Page 60 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

Chapter 3
General effects of cost-containment policies are difficult to distil due to the non-random nature of the interventions and the dependency on context. Therefore, we base our policy recommendations on the most robust evidence. Of 43 studies, 13 had low to medium risk of bias and high to medium content validity and reliability. High-quality studies were more likely to find no effect. No effect was found for delisting of benefits, decentralisation, case management, managed care and hospital competition (Costa-Font and Moscone, 2008; Gaynor et al., 2013; Kranker, 2016; Park et al., 2016).
3.3.4. High-quality evidence to guide policymaking
However, some high-quality papers do find significant cost-saving effects. Firstly, cost sharing could reduce costs. One study found that deductibles and coinsurance are associated with lower premium growth rates (Feldstein and Wickizer, 1995). Another study found (tiered) copayments to be effective (Joyce et al., 2002). Secondly, both managed care and competition have the potential to reduce costs. A 10% increase in HMO market share reduced premium growth with 6.5% between 1985 and 1992 (Feldstein and Wickizer, 1995). In addition, long-term effects of cost containment through competitive reforms were found (Mobley, 1998b). Cost sharing and competitive reform may go hand-in-hand; managed care might increase competition, and competition on premiums may benefit plans with high cost sharing (Newhouse, 2004). Also for reductions of pharmaceutical spending, high-quality evidence is available. Internal reference pricing reduced pharmaceutical spending in Denmark by over 10% (Kaiser et al., 2014). Closely related, generic substitution was shown to reduce pharmaceutical spending by 8% (Joyce et al., 2002). Lastly, two high- quality studies point to the potential of cost reductions in specific areas such as end-of-life care and tort reform (Gozalo et al., 2008; Hellinger and Encinosa, 2006).
Cost containment in healthcare is a leading policy challenge. Hence, identifying effective policies is vital, but articles evaluating policies on a macro-level are limited and often lack sufficient rigor. Low numbers of evaluations per policy make it challenging to infer effect sizes as well as time- country-, and health system dependency (Dixon and Poteliakhoff, 2012). Many policy options seem understudied and this includes routine strategies such as budgeting and price setting. All OECD countries would benefit from collective efforts to experiment with, and rigorously evaluate promising policies. As policies are often similar, country heterogeneity may be viewed as a strength. Many different approaches have been taken to tackle rising expenditure. Policymakers should harvest from the wide range of experiences, in order to identify the opportunities and challenges of various policy tools. Countries could then fine-tune cost-containment policies to their own setting, identifying
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3.4 Discussion