Page 15 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

The managed competition reform has met with mixed reviews. A number of authors are mildly positive, citing efficiency gains, premium competition and quality improvements as main accomplishments, although improvements were suggested in the area of risk equalization, merger control and quality transparency (Plexus, 2014; van de Ven et al., 2009; van Kleef et al., 2014). Other authors have been more sceptical, arguing the system does not –yet– function as envisioned (Maarse et al., 2016; Okma et al., 2011; Van Ginneken, 2015). Research mainly focused on the health insurance market and health care provision market, while quantitative research on the healthcare purchasing market has been limited (Maarse et al., 2016; Ruwaard, 2018). Competition on the health insurance market is deemed sufficient, but the healthcare purchasing market is believed to function suboptimal (Van de Ven et al., 2013; van Ginneken et al., 2011). For example, early evaluations of managed competition in the hospital sector concluded that active purchasing was limited (van de Ven et al., 2009). Main barriers are unpopularity of selective contracting by patients, fear of loss of reputation by insurers, hospital concentration, incomplete ex-ante risk equalization and lack of valid quality indicators (van de Ven et al., 2009). Over time, however, preconditions for managed competition improved (van Kleef et al., 2014). Selective contracting remained an exception directly after the reform, but has slowly increased (van Ginneken et al., 2011). Although selective contracting has always remained unpopular, restricted choice health plans gained in popularity, from 3.3% in 2013 to 13.1% in 2017 (NZa, 2017a). A gradual increase of active purchasing has been linked to improvements in cost containment (Plexus, 2014). Contracting with hospitals is based primarily on global budgets and mainly include volume agreements (van Ginneken et al., 2011). Up to date, there is little evidence that insurers use quality information in contracting (van den Berg et al., 2011; Van der Wees et al., 2014). Lack of quality transparency remains an important barrier to the functioning of managed competition (Plexus, 2014; Van Ginneken, 2015). However, the Dutch managed competition system tends to score high in international quality comparisons (Osborn et al., 2016; van den Berg et al., 2011).
General Introduction
Other critical points on managed competition included the absence of consequent cost containment policy (Helderman and Jeurissen, 2010). The Dutch government has insufficient means to control health costs, and insufficiently utilizes available options (Rekenkamer, 2013). Internationally, a relatively low number of cost containment policies has been described in literature for the Netherlands (Tenbensel et al., 2012). Sector agreements on expenditure caps have been effective in containing costs, but not in increasing efficiency (Rekenkamer, 2016). Use of the mandatory deductible as a means of cost sharing has been little effective in reducing utilization in the Netherlands, and is mainly used as a co-financing mechanism rather than a cost containment policy (Plexus, 2014;
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