Page 54 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

Chapter 3
decrease in fee-for-service (FFS) insurance costs (Chernew et al., 2008). Due to the managed care backlash in the US, MCOs lost importance for the private markets (Chernew et al., 2008), although Medicare and Medicaid continued to rely on managed care as alternative service providers. However, studies that evaluated Medicaid-managed care models found no significant effects on total costs (Burns, 2009; Harman et al., 2011). European experiences with managed care are also mixed. A study from Switzerland found large cost reductions due to managed care, up to 16% compared to traditional insurance (Reich et al., 2012a). This could be due to patient selection, as the effect on other insurers has not been taken into account. For German insurers, evidence for patient selection in managed care contracts was found. Managed care contracts increased the costs of pharmaceuticals in neighbouring regions and, as a result, total pharmaceutical expenditure increased by 0.2% to 0.8% following each percent increase in managed care penetration (Ehlert and Oberschachtsiek, 2014). For other forms of payer reforms, limited evidence was found. One study found short-term cost reductions of 30% to 40% due to mental health carve-outs, explained by a combination of financial incentives, reputation effects, patient selection and case management (Ma and McGuire, 1998).
Payers could reduce cost by altering provision structures and types of providers. One study found 4% cost savings after a Swiss insurer offered telecare as substitute of regular care (Reich et al., 2012a). An intervention in Florida to provide hospice care and cancer care to nursing home residents reduced government spending by 8% (Gozalo et al., 2008). No significant cost reductions were found for patient-centered medical homes (PCMHs) (Cole et al., 2015; Werner et al., 2013). Reviews on rehabilitation care (0 studies) (Ward et al., 2008) or mental health community care (42 studies) (Roberts et al., 2005) also found no cost savings. Such results indicate that it may be challenging to launch these provision models that lower costs in the short term whilst also improving quality (Cole et al., 2015).
As countries are searching for the optimal level of government involvement, waves of decentralisation and recentralization have been observed across Europe (Costa-Font and Greer, 2012; Saltman, 2008). For example, in the UK , commissioning centralized to district health authorities in 1974 (Allen, 2006), decentralized to NHS thrusts and fundholding in 1991 and to primary care trusts 2001, and recentralized in 2013 with the conception of clinical commissioning groups (Checkland et al., 2018). Even in very decentralized countries, e.g. Finland and Denmark, a trend towards centralization has been discerned (Medin et al., 2013; Vrangbaek and Christiansen, 2005) Decentralisation has been proposed as a measure to contain costs (Stadhouders et al., 2016). However, conflicting evidence was found. A multi-country analysis found between 12% and 25% higher cost growth among more decentralised systems (Mosca, 2007). A study on decentralisation in the Spanish NHS
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