Page 175 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

General Discussion
bargaining power towards hospitals and GPs (Schut and Varkevisser, 2017). Therefore, improvements in the functioning of the Dutch managed competition system should involve a strict competition policy (Schut and Varkevisser, 2017). Overall, policies to promote managed care and competition remain promising to contain costs in the Dutch hospital sector. However, important questions, for example on the effects of integrated networks, freeriding by other insurers, paying for performance and population based payments, remain to be answered.
Policies implemented in the Netherlands include internal and external reference pricing, mandatory generic prescribing, mandatory generic substitution and tendering (Rémuzat et al., 2015; Wouters et al., 2017). The Dutch Minister of Health, Welfare and Sports is able by law to set maximum prices for pharmaceuticals based on prices in Belgium, the UK, France and Germany. In 2012 these regulations were evaluated, concluding that they were effective in reducing pharmaceutical prices, and that these effects could be further increased if this approach were to be expanded (Huizendveld et al., 2012). Furthermore, the cost-saving potential of tendering has been acknowledged by stakeholders in the Netherlands (Vogler et al., 2017). A study from 2011 showed substantial potential in a further improvement of the uptake of generics (Pechlivanoglou et al., 2011). Insurers have also been purchasing actively on pharmaceuticals (van Ginneken, 2016). In 2013, the volume of generics in the Netherlands was 70%, which was higher than the European average, but lower than Germany (80%) and the United Kingdom (83%). Prices of generics were lowest after the UK (Wouters et al., 2017). Therefore, although the Netherlands has made much progress in the containment of pharmaceutical expenditures, additional policies could still be effective. However, offsetting effects of pharmaceutical policies are to be expected. For example, patient charges and prescription regulation turned out to be ineffective in reducing the total costs due to an offsetting volume response (Starmans et al., 1994). Also, restrictive pharmaceutical policies may reduce access to necessary care. More research will be needed on the long-term effects on quality of care and cost shifting by pharmaceutical companies to other drugs or other countries. It is unclear to what extent governments can or need to mitigate the effects of cost containment policies on reduced access to necessary care.
In the Netherlands, medical specialists are personally liable and mandatorily insured for liability. Little is known about the costs of medical liability in the Netherlands, but cost estimates range between €15-€45 million, or 0.02-0.05% of the total healthcare costs
Generic substitution and reference pricing
Tort reform
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