Page 61 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

Effective healthcare cost-containment policies: a systematic review
and accounting for divergent and paramount contextual factors. Considering the above, the lack of evaluations of effectiveness is disappointing.
Despite a broad search strategy and not overly limiting exclusion criteria, only 61 papers were included. Several factors might account for this. First, it may be challenging to isolate the effect of many policy interventions. For example, most containment policies are part of a broader reform package (Emanuel et al., 2012). Also, some policies exert effects in the long run which may be difficult to isolate. Even for policies that prove effective in the short run, it is questionable whether any significant effect endures in the long run. Second, policies may have been rigorously evaluated but not included in our search strategy, for example because these evaluations were not published in the peer-reviewed literature or have been written in another language. Of the 61 papers included in this review, 44 are from the US. This could result from the US being more suited for policy evaluations, but more likely is the result of language and publication bias. US bias could be alleviated by inclusion of evaluations published outside the peer-reviewed literature or in other languages. Last, and probably most important, a large number of studies evaluated costs from the patient or provider perspective and not from the perspective of the payers. Including such studies would greatly increase the number of papers, although the evidence would be much less robust because cost substitution may be mistaken for cost containment.
This review gives a broad overview of the literature, pointing towards effectiveness of certain specific policies such as cost sharing, managed care competition, reference pricing, generic substitution and tort reform. However, some reservations should be made regarding desirability of these measures. Cost sharing, for example, may reduce both necessary and unnecessary care (Kim et al., 2005; Kupor et al., 1995; Sinnott et al., 2013). Second, it could disproportionally affect access by low income groups, which may be undesirable from an ethical perspective (Denier, 2007). It is also highly unpopular with the electorate and thus comes with political barriers. Thirdly, cost sharing shifts costs to patients, thereby limiting the effect on total healthcare costs. Lastly, cost sharing could have spillover effects to other payers when providers increase treatment intensity of remaining patients (Ravesteijn et al., 2017). Control of pharmaceutical expenditure by reference pricing and generic substitution is promising. However, attention should be given to the possibilities of pharmaceutical companies shifting costs to unregulated areas (Mestre-Ferrandiz, 2003), or patients shifting to more expensive treatments (Soumerai et al., 1993). Tort reform appears an issue specific to the US.
A substantial body of evidence favours better coordination of care as an effective way to contain cost. This was one of the few policies where mostly positive effects on the quality of care were reported. However, studies on care coordination often contained a high risk of
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