longer waiting times. Who is the monopoly here? "These are three steps back for entrepreneurship," said Loek Winter this week.

Busts

DSW Director Chris Oomen calls it shameful that Slotervaart Hospital continued to pay former members of the board for some sort of program departure. Medical specialists Dees Brandjes and Jos Beijnen spent years alongside Aysel Erbudak on the board of directors, but they gave up on her during the 2013 crisis. After the 2014 takeover, they became advisers. They received more than 860,000 euros for advice in legal proceedings, for which the accountant did not find adequate support in 2015.

There are still two busts in the hospital. Slotervaart. On their identification plates is: "Driver from 2006-2014." Savior of the hospital during the existential shareholders (crises) of 2006 and 2013. "Doctors, who were once the highest paid doctors of the Country -Not, could prevent the third failure.