Financial risk allocation and provider incentives in hospital-insurer contracts in The Netherlands.

In healthcare systems with a purchaser-provider split, contracts are an important tool to define the conditions for the provision of healthcare services. Financial risk allocation can be used in contracts as a mechanism to influence provider behavior and stimulate providers to provide efficient and high-quality care. In this paper, we provide new insights into financial risk allocation between insurers and hospitals in a changing contracting environment. We used unique nationwide data from 901 hospital-insurer contracts in The Netherlands over the years 2013, 2016, and 2018. Based on descriptive and regression analyses, we find that hospitals were exposed to more financial risk over time, although this increase was somewhat counteracted by an increasing use of risk-mitigating measures between 2016 and 2018. It is likely that this trend was heavily influenced by national cost control agreements. In addition, alternative payment models to incentivize value-based health care were rarely used and thus seemingly of lower priority, despite national policies being explicitly directed at this goal. Finally, our analysis shows that hospital and insurer market power were both negatively associated with financial risk for hospitals. This effect becomes stronger if both hospital and insurer have strong market power, which in this case may indicate a greater need to reduce (financial) uncertainties and to create more cooperative relationships.

Does competition improve hospital performance: a DEA based evaluation from the Netherlands.

Many countries have introduced competition among hospitals aiming to improve their performance. We evaluate the introduction of competition among hospitals in the Netherlands over the years 2008-2015. The analysis is based on a unique longitudinal data set covering all Dutch hospitals and health insurers, as well as demographic and geographic data. We measure hospital performance using Data Envelopment Analysis and distinguish three components of competition: the fraction of freely negotiated services, market power of hospitals, and insurer bargaining power. We present new methods to define variables for each of these components which are more accurate than previously developed measures. In a multivariate regression analysis, the variables explain more than half of the variance in hospital efficiency. The results indicate that competition between hospitals and the relative fraction of freely negotiable health services are positively related to hospital efficiency. At the same time, the policy measure to steadily increase the fraction of health services contracted in competition may well have resulted in a decrease in hospital efficiency. The models show no significant association between insurer bargaining power and hospital efficiency. Altogether, the results offer little evidence that the introduction of competition for hospital care in the Netherlands has been effective.

Implementing value-based healthcare using a digital health exchange platform to improve pregnancy and childbirth outcomes in urban and rural Kenya.

Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of the United Nations Sustainable Development Goal 3. Value-based healthcare (VBHC) has the potential to outperform traditional supply-driven approaches in changing this dismal situation, and significantly improve maternal, neonatal and child health (MNCH) outcomes. We developed a theory of change and used a cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated in Kenya. At the core of the approach was a value-based care bundle for maternity care, with predefined cost and quality of care using WHO guidelines and adjusted to the risk profile of the pregnancy. The care bundle was implemented using a digital exchange platform that connects pregnant women, clinics and payers. The platform manages financial transactions, enables bi-directional communication with pregnant women via SMS, collects data from clinics and shares enriched information via dashboards with payers and clinics. While the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a predictable cost per enrolled person. This community case study shows that implementation of the VBHC framework in an LMIC setting is possible for MNCH. The incremental, cohort-based approach enabled iterative learning processes. This can support the restructuring of health systems in low resource settings from an output-driven model to a value based financing-driven model.

A new approach to preferred provider selection in health care.

In January 2015 Zilveren Kruis, the largest health insurer in The Netherlands, engaged in a new three-year, unlimited volume contract with five carefully selected providers of cataract surgery. Zilveren Kruis used a novel method, designed to identify the top expert providers in a certain discipline. This procedure for provider selection uses the principles of Best Value Procurement (BVP), and puts the provider in charge of defining key performance indicators for health care quality. The procedure empowers the professional and acknowledges that the provider, not the purchaser, is the true expert in defining what is high quality care. This new approach focuses purely on provider selection and is thus complementary to innovations in health care reimbursement, such as value-based hospital purchasing or outcome-based financing. We describe this novel approach to preferred provider selection and show how it makes affordable quality the core topic in negotiations with providers.

Adaption of a dermal in vitro method to investigate the uptake of chemicals across amphibian skin.

BACKGROUND: Literature data indicate that terrestrial life stages of amphibians may be more sensitive to xenobiotics than birds or mammals. It is hypothesized that dermal exposure could potentially be a significant route of exposure for amphibians, as there is evidence that their skin is more permeable than the skin of other vertebrate species. Thus, higher amounts of xenobiotics might enter systemic circulation by dermal uptake resulting in adverse effects. Heretofore, no guidelines exist to investigate dermal toxicity of chemicals to amphibians. In order to minimize vertebrate testing, this work was targeted to develop an in vitro test system as a possible model to assess the dermal uptake of chemicals across amphibian skin. RESULTS: The dermal absorption in vitro method (OECD guideline 428), an established toxicological (mammal) test procedure, was adapted to amphibian skin, in a first approach using the laboratory model organism Xenopus laevis and reference compounds (caffeine and testosterone). Skin permeability to both reference substances was significantly higher compared to published mammalian data. Caffeine permeated faster across the skin than testosterone, with ventral skin tending to be more permeable than dorsal skin. As usage of frozen mammalian skin is accepted, frozen skin of X. laevis was tested in parallel. To the freshly excised skin, however, freezing led to increased skin permeability, in particular to caffeine, indicating a loss of skin integrity due to freezing (without additional preservation measures). CONCLUSIONS: This work has demonstrated that the chosen method can be applied successfully to amphibian skin, providing the basis for further investigations. In future, well-established in vitro test systems and a broad dataset for many chemicals may help assess potential amphibian risk from xenobiotics without the need for extensive vertebrate testing.

Draft DG SANCO document: addressing the new challenges for risk assessment--an industry perspective.

The draft European Commission's Directorate General for Health and Consumer Policy (DG SANCO) document represents the state of the art in environmental risk assessment (ERA) including new trends and combining high level environmental protection and realism. Using the ecosystem services concept, it offers a promising approach to determine which impact may be tolerable, where, and when. Established ERA uses a stepwise approach starting with standardized internationally accepted studies combined with appropriate assessment factors (AFs) and where needed followed by higher tier assessments and respective adjusted AFs. The draft SANCO document follows this approach and presents additional refinements to improve the realism of risk assessment, which is desirable; however, that such additional data becomes a standard requirement without a clear need must be avoided. The idea of additional AFs presented in parts of this article should accordingly first consider risks and benefits in line with this approach and only be requested if data indicates their necessity. In addition, the suggested focus on uncertainty analysis without any obvious according benefits in terms of reduced assessment factors where uncertainty is reduced, is still a challenge. The requirement for science- and/or data-based relevant concerns before requesting more data, and the list of requirements for new innovative approaches that should be met before such approaches can be used in regulatory ecological risk assessments, is well-founded and strongly supported. Modeling has been included in ERA to allow extrapolation of risk assessments without the need of excessive (animal) testing; it will also address uncertainties more quantitatively. However, this should be done in an overall realistic ecological assessment; simply adding up various individual uncertainties and worst-case assumptions must be avoided, as this is counterproductive for the use of this valuable tool. The need for expert judgment should be low at the lower tiers of ERA; however, more complex and less standard ERA will still require significant expertise.

Effects of the fungicide metiram in outdoor freshwater microcosms: responses of invertebrates, primary producers and microbes.

The ecological impact of the dithiocarbamate fungicide metiram was studied in outdoor freshwater microcosms, consisting of 14 enclosures placed in an experimental ditch. The microcosms were treated three times (interval 7 days) with the formulated product BAS 222 28F (Polyram®). Intended metiram concentrations in the overlying water were 0, 4, 12, 36, 108 and 324 µg a.i./L. Responses of zooplankton, macroinvertebrates, phytoplankton, macrophytes, microbes and community metabolism endpoints were investigated. Dissipation half-life (DT50) of metiram was approximately 1-6 h in the water column of the microcosm test system and the metabolites formed were not persistent. Multivariate analysis indicated treatment-related effects on the zooplankton (NOEC(community) = 36 µg a.i./L). Consistent treatment-related effects on the phytoplankton and macroinvertebrate communities and on the sediment microbial community could not be demonstrated or were minor. There was no evidence that metiram affected the biomass, abundance or functioning of aquatic hyphomycetes on decomposing alder leaves. The most sensitive populations in the microcosms comprised representatives of Rotifera with a NOEC of 12 µg a.i./L on isolated sampling days and a NOEC of 36 µg a.i./L on consecutive samplings. At the highest treatment-level populations of Copepoda (zooplankton) and the blue-green alga Anabaena (phytoplankton) also showed a short-term decline on consecutive sampling days (NOEC = 108 µg a.i./L). Indirect effects in the form of short-term increases in the abundance of a few macroinvertebrate and several phytoplankton taxa were also observed. The overall community and population level no-observed-effect concentration (NOEC(microcosm)) was 12-36 µg a.i./L. At higher treatment levels, including the test systems that received the highest dose, ecological recovery of affected measurement endpoints was fast (effect period < 8 weeks).

Use of (eco)toxicity data as screening criteria for the identification and classification of PBT/POP compounds.

Characterization of "significant adverse ecotoxicological effects" of persistent organic pollutants (POPs) presents particular challenges. In the various international conventions on POPs and persistent, bioaccumulative, and toxic substances, guidance on classification is not detailed and, in some cases, is unclear. This paper focuses on several key issues in relation to selection of assessment endpoints, use of appropriate effect measures, and uncertainty in the face of limited data. Because POPs are persistent and bioaccumulative, measures of effect should be based not on concentrations in environmental matrices but rather on residues in the body of the organism or in tissues that are causally linked to adverse responses. To obtain these data, currently used toxicity testing methods may need to be modified or substantiated by toxicokinetic information to ensure that substances with POP-like properties are adequately characterized. These data can be more easily matched to environmental monitoring measurements of body or tissue residues for the purposes of assessing whether adverse effects occur in the environment. In the face of persistence and accumulation in the food chain, and considering the extent and suitability of available data, a suitable policy on the use of uncertainty factors may need to be applied when making judgments about toxicity. This paper offers guidance that can be used to identify candidate POPs that have the potential to cause significant adverse effects in the ecosystem.

Introduction to special series: science-based guidance and framework for the evaluation and identification of PBTs and POPs.

There is a growing sense of urgency among scientists and environmental policy-makers concerning the need for improving the scientific foundation supporting international regulations for identifying and evaluating persistent, bioaccumulative, and toxic (PBT) substances and persistent organic pollutants (POPs) in the environment. The current national and international regulations define PBTs and POPs in terms of fairly strict criteria that are based on the state of the science in the late 1970s and early 1980s. Since then, an evolution in the state of the science has produced new insights into PBT substances and an array of new methods to identify PBT chemicals. The development of regulatory criteria has not kept up with the rapid development in environmental chemistry and toxicology, and as a result, scientists often find themselves in the situation where guidance on PBT and POPs criteria is limited and, in some respects, out of date. With this background, a Society of Environmental Toxicology and Chemistry (SETAC) Pellston Workshop brought together experts from academia, government, and industry to reach consensus on the significance of advancements in our understanding of the behavior and potential impact of POPs and PBTs in the environment, the current understanding of the state of the science, as well as recommendations for policy-makers to improve and coordinate national and international regulations on this issue. The workshop builds on the outcome of a previous Pellston workshop, held in 1998, which focused on the evaluation of persistence and long-range transport of organic chemicals in the environment, and is linked to other recent Pellston workshops, among them the Tissue Residue Approach for Toxicity Assessment workshop held in 2007. The results of this workshop are conveyed in a series of 9 articles, published in this issue of Integrated Environmental Assessment and Management, and describe the coordination of science, regulation, and management needed to more effectively achieve a common goal of managing chemicals on our planet.