How is enrollees' trust in health insurers associated with choosing health insurance?

In a healthcare system based on managed competition, health insurers are intended to be the prudent buyers of care on behalf of their enrollees. Equally, citizens are expected to be critical consumers when choosing a health insurance policy. The choice of a health insurance policy may be related to trust in the health insurer, as enrollees must believe that the health insurer will make the right choices for them when it comes to purchasing care. This study aims to investigate how enrollees' trust in health insurers is associated with their choice of a health insurance policy in the Netherlands. We will focus on the switching behaviour of enrollees and the choice of a policy with restrictive conditions. In February 2022, a questionnaire was sent to a representative sample regarding gender and age of the adult Dutch population. In total 1,125 enrollees responded, a response rate of 56%. Respondents were asked about the choices they made in choosing health insurance. Trust in health insurers was measured using the Health Insurer Trust Scale (HITS), a validated multiple item scale. Descriptive statistics, a paired t-test and logistic regression models were conducted to analyse the results. Of all respondents, 35% indicated that they agree, or completely agree, with the statement that they trust health insurers completely. In addition, trust in enrollees' own insurer is slightly higher than trust in other insurers (36.29 vs. 33.59, p<0.001). Furthermore, we found no significant associations between trust in health insurers, and whether enrollees have either switched health insurers or have chosen a policy with restrictive conditions. This study showed that enrollees' trust in health insurance in the Netherlands is relatively low and that trust in their own insurer is slightly higher than trust in other insurers. Furthermore, this study does not show a relationship between trust in health insurers and, either switching health insurers, or choosing a policy with restrictive conditions. Nevertheless, attention for increasing the trust in health insurers might still be important, as low trust may have negative consequences for other elements of the functioning of the healthcare system.

Social context matters: The role of social support and social norms in support for solidarity in healthcare financing.

In many European countries, including the Netherlands, the healthcare system is financed according to the principles of solidarity. It is important, therefore, that public support for solidarity in healthcare financing is sufficient in order to ensure that people remain willing to contribute towards solidarity-based systems. The high willingness to contribute to the healthcare costs of others in the Netherlands suggests that support is generally high. However, there are differences between groups. Previous research has focused on mechanisms at the individual and institutional level to explain these differences. However, people's social context may also play a role. Little research has been conducted into this. To fill this gap, we examined the role of perceived social support and social norms in order to explain differences in the willingness to contribute to other people's healthcare costs. In November 2021, we conducted a survey study in which a questionnaire was sent to a representative sample of 1,500 members of the Dutch Healthcare Consumer Panel. This was returned by 837 panel members (56% response rate). Using logistic regression analysis, we showed that people who perceive higher levels of social support are more willing to contribute to the healthcare costs of others. We also found that the willingness to contribute is higher when someone's social context is more supportive of healthcare systems that are financed according to the principles of solidarity. This effect does not differ between people who perceive low and high levels of social support. Our results suggest that, next to the individual and institutional level, the social context of people has to be taken into consideration in policy and research addressing support for solidarity in healthcare financing.

Has public support for solidarity in healthcare financing in the Netherlands changed over time? A repeated cross-sectional study.

It is argued that solidarity-based healthcare systems are under pressure and that public support is decreasing. It can, therefore, be expected that support for solidarity in healthcare financing has diminished over time. However, little research has been conducted into this. To fill this gap, we used survey data from 2013, 2015, 2017, 2019, and 2021 to examine changes in public support for solidarity in healthcare financing in the Netherlands over time. This was operationalised as the own willingness and the expected willingness of others to contribute to other people's healthcare costs. Using logistic regression analysis, we found that the own willingness to contribute has slightly increased among the general population over time, although this was not observed in all subgroups. No change in the expected willingness of others to contribute was observed. Our results suggest that the willingness to contribute to other people's healthcare costs has, at least, not decreased over time. A majority of the Dutch population remains willing to share the burden of healthcare costs, indicating support for the principles of the solidarity-based healthcare system. However, not all people are willing to contribute to the healthcare costs of others. In addition, we do not know how much people want to pay. Further research into these topics is necessary.

The relation between trust and the willingness of enrollees to receive healthcare advice from their health insurer.

BACKGROUND: In a healthcare system based on managed competition, it is important that health insurers are able to channel enrollees to preferred providers. This results in incentives for healthcare providers to improve the quality and reduce the price of care. One of the instruments to guide enrollees to preferred providers is by providing healthcare advice. In order to use healthcare advice as an effective instrument, it is important that enrollees accept the health insurer as a healthcare advisor. As trust in health insurers is not high, this may be an obstacle for enrollees to be receptive to the health insurer's advice. This study aims to investigate the association between trust in the health insurer and the willingness to receive healthcare advice from the health insurer in the Netherlands. In terms of receiving healthcare advice, we examine both enrollees' willingness to approach the health insurer themselves and their willingness to be approached by the health insurer. METHODS: In February 2021, a questionnaire was sent to a representative sample of the Dutch population. The questionnaire was completed by 885 respondents (response rate 59%). Respondents were asked about their willingness to receive healthcare advice, and trust in the health insurer was measured using a validated multiple item scale. Logistic regression models were conducted to analyse the results. RESULTS: Enrollees with more trust in the health insurer were more willing to approach their health insurer for healthcare advice (OR = 1.07, p = 0.00). In addition, a higher level of trust in the health insurer is significantly associated with the odds that enrollees would like it/really appreciate it if their health insurer actively approached them with healthcare advice (OR = 1.07, p = 0.00). The role of trust in the willingness to receive healthcare advice is not proven to differ between groups with regard to educational levels, health status or age. CONCLUSIONS: This study confirms that trust plays a role in the willingness to receive healthcare advice from the health insurer. The association between the two emphasizes the importance to increase enrollees' trust in the health insurer. As a result, health insurers may be better able to fulfil their role as healthcare advisor.

Measures to improve patient needs assessments and reduce practice variation in Dutch home care organizations.

AIM: Worldwide, long-term care tends to shift from institutional care towards home care. In order to deliver high-quality and adequate care, the type, amount and cost of care is determined by a patient needs assessment. However, there are indications that this patient needs assessment varies between comparable patients. In the Netherlands, some home care organizations aim to improve patient needs assessments by implementing improvement measures to reduce this practice variation. The goal of this study was to explore the type and perceived impact of those implemented improvement measures. DESIGN: A cross-sectional explorative survey study was conducted among Dutch home care organizations between January and April 2021. METHODS: An online questionnaire with 26 items was developed by the research team, which was distributed through Dutch nationwide home care sector organizations, the Dutch nurses' association (V&VN) and the Dutch society for home care nursing (NWG). RESULTS: The survey was completed by 184 respondents, including home care nurses, managers and staff who are responsible for training, policy and quality of care. Intervision and peer review for home care nurses were the most common reported improvement measures that were implemented in home care organizations. The experiences of those improvement measures have been perceived as creating greater uniformity in the patient needs assessment, making home care nurses feel more supported and secure performing their patient needs assessment and that the provided care is more in line with patients' demand. Our findings give insights into type and perceived impact of improvement measures that Dutch home care organizations implemented. Further research is needed to find out whether improvement measures actually improve patient needs assessments and reduce practice variation.

Measuring health insurance literacy in the Netherlands - First results of the HILM-NL questionnaire.

BACKGROUND: There are several indications that citizens in the Netherlands struggle to make critical, well-considered decisions about which insurance policy best fits their needs and preferences. This can lead to citizens being sub-optimally insured, facing unexpected costs or suffering inadequate coverage. This study aims to examine how health insurance literacy (HIL) is distributed among citizens in the Netherlands; and to find out whether there are certain groups who have more difficulty choosing and using a health insurance policy. METHODS: We measured health insurance literacy using the HILM-NL questionnaire, the validated Dutch version of the original health insurance literacy measure (HILM). In February 2020, the HILM-NL was sent to 1,500 members of the Nivel Dutch Health Care Consumer Panel. The response rate was 54% (806). RESULTS: There is a wide variation in HIL among citizens in the Netherlands. The average total HILM-NL score is 55.14 (on a range of 21-84). The level of education and the household net income are significantly related to HIL. CONCLUSIONS: Citizens who completed less education or earn a lower income are relatively more likely to have difficulty choosing a health insurance policy or using policy benefits to pay for health services once enrolled. It is important to support these vulnerable groups properly in their choice and use of a health insurance policy.

To what degree are health insurance enrollees in the Netherlands aware of the restrictive conditions attached to their policies?

BACKGROUND: Within the Dutch healthcare system of managed competition, health insurers can contract healthcare providers selectively. Enrollees who choose a health insurance policy with restrictive conditions will have to make a co-payment if they consult a non-contracted provider. This study aims to gain insight into enrollees' awareness of the conditions of such health insurance policies. METHODS: In August 2020, an online questionnaire was sent out via health insurers to their enrollees with restrictive health plans. In total 13,588 enrollees responded. RESULTS: One fifth of the respondents appeared to be totally unfamiliar with the policy conditions. Men, younger people, people with a low level of education, a lower income, a poorer health status and non-care users were found to be less familiar with the conditions. Of those who have been in the situation that they wanted to visit a healthcare provider whose care was not fully reimbursed, 62% went to that provider. Of those who had to pay extra because hospital care was not fully reimbursed, 62% did not know this in advance and 30% indicated that paying extra was a serious problem. CONCLUSIONS: Not all enrollees who choose a policy with restrictive conditions are aware of the consequences of receiving care from non-contracted providers. Increased awareness among enrollees will benefit the functioning of the healthcare system based on managed competition.

The Importance of Choosing a Health Insurance Policy and the Ability to Comprehend That Choice for Citizens in the Netherlands.

BACKGROUND: In a health insurance system based on managed competition, such as in the Netherlands, it is important that all citizens can make well-informed decisions on which policy fits their needs and preferences best. However, partly due to the large variety of health insurance policies, there are indications that a significant group of citizens do not make rational decisions when choosing a policy. OBJECTIVE: This study aimed to provide more insight into (1) how important it is for citizens in the Netherlands to choose a health insurance policy and (2) how easy it is for them to comprehend the information they receive. METHODS: Data were collected by sending a survey to members of the Nivel Dutch Health Care Consumer Panel in February 2017. The response rate was 44% (N = 659). KEY RESULTS: Our results indicate that citizens in the Netherlands acknowledge the importance of choosing a health insurance policy, but they also point out that it is difficult to comprehend health insurance information. CONCLUSION: Our findings suggest that a section of the citizens do not have the appropriate skills to decide which insurance policy best fits their needs and preferences. Having better insight into their level of health insurance literacy is an important step in the process of evaluating the extent to which citizens can fulfill their role in the health insurance system. Our results suggest that it is important to better tailor information on health insurances to the specific needs and skills of the individual. By doing this, citizens will be better supported in making well-informed decisions regarding health insurance policies, which should have a positive effect on the functioning of the Dutch health insurance system. [HLRP: Health Literacy Research and Practice. 2021;5(4):e287-e294.] Plain Language Summary: The number of health insurance policy options to choose from is extensive in the Netherlands. This study explored to what extent citizens in the Netherlands find it important to choose a health insurance policy, and to what extent they comprehend the information they receive. The data were collected in 2017 using the Nivel Dutch Health Care Consumer Panel.

Does the chronically ill population in the Netherlands switch their health insurer as often as the general population? Empirical evidence from a nationwide survey study.

BACKGROUND: Consumer mobility is an important aspect of a health insurance system based on managed competition. Both the general population and insured with a chronic illness should enjoy an equal opportunity to switch their insurer every year. We studied possible differences in the rates of switching between these two groups in the Netherlands. METHODS: A structured questionnaire was sent to 1500 members of Nivel's Dutch Health Care Consumer Panel (response rate: 47%) and to 1911 chronically ill members of the National Panel of the Chronically ill and Disabled (response rate: 84%) in February 2016. Associations between switching and background characteristics were estimated using logistic regression analyses with interaction effects. RESULTS: In general, we did not find significant differences in switching rates between the general population and chronically ill population. However, a combination of the population and background characteristics demonstrated that young insured with a chronic illness switched significantly less often than young insured from the general population (1% versus 17%). CONCLUSIONS: Our results demonstrated that the group of young people with a chronic illness is less inclined to switch insurer. This observation suggests that this group might either face difficulties or barriers which prevents them from switching, or that they experience a high level of satisfaction with their current insurer. Further research should therefore focus on unravelling the mechanisms which explain the differences in switching rates.

Why do people not switch insurer in a market-based health insurance market? Empirical evidence from the Netherlands.

BACKGROUND: In market-based systems, the possibility to switch is an important precondition for a well-functioning health insurance market. To assess whether such a market works as intended, insight into the considerations and perceived barriers of insured is needed. This study examines the rates and reasons for not switching health insurer in the Netherlands, and whether these reasons differ between the general population and the population of people with a chronic illness. METHODS: We made use of survey data collected in 2017 among two panels representing the general population (n = 659, response 44%) and the chronically ill population (n = 1593, response 86%). RESULTS: We found differences regarding the reasons for not switching insurer. The chronically ill population seems to attach more importance to reasons related to the coverage of the health plan, whereas the general population is more focused on the level of service. Some people who considered switching experienced barriers, however, these barriers were not significantly more experienced by the chronically ill population. CONCLUSIONS: This study reveals differences between the general population and the chronically ill population when examining reasons for not switching related to quality and coverage. A subset from the people who initially considered to switch experienced barriers which might have altered their decision. Further research is recommended to include questions about information search behaviour to examine which consumers make an informed decision for not switching, and for whom barriers limit switching.

Does shared decision-making reduce antibiotic prescribing in primary care?

Background: Increasing antibiotic resistance is recognized as a major threat to global health and is related to antibiotic prescription rates in primary care. Shared decision-making (SDM), the process in which patients and doctors participate together in making decisions, is argued to possibly promote more appropriate use of antibiotics and reduce prescribing. However, it is unknown whether in practice fewer antibiotics are prescribed where more SDM takes place. Objectives: To investigate whether more SDM is related to less antibiotic prescribing and whether this relationship differs between subgroups of patients (male/female and age groups). Patients and methods: A questionnaire survey was conducted among 2670 members of the Dutch Health Care Consumer Panel to measure SDM (response rate 45%). Average practice-level SDM scores were calculated for 15 general practices. Data from routine electronic health records of 8192 adult patients of these general practices participating in the Nivel Primary Care Database were used to assess relevant illness episodes (acute cough, acute rhinosinusitis and urinary tract infection), the indication for antibiotics and antibiotic prescriptions. Logistic multilevel regression analyses were performed to investigate the relationship between practice-level SDM and patient-level antibiotic prescriptions. Results: In practices where more SDM takes place, general practitioners prescribed fewer antibiotics for adult patients under the age of 40 years in preference-sensitive situations (i.e. situations in which antibiotics could be considered according to clinical guidelines). Conclusions: SDM can be a framework to reduce the prescribing of antibiotics and thus to control antibiotic resistance.

Increased cost sharing and changes in noncompliance with specialty referrals in The Netherlands.

INTRODUCTION: The compulsory deductible, a form of patient cost-sharing in the Netherlands, has more than doubled during the past years. There are indications that as a result, refraining from medical care has increased. We studied the relation between patient cost-sharing and refraining from medical care by evaluating noncompliance with referrals to medical specialists over several years. METHODS: Noncompliance with specialty referrals was assessed in the Netherlands from 2008 until 2013, using routinely recorded referrals from general practitioners to medical specialists and claims from medical specialists to health insurers. Associations with patient characteristics were estimated using multilevel logistic regression analyses. RESULTS: Noncompliance rates were approximately stable from 2008 to 2010 and increased from 18% in 2010 to 27% in 2013. Noncompliance was highest in adults aged 25-39 years. The increase was highest in children and patients with chronic diseases. No significantly higher increase among patients from urban deprived areas was found. DISCUSSION/CONCLUSION: Noncompliance increased during the rise of the compulsory deductible. Our results do not suggest a one-to-one relationship between increased patient cost-sharing and noncompliance with specialty referrals. In order to develop effective policy for reducing noncompliance, it is advisable to focus on the mechanisms for noncompliance in the groups with the highest noncompliance rates (young adults) and with the highest increase in noncompliance (children and patients with chronic diseases).

Do social norms play a role in explaining involvement in medical decision-making?

BACKGROUND: Patients' involvement in medical decision-making is crucial to provide good quality of care that is respectful of, and responsive to, patients' preferences, needs and values. Whether people want to be involved in medical decision-making is associated with individual patient characteristics, and health status. However, the observation of differences in whether people want to be involved does not in itself provide an explanation. Insight is necessary into mechanisms that explain people's involvement. This study aims to examine one mechanism, namely social norms. We make a distinction between subjective norms, that is doing what others think one ought to do, and descriptive norms, doing what others do. We focus on self-reported involvement in medical decision-making. METHODS: A questionnaire was sent to members of the Dutch Health Care Consumer Panel in May 2015 (response 46%; N = 974). A regression model was used to estimate the relationship between socio-demographics, social norms and involvement in medical decision-making. RESULTS: In line with our hypotheses, we observed that the more conservative social norms are, the less people are involved in medical decision-making. The effects for both types of norms were comparable. CONCLUSION: This study indicates that social norms play a role as a mechanism to explain involvement in medical decision-making. Our study offers a first insight into the possibility that the decision to be involved in medical decision-making is not as individual as it at first seems; someone's social context also plays a role. Strategies aimed at emphasizing patient involvement have to address this social context.

Does a strategy to promote shared decision-making reduce medical practice variation in the choice of either single or double embryo transfer after in vitro fertilisation? A secondary analysis of a randomised controlled trial.

OBJECTIVES: The hypothesis that shared decision-making (SDM) reduces medical practice variations is increasingly common, but no evidence is available. We aimed to elaborate further on this, and to perform a first exploratory analysis to examine this hypothesis. This analysis, based on a limited data set, examined how SDM is associated with variation in the choice of single embryo transfer (SET) or double embryo transfer (DET) after in vitro fertilisation (IVF). We examined variation between and within hospitals. DESIGN: A secondary analysis of a randomised controlled trial. SETTING: 5 hospitals in the Netherlands. PARTICIPANTS: 222 couples (woman aged <40 years) on a waiting list for a first IVF cycle, who could choose between SET and DET (ie, ≥2 embryos available). INTERVENTION: SDM via a multifaceted strategy aimed to empower couples in deciding how many embryos should be transferred. The strategy consisted of decision aid, support of IVF nurse and the offer of reimbursement for an extra treatment cycle. Control group received standard IVF care. OUTCOME MEASURE: Difference in variation due to SDM in the choice of SET or DET, both between and within hospitals. RESULTS: There was large variation in the choice of SET or DET between hospitals in the control group. Lower variation between hospitals was observed in the group with SDM. Within most hospitals, variation in the choice of SET or DET appeared to increase due to SDM. Variation particularly increased in hospitals where mainly DET was chosen in the control group. CONCLUSIONS: Although based on a limited data set, our study gives a first insight that including patients' preferences through SDM results in less variation between hospitals, and indicates another pattern of variation within hospitals. Variation that results from patient preferences could be potentially named the informed patient rate. Our results provide the starting point for further research. TRIAL REGISTRATION NUMBER: NCT00315029; Post-results.

The relative effect of health literacy and patient activation on provider choice in the Netherlands.

Active provider choice by patients has become an important policy theme in western, countries over the last decades. However, not many patients and consumers exercise their right to, choose. Both health literacy and patient activation are likely to have an impact on the choice process. In, this article the relative effect of health literacy and patient activation on provider choice in the, Netherlands is studied. A questionnaire was sent to a representative sample of 2000 Dutch citizens. The questionnaire, included a measure of functional health literacy, the Dutch version of the Patient Activation Measure, and questions assessing active provider choice, reasons not to engage in it and other ways of provider, selection. The majority of respondents (59.6%) would not search for information on the basis of which they, could select the best provider or hospital. Most people rely on their general practitioner's advice. Both, low literacy and lower patient activation levels were negatively associated with active provider choice. In a regression analysis gender, education and patient activation proved the most important, predictors. The policy focus on active provider choice might result in inequity, with men, less educated, and less activated people being at a disadvantage.

Does market exclusivity hinder the development of Follow-on Orphan Medicinal Products in Europe?

BACKGROUND: We determined whether the market exclusivity incentive of the European Orphan Drug Regulation results in a market monopoly or that absence of another Orphan Medicinal Product (OMP) for the same rare disorder, a so-called follow-on OMP, is a matter of time or market size. In the interest of rare disorder patients better understanding of the effect of the market exclusivity incentive on follow-on OMP development is warranted. METHODS: First, the impact of various market-, product- and disease-related characteristics on follow-on OMP development in the EU was determined by comparing rare disorders with an approved OMP and at least one follow-on OMP (N = 26), with rare disorders with an approved OMP and no follow-on OMP (N = 18). Next, we determined whether manufacturers continued development of a follow-on OMP upon approval of the first OMP for the intended rare disorder. Since in the EU significant benefit of an OMP has to be established, we determined for each follow-on OMP for which development was continued on what grounds significant benefit was assumed by the sponsor. Data were collected from the public domain only. RESULTS: The likelihood of a rare disorder with an approved OMP to obtain at least one follow-on OMP development was strongly associated with disease prevalence, turnover of the first OMP, disease class, disease-specific scientific output and age of onset. Out of a total of 120 follow-on OMPs only one follow-on OMP could be identified for which development was discontinued upon approval of the first OMP for the same rare disorder. Only a substantial level of discontinuation of follow-on OMP development would have indicated the existence of a market monopoly. Moreover, sponsors that continued development of a follow-on OMP predominantly assumed that their product had an improved efficacy compared to the first approved OMP. CONCLUSIONS: This study provides evidence that absence of follow-on OMP development is a matter of time or market size, rather than that the market exclusivity incentive of the European Orphan Drug Regulation creates a market monopoly.