Professional autonomy and managed care in Dutch health centres: stakeholders' perceptions of a strategic option.

The on-going reforms of the Dutch health care systems call for the introduction of managed care elements. Health centres in the Netherlands already bear some resemblance to health maintenance organizations in the USA. However, managed care challenges provider autonomy, and the strategic development of managed care plans may be hampered by providers' perceptions. We draw a distinction between managed care within an insurance arrangement and managed care as a package of methods. Both options are evaluated as suitable for Dutch health centres, though with differences in terms of strategic logic and cultural fit. Lastly, some general conditions are formulated that should be considered before care management processes can be implemented. These include: specify clear objectives for introduction of managed care; strengthen corporate culture; develop internal motivation for change; develop a practice criterion with health centre professionals; reduce workloads in order to provide development time; and, promote better cooperation between general practitioners and specialists.

Competitive bidding for health insurance contracts.

The determination of the payment or premium to be paid to the insurer by a large purchaser of care must accurately represent the risk of the enrolled persons. One approach is a risk-adjusted payment established by a mathematical formula, which estimates the effect of many variables on total care costs, and for different groups of persons determine an average cost. This method has several problems, and an alternative is competitive bidding. Market forces pressure providers to offer the lowest possible bids while attempting to remain fiscally viable and provide high-quality services. Research from the U.S. demonstrates that competitive contracting effectively lowered the costs of health care for those sectors of the health care system that used this strategy. Bidding by area gave far more equitable results than could have been obtained with a state-wide system with crude adjustments for each area. It is an alternative which can create strong incentives for innovation and cost-containment, and at the same time allows insurers to take into account local variation in supply and demand of care. As a potential alternative to a regulatory system, competitive bidding should be considered for regional experimentation in health insurer payment.

Health insurance values and implementation in The Netherlands and the Federal Republic of Germany. An alternative path to universal coverage.

The health care systems in the Netherlands and the Federal Republic of Germany are based on a set of values that involve mutual obligations between private parties. These obligations are realized through systems incorporating private practice physicians, community and church- and municipality-affiliated hospitals, and nonprofit and for-profit insurers. The underlying values and implementation approaches in these systems provide an alternative to the adoption of a Canadian-style health insurance system. A discussion that focuses on "obligations" rather than "rights" may be a more useful approach for the design of reforms of the American health system in the 1990s. Such a discussion would focus on the mutual responsibility of all parties to create and maintain a universal private health care system.

Cost containment and physician payment methods in The Netherlands.

Cost containment in the Netherlands has been partly achieved by negotiated agreements between insurers and physician associations. The negotiating system in the Netherlands involves the determination of capitation and fee-for-service rates, based on negotiated norms for personal remuneration, practice costs, and practice size. Physician practice patterns are monitored in an effort to control volume. Selected aspects of the negotiating structure could be adopted by Medicare and HMOs to clarify issues in negotiations with physicians and to reimburse physicians more equitably. However, establishment of standardized fees and volume monitoring may not be as effective as global expenditure controls.