Page 172 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

Chapter 8
higher quality or care, additional services or lower waiting times. This might translate to high access for affluent consumers in terms of waiting times, although higher quality of care may come at a cost of lower efficiency due to additional inputs and extra capacity. On the other hand, private hospitals competing with public hospitals under mandatory insurance may act in a similar way to public hospitals and have similar outcomes in terms of access, quality and efficiency. A distinction between these two markets may therefore be necessary to fully assess differences in ownership. A complication in this distinction is that ownership may be endogeneous, for example when poorly performing public hospitals are privatised, or vice versa. Furthermore, this may depend on the health system and institutions in place. For the Dutch managed competition system, being fully private, introducing public hospitals has not been a relevant policy option. More research is required to determine the optimal mix of public, private non-profit and private for-profit hospitals in relation to existing systems and institutions.
This thesis implicitly assumes that effective policies might be transferable to other systems. However, socio-political factors influence an effective implementation and transferability across healthcare systems. For this reason, political feasibility and implementation need to be assessed in greater detail. Market-oriented policies that improve efficiency may invoke less resistance than command-and-control policies such as budgeting or price controls, but may result in more evasive behaviour. As effective cost containment policies jeopardise incomes of health professionals and access of patients, socio-political resistance may be expected. As another example, based on the economic utilitarian paradigm of the cost-effectiveness theory, new technologies should not be reimbursed if they displace more valuable care. However, socio-political arguments, such as disease burden and age of the patients, but also media attention, visibility and lobbying may be equally important factors in the assessment of new technologies. Chapters 5 and 6 scrutinised the role of insurers in the active purchasing of hospital care. However, the role of insurers in the socio-political system is generally disregarded. For example, insurers may function as countervailing forces to hospitals, being less dependent on politics than nationalised purchasers. It is conceivable that the system of managed competition in itself raised hospital awareness for the importance of quality improvements and cost containment, which could spur intrinsic hospital efficiency gains. This is compatible with the findings of chapter 6, showing quality improvements and cost reductions in the absence of active purchasing or active patient choice. Assessing the socio-political functions of insurers under managed competition is actually beyond the scope of this thesis. Specifically, the question how insurers in the Dutch managed competition system can steer patients towards
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