Healthcare reform in the Netherlands: after 15 years of regulated competition.

This article discusses the results and prospects of the market reform in Dutch health care which came into force in 2006. Attention is paid to the results of the health insurance reform, the experience with the shift from passive to active purchasing and the impact of the reform on healthcare provision and cost control respectively. Other topics discussed are the consequences of the reform for administrative costs, institutional trust in health insurance, and the power balance in health care after reform. The central message is that the high expectations of the market reform have not come true. Dutch health care features a high degree of hybridity and there are indications that the system is becoming ever more hybrid: the system operates much less market-like than the market frame suggests. Currently, the policy narrative on the reform is changing. Policymakers and policy documents underscore the need for cooperation in provider networks and more state direction. The Dutch experience with health care reform illustrates the pendulum theory. After a period of a belief in competition and less state direction the pendulum in policymaking swings back to a belief in cooperation and a pro-active role of the state.

Measuring Active Purchasing in Healthcare: Analysing Reallocations of Funds Between Providers to Evaluate Purchasing Systems Performance in the Netherlands.

BACKGROUND: Purchasing systems aim to improve resource allocation in healthcare markets. The Netherlands is characterized by four different purchasing systems: managed competition in the hospital market, a non-competitive single payer system for long-term care (LTC), municipal procurement for home care and social services, and self-procurement via personal budgets. We hypothesize that managed competition and competitive payer reforms boost reallocations of provider market share by means of active purchasing, ie, redistributing funds from high-quality providers to low-quality providers. METHODS: We define a Market Activity Index (MAI) as the sum of funds reallocated between providers annually. Provider expenditures are extracted from provider financial statements between 2006 and 2019. We compare MAI in six healthcare sectors under four different purchasing systems, adjusting for reforms, and market entry/exit. Next, we perform in-depth analyses on the hospital market. Using multivariate linear regressions, we relate reallocations to selective contracting, provider quality, and market characteristics. RESULTS: No difference was found between reallocations in the hospital care market under managed competition and the non-competitive single payer LTC (MAI between 2% and 3%), while MAI was markedly higher under procurement by municipalities and personal budget holders (between 5% and 15%). While competitive reforms temporarily increased MAI, no structural effects were found. Relatively low hospital MAI could not be explained by market characteristics. Furthermore, the extent of selective contracting or hospital quality differences had no significant effects on reallocations of funds. CONCLUSION: Dutch managed competition and competitive purchaser reforms had no discernible effect on reallocations of funds between providers. This casts doubt on the mechanisms advocated by managed competition and active purchasing to improve allocative efficiency.

The market reform in Dutch health care: results, lessons and prospects

In January 2006 the Dutch embarked upon a reform of their health care system based upon the principles of regulated competition (Enthoven, 1988). The flagship of the reform was the Health Insurance Act Zorgverzekeringswet), which integrated statutory health insurance and all other (mainly private) health insurance schemes into a single mandated health insurance scheme with free consumer choice that covered the entire population. In the new system, consumers were given free choice of an insurer in order to trigger competition. Private insurers would act as prudent purchasers of health services on behalf of their clients, offering them an attractive health plan in terms of quality and costs. For their part, providers would compete for contracts with insurers. The main policy goals (in policy documents often referred to as public values) of this “market reform” were to achieve a health care system offering high-quality care to patients that would be accessible to every person (universal access), based upon solidarity and affordability (financial sustainability). Another goal of the reform was to enhance freedom of choice. The primary function of the state was to regulate health care and preserve the public values in health care. The Netherlands now has 15 years of experience with regulated competition among private health insurers. This is enough time to find out how the system has worked in practice and what can be learned from the Dutch experience.

Low institutional trust in health insurers in Dutch health care.

A central element of the 2006 health insurance reform in the Netherlands is strategic purchasing by health insurers. After a brief elaboration of the concept of trust this article discusses the trust of insured in the new purchasing role of health insurers. There are various indications of a trust problem or credible commitment problem in Dutch health care. Insured say to trust their own health insurer (specific trust) but also say to have little trust in the behaviour of health insurers in general(institutional trust). The article briefly explores four models to explain the trust problem: the lack-of information model, the anticompetition model, the pro-profession model and the political communication model. A critical analysis demonstrates that the 'objective ground' for low institutional trust is rather questionable. Low trust seems to be based more on perceptions than on the insurers' objective purchasing behaviour. The article ends with a discussion on some potential strategies to address the trust problem. Low institutional trust may be something insurers have to live with.

New Provider Models for Sweden and Spain: Public, Private or Non-profit? Comment on "Governance, Government, and the Search for New Provider Models".

Sweden and Spain experiment with different provider models to reform healthcare provision. Both models have in common that they extend the role of the for-profit sector in healthcare. As the analysis of Saltman and Duran demonstrates, privatisation is an ambiguous and contested strategy that is used for quite different purposes. In our comment, we emphasize that their analysis leaves questions open on the consequences of privatisation for the performance of healthcare and the role of the public sector in healthcare provision. Furthermore, we briefly address the absence of the option of healthcare provision by not-for-profit providers in the privatisation strategy of Sweden and Spain.

Policy options to contain healthcare costs: a review and classification.

Containing health care costs has been a challenge for most OECD member states. We classify 2250 cost containment policies in forty-one groups of policy options. This conceptual framework might act as a toolkit for policymakers that seek to develop strategies for cost control; and for researchers that seek to evaluate them. We found that certain important cost drivers such as wages and capital are being sparsely covered. We distinguish four primary targets to contain costs: volume controls, price controls, budgeting and market oriented policies. Price controls and budgeting, both seen as relatively effective, appear substantially less often in literature than volume controls and market oriented policies. The relative use of each option hardly changed over time, although the health system type did matter. Market oriented policies were more likely to be suggested for countries with public provision of health care, as well as for the US system. In contrast, budgeting policy proposals were more likely to be suggested for countries with market provision systems, such as Canada, Germany and France. Implementation of cost containment policies could lead to convergence of health care systems, except for the US system, if policies are implemented based on the literature.

Private capital investments in health care provision through mergers and acquisitions: from long-term to acute care.

OBJECTIVES: This work aims to test whether different segments of healthcare provision differentially attract private capital and thus offer heterogeneous opportunities for private investors' diversification strategies. METHODS: Thomson Reuter's SDC Platinum database provided data on 2563 merger and acquisition (M&A) deals targeting healthcare providers in Western Europe between 1990 and 2010. Longitudinal trends of industrial and geographical characteristics of M&As' targets and acquirers are examined. RESULTS: Our analyses highlight: (i) a relative decrease of long-term care facilities as targets of M&As, replaced by an increasing prominence of general hospitals, (ii) a shrinking share of long-term care facilities as targets of financial service organizations' acquisitions, in favor of general hospitals, and (iii) an absolute and relative decrease of long-term care facilities' role as target of cross-border M&As. CONCLUSIONS: We explain the decreasing interest of private investors towards long-term care facilities along three lines of reasoning, which take into account the saturation of the long-term care market and the liberalization of acute care provision across Western European countries, regulatory interventions aimed at reducing private ownership to ensure resident outcomes and new cultural developments in favor of small-sized facilities, which strengthen the fragmentation of the sector. These findings advance the literature investigating the effect of private ownership on health outcomes in long-term facilities. Market, policy and cultural forces have emerged over two decades to jointly regulate the presence of privately owned, large-sized long-term care providers, seemingly contributing to safeguard residents' well-being. Copyright © 2016 John Wiley & Sons, Ltd.

Retaining health workforce in rural and underserved areas of India: What works and what doesn't? A critical interpretative synthesis.

BACKGROUND: Human resource for health is critical in quality healthcare delivery. India, with a large rural population (68.8%), needs to urgently bridge the gaps in health workforce deployment between urban and rural areas. METHODS: We did a critical interpretative synthesis of the existing literature by using a predefined selection criteria to assess relevant manuscripts to identify the reasons for retaining the health workforce in rural and underserved areas. We discuss different strategies for retention of health workforce in rural areas on the basis of four major retention interventions, viz. education, regulation, financial incentives, and personal and professional support recommended by WHO in 2010. This review focuses on the English-language material published during 2005-14 on human resources in health across low- and middle-income countries. RESULTS: Healthcare in India is delivered through a diverse set of providers. Inequity exists in health manpower distribution across states, area (urban-rural), gender and category of health personnel. India is deficient in health system development and financing where health workforce education and training occupy a low priority. Poor governance, insufficient salary and allowances, along with inability of employers to provide safe, satisfying and rewarding work conditions-are causing health worker attrition in rural India. The review suggests that the retention of health workers in rural areas can be ensured by multiplicity of interventions such as medical schools in rural areas, rural orientation of medical education, introducing compulsory rural service in lieu of incentives providing better pay packages and special allowances, and providing better living and working conditions in rural areas. CONCLUSIONS: A complex interplay of factors that impact on attraction and retention of health workforce necessitates bundling of interventions. In low-income countries, evidence- based strategies are needed to ensure context-specific, field- tested and cost-effective solutions to various existing problems. To ensure retention these strategies must be integrated with effective human resource management policies and rural orientation of the medical education system.

Results of the market-oriented reform in the Netherlands: a review.

The market-oriented reform in the Dutch health care system is now in its 10th year. This article offers a concise overview of some of its effects thus far on health insurance, healthcare purchasing and healthcare provision. Furthermore, attention is given to its impact on healthcare expenditures, power and trust relationships as well as the relationship between the Minister of Health and the Dutch Healthcare Authority. The reform triggered various alterations in Dutch health care some occurring quickly (e.g. health insurance), others taking longer (e.g. purchasing). These developments suggest a process of gradual transformation. The reform has instigated controversy which is increasingly framed as a power conflict between insurers and providers. Weakened consumer trust in insurers threatens the legitimacy of the reform. The relationship between Minister and Healthcare Authority appears to be more intimate than the formal independent status of this regulatory agency would suggest.

The use of publicly available quality information when choosing a hospital or health-care provider: the role of the GP.

BACKGROUND: Patients barely use publicly available quality information for making a decision concerning secondary health care, but instead rely on information coming from their general practitioner (GP). An intermediate role of GPs has been suggested concerning the use of publicly available quality information. The aim of the study is to quantify and explore GPs' use of publicly available quality information when referring patients or suggesting secondary health-care provider to them. METHODS: In this cross-sectional study, an invitation to an electronic questionnaire was sent to 858 GPs in the south of the Netherlands. GPs were asked about their use of and perception towards publicly available quality information through closed-ended and open-ended questions. Differences among subgroups were tested for significance using Pearson's chi-square tests. RESULTS: The majority of respondents (89.5%) never or rarely use publicly available quality information. They perceive them as invalid and unreliable. Distance to the hospital, prior experiences and personal contacts with specialists guide them when advising and referring. Almost 90% of respondents never or rarely suggest quality information as support for decision making to their patients. No significant differences between subgroups were observed. CONCLUSION: This study is among the firsts exploring and quantifying GPs' use of publicly available quality information. The results suggest that publicly available quality information appears in its current format and application not useful for GPs. GPs have to be aware of their influential role in patients' decision making and possibly have to take more responsibility in guiding them through the jungle of quality information.

Challenging Health in All Policies, an action research study in Dutch municipalities.

The Dutch government encourages municipalities to develop 'Health in All Policies' (HiAP). The development of such a policy requires inter-sectoral collaboration, however municipalities show little initiative in this regard. Operating in an advisory role, the regional Public Health Service (PHS) has supported municipalities in South-Limburg in setting up inter-sectoral collaboration. A coaching program for municipal stakeholders was developed and implemented to improve HiAP, using obesity as an example. To determine the effectiveness of this coaching program, civil servants, managers and municipal councilors were invited to fill in an Internet questionnaire prior to and at the completion of the program. By means of a log-book all activities were registered in coached municipalities and in-depth interviews were held with municipal managers. Outcomes were scored depending on the stage of HiAP proposals. Six of the nine coached municipalities showed concrete outcomes in terms of HiAP proposals. The results show that more support and involvement at each system level stimulates the development of HiAP. The program contributed positively to the implementation of HiAP interventions targeting obesity. The pretest results for coached municipalities were better compared to non-coached municipalities. However, after 30 months of coaching this positive starting position faded away. We recommend that the municipal management become more involved in the development of HiAP and advise the PHS to increasingly demonstrate their expertise. Here lies a challenge for municipalities and their regional PHS.

Mergers and acquisitions in Western European health care: exploring the role of financial services organizations.

Recent policy developments in Western European health care - for example in the Netherlands - aim to enhance efficiency and curb public expenditures by strengthening the role of private sector. Mergers and acquisitions (M&As) play an important role in this respect. This article presents an analysis of 1606 acquisition deals targeting health care provider organizations in Western Europe between 1990 and 2009. We particularly investigate the role of financial services organisations as acquirers. Our analysis highlights (a) a rise of M&As in Western Europe since 2000, (b) an increase of M&As with financial service organisations acting as acquirer in absolute terms, and (c) a dominant role of the latter type of M&As in cross-border deals. To explain these developments, we make a distinction between an integration and a diversification rationale for M&As and we argue that the deals with financial services organisations in the role of acquirer are driven by a diversification rationale. We then provide arguments why health care, from the acquirer's perspective, can be considered as an interesting target in a diversification strategy and we advance reasons why health care providers may welcome this development. Although caution in drawing conclusions is needed, our findings suggest a penetration of private capital into health care provision that may be interpreted as a specific form of privatisation. Furthermore, they point to a rising internationalisation of health care. Both findings may entail far-reaching implications for health care, as they may induce both cultural privatisation and cultural internationalisation.

Travelling home for treatment and EU patients' rights to care abroad: results of a survey among German students at Maastricht University.

Empirical evidence on patient mobility in Europe is lacking despite widespread legal, policy and media attention which the phenomenon attracts. This paper presents quantitative data on the health care seeking behaviour of German students at Maastricht University in the Netherlands. A cross-sectional survey design was applied with a mixed-methods approach including open and closed questions. Questionnaire items were based on a theoretical model of patient mobility and input from focus group discussions with German students living in Maastricht. 235 valid surveys were completed, representing ca. 8% of the target population. Data collection took place in Oct-Dec 2010. Of respondents who received medical care over the last two years, 97% returned to Germany; of these, 76% travelled to their home city for medical treatment. 72% received care only in Germany, i.e. not even once in Maastricht. Distance partly influenced whether students travelled to Germany, returned home or stayed in Maastricht, and the type of care accessed. Key motivations were familiarity with home providers/system, and reimbursement issues. In the context of the new EU Directive on patients' rights, the findings call into question whether Europeans use entitlements to cross-border care and what the real potential of patient mobility is. The results demonstrate the existence and magnitude of return movements as a sub-group of patient mobility.

How do patient characteristics influence informal payments for inpatient and outpatient health care in Albania: results of logit and OLS models using Albanian LSMS 2005.

BACKGROUND: Informal payments for health care are common in most former communist countries. This paper explores the demand side of these payments in Albania. By using data from the Living Standard Measurement Survey 2005 we control for individual determinants of informal payments in inpatient and outpatient health care. We use these results to explain the main factors contributing to the occurrence and extent of informal payments in Albania. METHODS: Using multivariate methods (logit and OLS) we test three models to explain informal payments: the cultural, economic and governance model. The results of logit models are presented here as odds ratios (OR) and results from OLS models as regression coefficients (RC). RESULTS: Our findings suggest differences in determinants of informal payments in inpatient and outpatient care. Generally our results show that informal payments are dependent on certain characteristics of patients, including age, area of residence, education, health status and health insurance. However, they are less dependent on income, suggesting homogeneity of payments across income categories. CONCLUSIONS: We have found more evidence for the validity of governance and economic models than for the cultural model.

The politics of health-care reform in the Netherlands since 2006.

This article comments on Schut and van de Ven's overview of the results of purchaser competition in Dutch health care, which concludes that the glass can be seen as half full or half empty. Although it is true that results have been achieved, we believe that the evidence is incomplete and in some respects flimsy. More importantly, however, Schut and van de Ven neglect the political context of the market reform introduced in 2006. The reform is far from finished and there has been a constant need for political compromise. Optimism about the market's potential also seems to be on the wane. Several insurer and provider initiatives have provoked political resistance. As a result, there are good reasons to argue that the reform's future is uncertain.

European policymaking on the tobacco advertising ban: the importance of escape routes.

This article analyses the European Union policymaking process regarding tobacco advertising. While others already highlighted the importance of intergovernmental bargaining between member states to explain the outcome of the tobacco advertising case, the main aim of this article is to identify the use of escape routes by the Commission, the European Parliament, the Council and interest groups that played an important role in overcoming the deadlock. When looking at the different institutions that structure policymaking, we argue that indeed focusing on escape routes provides a clear insight in the process and in what strategies were necessary to 'make Europe work'. In the end, it appears to be a combination of escape routes that resulted in the final decision.

A typology of cross-border patient mobility.

Based on systematic observation and analysis of available evidence, we propose a typology of cross-border patient mobility (rather than the so-called 'medical tourism') defined as the movement of a patient travelling to another country to seek planned health care. The typology is constructed around two dimensions based on the questions 'why do patients go abroad for planned health care?' and 'how is care abroad paid for?' Four types of patient motivations and two funding types have been identified. Combined in a matrix, they make eight possible scenarios of patient mobility each illustrated with international examples.