Page 48 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

Chapter 3
A large number of cost containment policies have been identified, targeting all aspects of the health system, such as prices, volumes, supply, demand and market processes (Stadhouders et al., 2016). However, the adaptive capability of the health system may complicate attaining the goal of containing total costs. For example, price reductions may invoke volume increases (Evans et al., 1989; Lomas et al., 1989; Tai‐Seale et al., 1998), or compensation in other areas (Dobson et al., 2006; Yip, 1998). In general, intervening in market processes may invoke adverse behavioural responses (Burns and Pauly, 2018; Simoens and Giuffrida, 2004). Therefore, whether policies are effective in containing total spending remains an empirical query.
To our knowledge, a robust overview of the available evidence is lacking. The few reviews undertaken focus on areas such as pharmaceuticals (Han et al., 2015) or hospitals (Schwierz, 2016), Medicare and Medicaid (Berenson et al., 2008), payment reform (Hsiao et al., 1993; NCSL, 2011), and efficiency (Liu, 2003). None of these reviews has systematically appraised the reliability and risk of bias of the included articles. Moreover, most reviews do not assess the evidence from a payer perspective, whether governments (in National Health Service systems), healthcare insurers (in Social Health Insurance systems) or governmental organisations like Medicare and Medicaid. Instead, most studies in this field take either a patient or provider perspective. Patient level policies may reduce patient treatment cost, but may forego the provider response to use the access capacity for additional care for other patient groups. Similarly, provider level policies (e.g. hospitals implementing policies to reduce their operating costs) may fail to incorporate additional burdens that may fall on primary care providers or other hospitals (Sharfstein et al., 2018). From a provider or patient perspective, costs may decrease, but due to possible spillovers to other sectors, providers and/or patients render the effect on total payer expenditure ambiguous.
This review addresses this issue by focusing on the effect of policies from a societal/payer perspective (Garattini and Ghislandi, 2006). From a societal perspective, costs are contained when total healthcare expenditures are reduced (combining all payers and patients); while from a payer perspective cost containment implies a reduction in payer expenditures. This allows cost shifting to patients and cost shifting between payers, but not between patient groups or hospitals. The aim of this review is threefold: (1) to summarise existing literature on the effectiveness of healthcare cost-containment policies; (2) to identify knowledge gaps; and (3) to inform policymakers on promising cost-containment policies.
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