Page 183 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders
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General Discussion
bargaining power in mental care, which is less concentrated than hospital care (Westra et al., 2016). Other recommendations include improvement of risk equalisation, improvement of quality transparency, and improvement of payment mechanisms (van Kleef et al., 2014). New payment mechanisms could include outcome-based payment schemes (Vlaanderen et al., 2018), while some additional policy recommendations could also be made. Besides reducing legal requirements to contract sufficient care and reimburse 75% of non- contracted care, the government could improve the relative bargaining position of insurers by increasing public acceptance of selective contracting. These measures reduce the disutility of no agreement for insurers and make selective contracting a more credible treat. As free choice of healthcare providers is an important value in the Netherlands (Victoor et al., 2012), this would require a paradigm shift in public opinion. However, evidence from the US and the Netherlands suggests that patients may be willing to trade off free choice for a lower premium (Bes et al., 2017; Mobley, 1998a; Zwanziger et al., 2000). This is also demonstrated by increases in the uptake of restricted choice plans and voluntary deductibles (NZA, 2017b). However, the managed care backlash in the US demonstrates that public opinion, supported by a strong hospital lobby, could quickly turn against selective contracting, requiring a significant amount of policy scrutiny (Blendon et al., 1998). Secondly, a more flexible labour market would provide hospitals with more room to manoeuvre on the expenses side. This could lower the disutility of no agreement for hospitals and make it easier to accommodate changes in the income side. Thirdly, addressing patient demand could reduce the mismatch between available (limited) supply and demand. This may require patient education, empowerment and person-centred care (Ekman et al., 2011). Insurers find it rather a challenge to steer patients to efficient providers due to a lack of trust (Klink et al., 2017). More research will be necessary on how insurers can influence demand and align interests to steer patients towards the most efficient providers. One reason for low acceptance may be patients’ expectations that insurers mainly contract on price and not on quality. For example, in mental care insurers selectively contract on price in the absence of quality indicators (Westra et al., 2016). While contracting up to now primarily focuses on price or lumpsum payments, it should be more focused on quality (den Exter and Guy, 2014). Lastly, the question how purchasers could stimulate quality improvements requires more attention. A well-functioning managed competition system should provide sufficient incentives for hospitals to improve quality. The issue of how hospitals could create an innovative environment where health professionals may continuously strive to improve quality while containing costs may require more research. A number of promising developments are currently taking place in this area, for example at the hospitals Bernhoven and Rivas (Kroon, 2018). Chapter 6
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