Page 174 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

Chapter 8
Since 2008 a mandatory deductible has been applied to all medical care in the Netherlands covered under the Health Insurance Act, including hospital care. This deductible replaced a no-claim system, which was shown to be less effective in containing costs (Remmerswaal et al., 2017). Care for persons under 18, as well as GP visits and some preventative services are exempt from cost sharing. Additional copayments may be required for certain on-label drugs, physical therapy and medical transportation (Garattini and van de Vooren, 2013). In return for a lower premium, an additional voluntary deductible of up to €500 can be offered (van Winssen et al., 2015). Insurers may additionally steer patients to preferred providers using deductible exemptions, with mixed effects (van der Geest and Varkevisser, 2016). The statutory deductible has increased over the last years, from €150 in 2008 to €385 in 2018. Noncompliance rates following referrals have also increased, although this could not be causally related to the deductible increases (van Esch et al., 2017). In 2012, additional copayments for mental care were introduced of €200 per year for outpatient care and €150 per year for inpatient care. In response, mental care utilisation decreased by 13.4%, rendering €13 million in savings. However, acute admissions increased as well, signalling reductions in necessary care (Ravesteijn et al., 2017). Despite reductions in utilisation, additional copayments were abandoned in 2013 (Lambregts and van Vliet, 2018). Additional research should focus on the effects of increases in the mandatory deductible, as well as the relative effectiveness of alternative cost sharing arrangements, such as co- payments and coinsurance. While cost sharing may be used to reduce costs in the Netherlands, consistent with international evidence (Frean and Pauly, 2018), this could reduce both necessary and unnecessary care (Lambregts and van Vliet, 2018; Newhouse, 2004). Furthermore, deductible increases disproportionally burden the less affluent, which may prove to be unpopular. The current government has actually refrained from deductible increases up to 2021. While cost sharing may be effective, attention should be given to distributional effects, reductions in necessary care and public acceptance of cost sharing arrangements.
Cost sharing
Managed care is on the increase in the Netherlands (Klink et al., 2017). Furthermore, competition principles have been introduced and expanded since 2006. A positive relation between competition and quality has been found for a selection of hospital treatments in the Netherlands (Beukers et al., 2014; Croes et al., 2018; Ruwaard and Douven, 2014). However, as chapters 5 and 6 demonstrate, there is much to be gained by improving insurer competition, specifically on the purchaser market. Insurers are known to have low
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Managed care and competition