Page 134 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders
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Chapter 6
improve quality. Indeed, our results already indicate somewhat higher success rates in the more competitive regions. Furthermore, over the last couple decades quality has improved and costs were reduced in absence of active purchasing and despite perverse financial incentives. Our results stipulate the importance of professional autonomy of medical specialists as a means of quality improvement. The role of health insurers may be limited to stimulating professional development through e.g. trans-clinic learning programs.
 This study is contributing to the literature by elucidating the effects of mechanisms of patient choice and active purchasing on incentives to increase quality in a regulated competition setting. This study has several limitations. Firstly, as data is restricted to number of treatments, dropout rates and transfers to other clinics are unknown. However, our results are robust to different dropout percentages in modeling. Secondly, background characteristics of patients are unknown. Some of the differences in success rates may be explained by case-mix, as clinics focusing on more complicated cases may have lower success rates. However, due to the certificate-of-needs status of ART clinics no differentiation or specialization between clinics may be expected. Clinics may also employ patient selection and cream skimming (Brekke et al., 2014). The negative correlation in the same year between success rates and patient numbers supports this. However, the large number of patients in the VU Amsterdam, which is best performing with high patient numbers, suggests that cream skimming may not be a major concern. This is supported by relatively strict guidelines for ART in the Netherlands. However, it would require additional research to definitely rule out patient selection.
To conclude, we found that patient choice and active purchasing is functioning insufficiently to reward clinics for quality improvements. Dutch ART clinics have no financial incentive for quality improvements. Despite a lack of financial stimulus, quality has improved drastically over two decades. This indicates that technological innovations and the intrinsic motivation of health professionals are the dominant mechanisms to improve the quality of care. Currently, both active purchasing and patient choice do not perform sufficiently well to ensure efficient functioning of the ‘market’ for AR. If policy makers seek for an effective system of regulated competition they need to either stimulate active purchasing by insurers, active choice by patients, or both.
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