Page 171 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

In chapter 4 we estimated the relation between cost reductions and quality loss at the macro level, concluding that for every €73,600 taken from the hospital sector, one quality adjusted life year might be lost. Research on the macro level does not provide any clues on how this relation materialises at the micro level: which treatments have been displaced, which patient groups were harmed by cost reductions, which efficiency increases were obtained and which disease areas have been more prone to cost reductions. Substantial differences in marginal values between disease categories were observed, but more research will be necessary to verify these findings and provide clues to potential efficiency gains.
In chapters 5 and 6 we investigated the effects of managed competition on market shares on a macro level. While to our knowledge this was the first study providing quantitative evidence on the effects of active purchasing, the precise mechanisms remain elusive. Providers are possibly able to stabilise market share by compensating market share losses by one insurer for gains by another. Moreover, insurers may steer expenditures towards effective interventions within a hospital. For example, they ask hospitals to specialise in specific treatments at the cost of other treatments, within a given budget. Little evidence is available that insurers actively engage in specialisation requirements, although they may enforce minimum requirements formulated by the medical specialist associations (Mesman et al., 2017). Also, the large differences between marginal effectiveness of spending between disease categories in chapter 4 suggest little steering on cost effectiveness of treatments. Additional research may focus on contracting between hospitals and insurers (Ruwaard, 2018), the effects of contracts on allocative efficiency, how hospitals react to restrictive contracts and how purchasers could stimulate hospitals to increase efficiency. Quantitative research on the effects of insurer purchasing of price and quality on a micro level may be required to fully assess the effectiveness of managed competition.
A major limitation in chapter 7 is that no distinction has been made between for- profit and non-profit private hospitals. Aggregating for-profit and non-profit hospitals in a comparison with public hospitals may elude important differences in performance. Studies from the US did not find structural differences in performance of for-profit and non-profit hospitals (Hollingsworth, 2003; Schlesinger and Gray, 2006; Sibbel and Nagarajah, 2012). However, this finding could perhaps not be extrapolated to Europe. A second limitation is that differences in hospital performance may depend on institutional factors. Pita Barros and Siciliani distinguish two markets for private hospitals: as complements to the public sector and as competitors of public hospitals (Pita Barros and Siciliani, 2011). Outcomes may depend on which market a private hospital operates. Private hospitals under complementary insurance may target more affluent consumers, for example by offering
General Discussion
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