Page 169 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

In chapter 5 we empirically investigated one presumption of the managed competition system. According to theory, managed competition incentivises insurers to selectively contract the most efficient providers to improve quality and reduce costs. Selective contracting entails the reallocation of funds from underperforming providers to well-performing providers. Using data from 2007 to 2014 we compared the extent of these reallocations to other healthcare markets in Dutch health care with different purchasing arrangements and incentives. We hypothesised that reallocations in hospital care (managed competition) would be higher than in long-term care (a corporatist single payer system lacking incentives to purchase actively). Furthermore, we hypothesised that reallocations would be high in a system where municipalities purchase care under almost maximal financial risk, and where patients self-purchase care using personal budgets. While the latter two hypotheses were confirmed, the former was not; we found little evidence that insurers purchase more actively than corporatist single payers. We conclude that this aspect of managed competition does not –yet– function as envisioned.
Chapter 6 described the results of a case study to further substantiate the findings of chapter 5. Assisted reproduction (AR) is one of the hospital procedures in the Netherlands where relevant quality information is publicly available. Furthermore, preconditions for patient choice and selective purchasing appear to be comparatively good for this service. Therefore, insurers were expected to actively engage in selective contracting and to steer patients towards high performing providers. All the more since hospitals with good outcomes have lower costs: fewer attempts are necessary. Any efficient health system therefore would ensure that high-quality hospitals attract more patients. Using data from 1996 to 2016, we found little evidence for this premise. The lack of active purchasing implies that hospitals experience few financial incentives to improve quality, as revenue would be lost. Nevertheless, quality spectacularly improved over the research period for all 15 AR centres in the Netherlands. While managed competition did not function as envisioned in terms of steering patients, government objectives of quality increased and cost reductions were still obtained.
Managed competition may require private parties to compete, either on a for-profit base or a non-profit base. In the Netherlands, hospitals are private, non-profit entities. Countries contemplating introducing managed competition principles may require privatisation of public hospitals. This could affect outcomes, as public hospitals may experience incentives differently than private hospitals. To research ownership differences in efficiency, access and quality, chapter 7 collected evidence from the literature published since 2000 from European countries with a mix of private and public hospitals. The results found few structural differences between private and public hospitals. Factors such as profit
General Discussion
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