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.

Dynamic Public Perceptions of the Coronavirus Disease Crisis, the Netherlands, 2020.

A key component of outbreak control is monitoring public perceptions and public response. To determine public perceptions and public responses during the first 3 months of the coronavirus disease (COVID-19) outbreak in the Netherlands, we conducted 6 repeated surveys of ≈3,000 persons. Generalized estimating equations analyses revealed changes over time as well as differences between groups at low and high risk. Overall, respondents perceived the risks associated with COVID-19 to be considerable, were positive about the mitigation measures, trusted the information and the measures from authorities, and adopted protective measures. Substantial increases were observed in risk perceptions and self-reported protective behavior in the first weeks of the outbreak. Individual differences were based mainly on participants' age and health condition. We recommend that authorities constantly adjust their COVID-19 communication and mitigation strategies to fit public perceptions and public responses and that they tailor the information for different groups.

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 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.

To what degree do patients actively choose their healthcare provider at the point of referral by their GP? A video observation study.

BACKGROUND: Many countries in Europe have implemented managed competition and patient choice during the last decade. With the introduction of managed competition, health insurers also became an important stakeholder. They purchase services on behalf of their customers and are allowed to contract healthcare providers selectively. It has, therefore, become increasingly important to take one's insurance into account when choosing a provider. There is little evidence that patients make active choices in the way that policymakers assume they do. This research aims to investigate, firstly, the role of patients in choosing a healthcare provider at the point of referral, then the role of the GP and, finally, the influence of the health insurer/insurance policies within this process. METHODS: We videotaped a series of everyday consultations between Dutch GPs and their patients during 2015 and 2016. In 117 of these consultations, with 28 GPs, the patient was referred to another healthcare provider. These consultations were coded by three observers using an observation protocol which assessed the role of the patient, GP, and the influence of the health insurer during the referral. RESULTS: Patients were divided into three groups: patients with little or no input, patients with some input, and those with a lot of input. Just over half of the patients (56%) seemed to have some, or a lot of, input into the choice of a healthcare provider at the point of referral by their GP. In addition, in almost half of the consultations (47%), GPs inquired about their patients' preferences regarding a healthcare provider. Topics regarding the health insurance or insurance policy of a patient were rarely (14%) discussed at the point of referral. CONCLUSIONS: Just over half of the patients appear to have some, or a lot of, input into their choice of a healthcare provider at the point of referral by their GP. However, the remainder of the patients had little or no input. If more patient choice continues to be an important aim for policy makers, patients should be encouraged to actively choose the healthcare provider who best fits their needs and preferences.

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.

Advice from the health insurer as a channelling strategy: a natural experiment at a Dutch health insurance company.

BACKGROUND: In a health care system based on managed competition it is important that health insurers are able to channel their enrolees to preferred care providers. However, enrolees are often very negative about financial incentives and any limitations in their choice of care provider. Therefore, a Dutch health insurance company conducted an experiment to study the effectiveness of a new method of channelling their enrolees. This method entails giving enrolees advise on which physiotherapists to choose when they call customer service. Offering this advice as an extra service is supposed to improve service quality ratings. Objective of this study is to evaluate this channelling method on effectiveness and the impact on service quality ratings. METHODS: In this experiment, one of the health insurer's customer service call teams (pilot team) began advising enrolees on their choice of physiotherapist. Three data sources were used. Firstly, all enrolees who called customer service received an online questionnaire in order to measure their evaluation of the quality of service. Enrolees who were offered advice received a slightly different questionnaire which, in addition, asked about whether they intended to follow the advice they were offered. Multilevel regression analysis was conducted to analyse the difference in service quality ratings between the pilot team and two comparable customer service teams before and after the implementation of the channelling method. Secondly, employees logged each call, registering, if they offered advice, whether the enrolee accepted it, and if so, which care provider was advised. Thirdly, data from the insurance claims were used to see if enrolees visited the recommended physiotherapist. RESULTS: The results of the questionnaire show that enrolees responded favorably to being offered advice on the choice of physiotherapist. Furthermore, 45% of enrolees who received advice and then went on to visit a care provider, followed the advice. The service quality ratings were higher compared to control groups. However, it could not be determined whether this effect was entirely due to the intervention. CONCLUSIONS: Channelling enrolees towards preferred care providers by offering advice on their choice of care provider when they call customer service is successful. The effect on service quality seems positive, although a causal relationship could not be determined.

[The conversation with the patient is essential for good pharmacotherapeutic care]. / Het gesprek met de patiënt is essentieel voor goede farmacotherapeutische zorg.

Frail elderly with polypharmacy are at greater risk of preventable medication-related health damage. To improve medication safety, the healthcare field prepared, in consultation with the Dutch Health Care Inspectorate, a number of guidelines and standards containing conditions for safe prescribing. According to these standards the active involvement of patients by health care professionals is essential for good pharmacotherapeutic care. However, two studies with patients show that there is still room for improvement. According to patients, they can be (even) better informed about changes in their medication. Also the caregivers could communicate more clearly who is the central contact point and who is ultimately responsible for the medication. Patients are not sufficiently informed on this. Furthermore, there is uncertainty about how and why medication reviews are performed. More explanation to patients about this is desirable. In addition, patients experience that keeping their medication list up to date and transferring medication data between health care providers could be improved. Finally, a group of patients welcomes the opportunity to co-decide on changes in their medication. In order to prescribe safely, it is crucial that caregivers actively involve patients in pharmacotherapeutic care and really enter into conversation with them about their medication.

Adherence to cancer treatment guidelines: influence of general and cancer-specific guideline characteristics.

Background: Guideline adherence remains a challenge in clinical practice, despite guidelines' ascribed potential to improve patient outcomes. We studied the level of adherence to recommendations from Dutch national cancer treatment guidelines, and the influence of general and cancer-specific guideline characteristics on adherence. Methods: Based on data from a national cancer registry, adherence was evaluated for 15 treatment recommendations for breast, colorectal, prostate and lung cancer, and melanoma. Recommendations were selected by representatives of the medical specialist associations responsible for developing and implementing the guidelines. We used multivariable multilevel analysis to calculate mean adherence and variation between individual hospitals. Results: Mean adherence to the different treatment recommendations ranged from 40 to 99%. Adherence differed only slightly between older and newer guidelines and between recommendations with low, moderate or high levels of evidence (range 79-84% and 77-91%, respectively), while adherence differed more between recommendations for different cancer types (range 54-99%), different treatment modalities (adherence ranged from 40 to 92%) or recommendations that advised against or recommended in favour of particular treatment (adherence ranged from 75 to 98%). Conclusion: We found significant variation in adherence between different cancer treatment guidelines. While some guideline characteristics that seem to explain this variation may be considered difficult to modify, the potential for variance across cancer types and treatment modalities suggests that adherence could be further improved. At the same time, these results warrant tailored strategies for the improvement of adherence to clinical practice guidelines.

Self-monitoring of health data by patients with a chronic disease: does disease controllability matter?

BACKGROUND: There is a growing emphasis on self-monitoring applications that allow patients to measure their own physical health parameters. A prerequisite for achieving positive effects is patients' willingness to self-monitor. The controllability of disease types, patients' perceived self-efficacy and health problems could play an essential role in this. The purpose of this study is to investigate the relationship between patients' willingness to self-monitor and a range of disease and patient specific variables including controllability of disease type, patients' perceived self-efficacy and health problems. METHODS: Data regarding 627 participants with 17 chronic somatic disease types from a Dutch panel of people with chronic diseases have been used for this cross-sectional study. Perceived self-efficacy was assessed using the general self-efficacy scale, perceived health problems using the Physical Health Composite Score (PCS). Participants indicated their willingness to self-monitor. An expert panel assessed for 17 chronic disease types the extent to which patients can independently keep their disease in control. Logistic regression analyses were conducted. RESULTS: Patients' willingness to self-monitor differs greatly among disease types: patients with diabetes (71.0%), asthma (59.6%) and hypertension (59.1%) were most willing to self-monitor. In contrast, patients with rheumatism (40.0%), migraine (41.2%) and other neurological disorders (42.9%) were less willing to self-monitor. It seems that there might be a relationship between disease controllability scores and patients' willingness to self-monitor. No evidence is found of a relationship between general self-efficacy and PCS scores, and patients' willingness to self-monitor. CONCLUSIONS: This study provides the first evidence that patients' willingness to self-monitor might be associated with disease controllability. Further research should investigate this association more deeply and should focus on how disease controllability influences willingness to self-monitor. In addition, since willingness to self-monitor differed greatly among patient groups, it should be taken into account that not all patient groups are willing to self-monitor.

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.

Social support plays a role in the attitude that people have towards taking an active role in medical decision-making.

BACKGROUND: There is a growing emphasis towards including patients in medical decision-making. However, not all patients are actively involved in such decisions. Research has so far focused mainly on the influence of patient characteristics on preferences for active involvement. However, it can be argued that a patient's social context has to be taken into account as well, because social norms and resources affect behaviour. This study aims to examine the role of social resources, in the form of the availability of informational and emotional support, on the attitude towards taking an active role in medical decision-making. METHODS: A questionnaire was sent to members of the Dutch Health Care Consumer Panel (response 70 %; n = 1300) in June 2013. A regression model was then used to estimate the relation between medical and lay informational support and emotional support and the attitude towards taking an active role in medical decision-making. RESULTS: Availability of emotional support is positively related to the attitude towards taking an active role in medical decision-making only in people with a low level of education, not in persons with a middle and high level of education. The latter have a more positive attitude towards taking an active role in medical decision-making, irrespective of the level of emotional support available. People with better access to medical informational support have a more positive attitude towards taking an active role in medical decision-making; but no significant association was found for lay informational support. CONCLUSIONS: This study shows that social resources are associated with the attitude towards taking an active role in medical decision-making. Strategies aimed at increasing patient involvement have to address this.

Compliance with referrals to medical specialist care: patient and general practice determinants: a cross-sectional study.

BACKGROUND: In a gatekeeper system, primary care physicians and patients jointly decide whether or not medical specialist care is needed. However, it is the patient who decides to actually use the referral. Referral non-compliance could delay diagnosis and treatment. The objective of this study was to assess patient compliance with a referral to medical specialist care and identify patient and practice characteristics that are associated with it. METHODS: Observational study using data on 48,784 referrals to medical specialist care derived from electronic medical records of 58 general practices for the period 2008-2010. Referral compliance was based on claims data of medical specialist care. Logistic multilevel regression analyses were conducted to determine associations between patient and general practice characteristics and referral compliance. RESULTS: In 86.6% of the referrals, patients complied. Patient and not practice characteristics were significantly associated with compliance. Patients from deprived urban areas and patients aged 18-44 years were less likely to comply, whereas patients aged 65 years and older were more likely to comply. CONCLUSION: About 1 in 8 patients do not use their referral. These patients may not receive adequate care. Demographic and socio-economic factors appear to affect compliance. The results of this study may be used to make general practitioners more aware that some patients are more likely to be noncompliant with referrals.

Patients' Need for Tailored Comparative Health Care Information: A Qualitative Study on Choosing a Hospital.

BACKGROUND: The Internet is increasingly being used to provide patients with information about the quality of care of different health care providers. Although online comparative health care information is widely available internationally, and patients have been shown to be interested in this information, its effect on patients' decision making is still limited. OBJECTIVE: This study aimed to explore patients' preferences regarding information presentation and their values concerning tailored comparative health care information. Meeting patients' information presentation needs might increase the perceived relevance and use of the information. METHODS: A total of 38 people participated in 4 focus groups. Comparative health care information about hip and knee replacement surgery was used as a case example. One part of the interview focused on patients' information presentation preferences, whereas the other part focused on patients' values of tailored information (ie, showing reviews of patients with comparable demographics). The qualitative data were transcribed verbatim and analyzed using the constant comparative method. RESULTS: The following themes were deduced from the transcripts: number of health care providers to be presented, order in which providers are presented, relevancy of tailoring patient reviews, and concerns about tailoring. Participants' preferences differed concerning how many and in which order health care providers must be presented. Most participants had no interest in patient reviews that were shown for specific subgroups based on age, gender, or ethnicity. Concerns of tailoring were related to the representativeness of results and the complexity of information. A need for information about the medical specialist when choosing a hospital was stressed by several participants. CONCLUSIONS: The preferences for how comparative health care information should be presented differ between people. "Information on demand" and information about the medical specialist might be promising ways to increase the relevancy and use of online comparative health care information. Future research should focus on how different groups of people use comparative health care information for different health care choices in real life.

The public's voice about healthcare quality regulation policies. A population-based survey.

BACKGROUND: In the wake of various high-profile incidents in a number of countries, regulators of healthcare quality have been criticised for their 'soft' approach. In politics, concerns were expressed about public confidence. It was claimed that there are discrepancies between public opinions related to values and the values guiding regulation policies. Although the general public are final clients of regulators' work, their opinion has only been discussed in research to a limited extent. The aim of this study is to explore possible discrepancies between public values and opinions and current healthcare quality regulation policies. METHODS: A questionnaire was submitted to 1500 members of the Dutch Healthcare Consumer Panel. Questions were developed around central ideas underlying healthcare quality regulation policies. RESULTS: The response rate was 58.3%. The regulator was seen as being more responsible for quality of care than care providers. Patients were rated as having the least responsibility. Similar patterns were observed for the food service industry and the education sector. Complaints by patients' associations were seen as an important source of information for quality regulation, while fewer respondents trusted information delivered by care providers. However, respondents supported the regulator's imposition of lighter measures firstly. CONCLUSIONS: There are discrepancies and similarities between public opinion and regulation policies. The discrepancies correspond to fundamental concepts; decentralisation of responsibilities is not what the public wants. There is little confidence in the regulator's use of information obtained by care providers' internal monitoring, while a larger role is seen for complaints of patient organisations. This discrepancy seems not to exist regarding the regulator's approach of imposing measures. A gradual, and often soft approach, is favoured by the majority of the public in spite of the criticism that is voiced in the media regarding this approach. Our study contributes to the limited knowledge of public opinion on government regulation policies. This knowledge is needed in order to effectively assess different approaches to involve the public in regulation policies.

Market competition and price of disease management programmes: an observational study.

BACKGROUND: Managed competition was introduced into the health care system in several countries including the Netherlands, although effects of competition of both providers and health insurers on the price of health care are inconclusive. We investigated the association between competition of both providers (care groups) and health insurers and the price of disease management programmes (DMPs). METHODS: Data from 76 DMP contractual agreements for type II diabetes mellitus in 2008, 2009 and 2010 were used to analyse the association between market competition and the price of DMPs. Market competition was calculated per municipal health services region (GGD). Insurer market competition was measured by the Herfindahl-Hirschman Index (HHI), care group competition by the number of care groups and the care group market share of GPs. The effect of competition was cross-sectionally studied with linear regression analyses. RESULTS: Insurer market concentration (HHI) and care group market share were not associated with the price of DMPs. The number of care groups in a GGD region was associated with a lower price (-€4.68; 95% CI: -8.36 - -1.00). The mean difference in the price of DMPs between health insurers was €58. CONCLUSIONS: The price of DMPs seems to be more dependent on the particular health insurer than on market conditions. For competition among health insurers and provider groups to develop, preconditions such as selective contracting and option for patient to change provider should be in place.

A comparison of social prescribing approaches across twelve high-income countries.

BACKGROUND: Social prescribing connects patients with community resources to improve their health and well-being. It is gaining momentum globally due to its potential for addressing non-medical causes of illness while building on existing resources and enhancing overall health at a relatively low cost. The COVID-19 pandemic further underscored the need for policy interventions to address health-related social issues such as loneliness and isolation. AIM: This paper presents evidence of the conceptualisation and implementation of social prescribing schemes in twelve countries: Australia, Austria, Canada, England, Finland, Germany, Portugal, the Slovak Republic, Slovenia, the Netherlands, the United States and Wales. METHODS: Twelve countries were identified through the Health Systems and Policy Monitor (HSPM) network and the EuroHealthNet Partnership. Information was collected through a twelve open-ended question survey based on a conceptual model inspired by the WHO's Health System Framework. RESULTS: We found that social prescribing can take different forms, and the scale of implementation also varies significantly. Robust evidence on impact is scarce and highly context-specific, with some indications of cost-effectiveness and positive impact on well-being. CONCLUSIONS: This paper provides insights into social prescribing in various contexts and may guide countries interested in holistically tackling health-related social factors and strengthening community-based care. Policies can support a more seamless integration of social prescribing into existing care, improve collaboration among sectors and training programs for health and social care professionals.

Acceptance of selective contracting: the role of trust in the health insurer.

BACKGROUND: In a demand oriented health care system based on managed competition, health insurers have incentives to become prudent buyers of care on behalf of their enrolees. They are allowed to selectively contract care providers. This is supposed to stimulate competition between care providers and both increase the quality of care and contain costs in the health care system. However, health insurers are reluctant to implement selective contracting; they believe their enrolees will not accept this. One reason, insurers believe, is that enrolees do not trust their health insurer. However, this has never been studied. This paper aims to study the role played by enrolees' trust in the health insurer on their acceptance of selective contracting. METHODS: An online survey was conducted among 4,422 people insured through a large Dutch health insurance company. Trust in the health insurer, trust in the purchasing strategy of the health insurer and acceptance of selective contracting were measured using multiple item scales. A regression model was constructed to analyse the results. RESULTS: Trust in the health insurer turned out to be an important prerequisite for the acceptance of selective contracting among their enrolees. The association of trust in the purchasing strategy of the health insurer with acceptance of selective contracting is stronger for older people than younger people. Furthermore, it was found that men and healthier people accepted selective contracting by their health insurer more readily. This was also true for younger people with a low level of trust in their health insurer. CONCLUSION: This study provides insight into factors that influence people's acceptance of selective contracting by their health insurer. This may help health insurers to implement selective contracting in a way their enrolees will accept and, thus, help systems of managed competition to develop.

Are patients' preferences for shifting services from medical specialists to general practitioners related to the type of medical intervention?

BACKGROUND: To improve the feasibility of shifting medical specialist to general practitioner (GP) services in patient-centred health care systems, it is important to know how this substitution is valued by patients. However, insight into patients' preferences is lacking. AIM: This study aims to fill this gap by assessing whether patients' preferences for substitution are related to the type of medical intervention. METHODS: Questionnaires were sent to 1000 members of the Dutch Insurants Panel (potential patients). Panel members were asked about their preferences for and use of medical specialist and GP services regarding 11 medical interventions. Six hundred and ninety-four members (69%) responded. We used multilevel multinomial regression to analyse the data. RESULTS: Preferences were significantly related to medical intervention type. GP services were preferred for follow-up treatments (e.g. removing stitches) and non-complex invasive treatments (e.g. removal of lumps), and medical specialist services were preferred for complex invasive treatments (e.g. injection therapy for varicose veins), non-invasive treatments (e.g. start of insulin therapy) and diagnostic examinations (e.g. abdominal ultrasound). Age, effort required to visit a GP, perceived health status and previous treatment experiences also influenced preferences but did not confound the effects of medical intervention type. CONCLUSION: This study provides strong indications that patients' preferences for substitution are influenced by the type of medical intervention. Therefore it seems important that health policy makers, purchasers and practitioners take the preferences of (potential) patients into account.

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.