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In market-based healthcare systems, due to the high and increasing degree of integration between healthcare providers and purchasers, the enforcement of the cartel prohibition is both important and ever more complex. Competition authorities operate independently, but their approach to enforcement may be influenced by the public and political context. Within the setting of the Dutch healthcare system, we study how the cartel prohibition was enforced between 2004 and 2020 and focus on whether a relationship with public and political attitudes towards competition in healthcare can be observed. Using both qualitative and sentiment analyses, we assessed 38 formal and informal documents issued by the competition authority, 126 written parliamentary questions and almost 1,500 newspaper articles. Our findings reveal that during the first half of the study period (2004–2012), ex-post punitive formal enforcement of violations of the cartel prohibition, such as market-sharing and price-fixing agreements, predominated. During the second half of the study period (2012–2020); however, the competition authority’s focus seems to have shifted toward providing ex-ante informal guidance. We clearly observe negative public and political attitudes towards competition in healthcare as well as a distinct shift in enforcement of the cartel prohibition in Dutch health care. However, we are not able to test for a causal relationship between both observations.

Existing risk-equalization models in individual health insurance markets with premium-rate restrictions do not completely compensate insurers for predictable profits/losses, confronting insurers with risk selection incentives. To guide further improvement of risk-equalization models, it is important to obtain insight into the drivers of remaining predictable profits/losses. This article studies a specific potential driver: end-of-life spending (defined here as spending in the last 1–5 years of life). Using administrative ( N = 16.9 m) and health survey ( N = 384 k) data from the Netherlands, we examine the extent to which end-of-life spending contributes to predictable profits/losses for selective groups. We do so by simulating the predictable profits/losses for these groups with and without end-of-life spending while correcting for the overall spending difference between these two situations. Our main finding is that—even under a sophisticated risk-equalization model—end-of-life spending can contribute to predictable losses for specific chronic conditions.

BACKGROUND: Centralisation of specialist cancer services is occurring in many countries, often without evaluating the potential impact before implementation. We developed a health service planning model that can estimate the expected impacts of different centralisation scenarios on travel time, equity in access to services, patient outcomes, and hospital workload, using rectal cancer surgery as an example.METHODS: For this population-based modelling study, we used routinely collected individual patient-level data from the National Cancer Registration and Analysis Service (NCRAS) and linked to the NHS Hospital Episode Statistics (HES) database for 11 888 patients who had been diagnosed with rectal cancer between April 1, 2016, and Dec 31, 2018, and who subsequently underwent a major rectal cancer resection in 163 National Health Service (NHS) hospitals providing rectal cancer surgery in England. Five centralisation scenarios were considered: closure of lower-volume centres (scenario A); closure of non-comprehensive cancer centres (scenario B); closure of centres with a net loss of patients to other centres (scenario C); closure of centres meeting all three criteria in scenarios A, B, and C (scenario D); and closure of centres with high readmission rates (scenario E). We used conditional logistic regression to predict probabilities of affected patients moving to each of the remaining centres and the expected changes in travel time, multilevel logistic regression to predict 30-day emergency readmission rates, and linear regression to analyse associations between the expected extra travel time for patients whose centre is closed and five patient characteristics, including age, sex, socioeconomic deprivation, comorbidity, and rurality of the patients' residential areas (rural, urban [non-London], or London). We also quantified additional workload, defined as the number of extra patients reallocated to remaining centres.FINDINGS: Of the 11 888 patients, 4130 (34·7%) were women, 5249 (44·2%) were aged 70 years and older, and 5005 (42·1%) had at least one comorbidity. Scenario A resulted in closures of 43 (26%) of the 163 rectal cancer surgery centres, affecting 1599 (13·5%) patients; scenario B resulted in closures of 112 (69%) centres, affecting 7029 (59·1%) patients; scenario C resulted in closures of 56 (34%) centres, affecting 3142 (26·4%) patients; scenario D resulted in closures of 24 (15%) centres, affecting 874 (7·4%) patients; and scenario E resulted in closures of 16 (10%) centres, affecting 1000 (8·4%) patients. For each scenario, there was at least a two-times increase in predicted travel time for re-allocated patients with a mean increase in travel time of 23 min; however, the extra travel time did not disproportionately affect vulnerable patient groups. All scenarios resulted in significant reductions in 30-day readmission rates (range 4-48%). Three hospitals in scenario A, 41 hospitals in in scenario B, 13 hospitals in scenario C, no hospitals in scenario D, and two hospitals in scenario E had to manage at least 20 extra patients annually.INTERPRETATION: This health service planning model can be used to to guide complex decisions about the closure of centres and inform mitigation strategies. The approach could be applied across different country or regional health-care systems for patients with cancer and other complex health conditons.FUNDING: National Institute for Health Research.

Many regulated health insurance markets include risk adjustment (aka risk equalization) to mitigate selection incentives for insurers. Empirical studies on the design and evaluation of risk-adjustment algorithms typically focus on mandatory health insurance schemes. This paper considers risk adjustment in the context of voluntary health insurance, as found in Chile, Ireland, and Australia. In addition to the challenge of mitigating selection by insurers, regulators of these voluntary schemes have to deal with selection by consumers in and out of the market. A strategy for mitigating selection by consumers is to apply some form of risk rating. Our paper shows how risk adjustment and risk rating interact: (1) risk rating reduces the need for risk adjustment and (2) risk adjustment reduces premium variation across rating factors, thereby increasing incentives for consumers to select in and out of the market.

Health insurance markets with community-rated premiums typically use risk equalization (RE) to compensate insurers for predictable profits on people in good health and predictable losses on those with a chronic disease. Over the past decades RE models have evolved from simple demographic models to sophisticated health-based models. Despite the improvements, however, non-trivial predictable profits and losses remain. This study examines to what extent the Dutch RE model can be further improved by redesigning one key morbidity adjuster: the Diagnosis-based Cost Groups (DCGs). This redesign includes (1) revision of the underlying hospital diagnoses and treatments (‘dxgroups’), (2) application of a new clustering procedure, and (3) allowing multi-qualification. We combine data on spending, risk characteristics and hospital claims for all individuals with basic health insurance in the Netherlands in 2017 (N = 17 m) with morbidity data from general practitioners (GPs) for a subsample (N = 1.3 m). We first simulate a baseline RE model (i.e., the RE model of 2020) and then modify three important features of the DCGs. In a second step, we evaluate the effect of the modifications in terms of predictable profits and losses for subgroups of consumers that are potentially vulnerable to risk selection. While less prominent results are found for subgroups derived from the GP data, our results demonstrate substantial reductions in predictable profits and losses at the level of dxgroups and for individuals with multiple dxgroups. An important takeaway from our paper is that smart design of morbidity adjusters in RE can help mitigate selection incentives.

De Hoge Raad heeft in 2014 bepaald dat verzekerden recht hebben op een substantiële vergoeding van niet door de zorgverzekeraar gecontracteerde zorg. Het is echter onduidelijk hoe hoog deze vergoeding minimaal moet zijn. Deze onduidelijkheid zorgt voor onzekerheid bij zorgverzekeraars en verzekerden. Het wordt tijd dat de wetgever duidelijke regels maakt die zekerheid bieden over de vergoeding. IN HET KORT ● Rechters nemen beslissingen over de vergoeding van nietgecontracteerde zorg, terwijl de wetgever dit zou moeten doen. ● Een oplossing is om verzekerden niet meer dan een maximumbedrag per jaar aan niet-gecontracteerde zorg te laten betalen. ● Een maximumbedrag biedt duidelijkheid voor alle partijen en moet zorgaanbieders stimuleren om contracten af te sluiten.

Many community-rated health insurance markets include risk equalization (also known as risk adjustment) to mitigate risk selection incentives for competing insurers. Empirical evaluations of risk equalization typically quantify selection incentives through predictable profits and losses net of risk equalization for various groups of consumers (e.g. the healthy versus the chronically ill). The underlying assumption is that absence of predictable profits and losses implies absence of selection incentives. This paper questions this assumption. We show that even when risk equalization perfectly compensates insurers for predictable differences in mean spending between groups, selection incentives are likely to remain. The reason is that the uncertainty about residual spending (i.e., spending net of risk equalization) differs across groups, e.g., the risk of substantial losses is larger for the chronically ill than for the healthy. In a risk-rated market, insurers are likely to charge a higher profit mark-up (to cover uncertainty in residual spending) and a higher safety mark-up (to cover the risk of large losses) to chronically ill than to healthy individuals. When such differentiation is not allowed, insurers face incentives to select in favor of the healthy. Although the exact size of these selection incentives depends on contextual factors, our empirical simulations indicate they can be non-trivial. Our findings suggest that – in addition to the equalization of differences in mean spending between the healthy and the chronically ill – policy measures might be needed to diminish (or compensate insurers for) heteroscedasticity of residual spending across groups.

Many social health insurance systems rely on ‘regulated competition’ among insurers to improve efficiency. In the presence of community-rated premiums, risk equalization is an important regulatory feature to mitigate risk-selection incentives in such systems. Empirical studies evaluating selection incentives have typically quantified group-level (un)profitability for one contract period. However, due to switching barriers, a multiple contract period perspective might be more relevant. In this paper, using data from a large health survey (N≈380k) we identify subgroups of chronically ill and healthy individuals in year t and follow these groups over three consecutive years. Using administrative data covering the entire Dutch population (N≈17m), we then simulate the mean per person predictable profits and losses (i.e. spending predicted by a sophisticated risk-equalization model minus actual spending) of these groups over the three follow-up years. We find that most of the groups of chronically ill are persistently unprofitable on average, while the healthy group is persistently profitable. This implies that selection incentives might be stronger than initially thought, underscoring the necessity of eliminating predictable profits and losses for the adequate functioning of competitive social health insurance markets.

Background Insight into outcome variation between hospitals could help to improve quality of care. We aimed to assess the validity of early outcomes as quality indicators for acute ischemic stroke care for patients treated with endovascular therapy (EVT). Methods and Results We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, a large multicenter prospective cohort study including 3279 patients with acute ischemic stroke undergoing EVT. Random effect linear and proportional odds regression were used to analyze the effect of case mix on between‐hospital differences in 2 early outcomes: the National Institutes of Health Stroke Scale (NIHSS) score at 24 to 48 hours and the expanded thrombolysis in cerebral infarction score. Between‐hospital variation in outcomes was assessed using the variance of random hospital effects (tau 2 ). In addition, we estimated the correlation between hospitals' EVT‐patient volume and (case‐mix–adjusted) outcomes. Both early outcomes and case‐mix characteristics varied significantly across hospitals. Between‐hospital variation in the expanded thrombolysis in cerebral infarction score was not influenced by case‐mix adjustment (tau 2 =0.17 in both models). In contrast, for the NIHSS score at 24 to 48 hours, case‐mix adjustment led to a decrease in variation between hospitals (tau 2 decreases from 0.19 to 0.17). Hospitals' EVT‐patient volume was strongly correlated with higher expanded thrombolysis in cerebral infarction scores ( r =0.48) and weakly with lower NIHSS score at 24 to 48 hours ( r =0.15). Conclusions Between‐hospital variation in NIHSS score at 24 to 48 hours is significantly influenced by case‐mix but not by patient volume. In contrast, between‐hospital variation in expanded thrombolysis in cerebral infarction score is strongly influenced by EVT‐patient volume but not by case‐mix. Both outcomes may be suitable for comparing hospitals on quality of care, provided that adequate adjustment for case‐mix is applied for NIHSS score.

In many countries, governments use payment systems to compensate health insurers more for enrollees with higher expected costs. However, little empirical research has examined whether these payment systems should also include health insurers' administrative costs. We provide two sources of evidence that health insurers with a more morbid population have higher administrative costs. First, we show at the customer level a causal relationship between individual morbidity and individual administrative contacts with the insurer, using the weekly evolution of the number of individual customer contacts (calls, emails, in-person visits etc.) of a large Swiss health insurer. Using a difference-in differences design, we find that the onset of a chronic illness causes on average a persistent increase of about 40% in individuals' contacts with the health insurer. Second, we provide evidence that this relationship also holds for total administrative costs at the insurer level. We study twenty years of Swiss health insurance market data and find a positive elasticity of around 1, indicating that, all else equal, an insurer with a more morbid population, equal to 1% more health care spending, faces about 1% higher administrative costs., + ID der Publikation: unilu_68256 + Sprache: Englisch + Letzte Aktualisierung: 2023-06-09 15:28:56

The Dutch health system provides broad universal health care coverage and is based on the principles of regulated competition. According to the OECD (2022), it is one of the best health systems in the world with regard to access to health care, equity and clinical outcomes. However, as also concluded by the Netherlands Scientific Council for Government Policy (WRR, 2021), as with other health systems, it faces important sustainability and resilience challenges, some of which were exposed and exacerbated during the COVID-19 pandemic. This report provides a comprehensive overview of the Dutch health system’s key features across the seven domains of the PHSSR framework: health system governance, health system financing, workforce, medicines and technology, health service delivery, population health and environmental sustainability. For each of these domains, the aim of the report is to (1) produce a critical assessment of the country’s most salient strengths, weaknesses and threats regarding the sustainability and resilience of its health system and (2) derive recommendations for health care policy. In addition to the seven domains mentioned above, we present two case studies. The first focuses on the resilience of the Dutch health system to the financial shock caused by the COVID-19 pandemic. The second examines whether collaboration (aimed at reducing coordination problems and facilitating integrated health care) and competition are reconcilable in the Dutch health system.

Co‐payments for long‐term care (LTC) can impose a substantial financial burden on the elderly. How this burden is distributed across income groups depends on the design of the co‐payment. We estimate the lifecycle dynamics of LTC using Dutch administrative data. These estimates are inputs in a stochastic lifecycle decision model. Using the model, we analyze the welfare effects of the Dutch income‐ and wealth‐ dependent co‐payment system and compare it to alternative systems. We find that the Dutch co‐payment system redistributes income to low‐income groups, who use the most care over their life but contribute the least co‐payments, from high‐income groups, who pay the most. Moreover, the Dutch system protects the middle‐income groups relatively well against financial risk: although alternative co‐payment systems hardly affect these groups average payments, they induce welfare losses of 2% to 4% due to an increased risk of very high co‐payments.

Most countries that apply risk-equalization in their health insurance market(s) perform risk-equalization on medical claims but do not include other components of the insurance premium, such as administrative costs. Using fixed effects panel regressions from individual insurers in Australia, Germany, the Netherlands, Switzerland, and the US, we find evidence that health insurers with a high morbidity population on average have higher administrative costs. We argue that administrative costs should also be included in risk-equalization and we show that such equalization results in additional equalization payments nontrivial in size. Using examples from Germany and the US, we show how in practice policymakers can include administrative costs in risk-equalization. We are skeptical about applying risk-equalization to other components of the insurance premium, such as profits or costs related to solvency requirements of insurers., + ID der Publikation: unilu_68259 + Sprache: Englisch + Letzte Aktualisierung: 2023-06-06 12:23:46

In health care systems based on managed competition, enrolees can choose between insurers who are positioned as prudent buyers of care on their behalf. To avoid risk selection, insurers are compensated through a system of risk equalisation. The Dutch system of risk equalisation is generally considered to be one of the most sophisticated in the world. Empirical evidence, however, shows there are still consumer segments that are profitable for insurers. To examine whether insurers use target marketing for attracting these segments, we assessed promotional material used by Dutch insurers during the switching season of 2019. Our findings provide preliminary evidence that large insurers with different brands primarily use their sub brands as strategic vehicles to improve their competitive positions by targeting these brands at financially favourable groups and price sensitive buyers. By contrast, the more visible main brands are targeted at a much broader spectrum of consumer groups to display the insurer's social character. Only a minority of insurers’ marketing expressions are targeted at actual users of care. Despite continuous improvements in the risk equalisation system, on average this group is still unprofitable for insurers. From a health policy perspective, further improvements are key to motivate health insurers to target their efforts at improving care for the chronically ill and to eliminate incentives for risk selection.

An important societal problem is that people underinsure against risks that are unlikely or occur in the far future, such as natural disasters and long-term care needs. One explanation is that uncertainty about the risk of non-reimbursement induces ambiguity averse and risk prudent decision makers to take out less insurance. We set up an insurance experiment to test this explanation. Consistent with the theoretical predictions, we find that the demand for insurance is lower when the nonperformance risk is ambiguous than when it is known and when decision makers are risk prudent. We cannot attribute the lower take-up of insurance to our measure of ambiguity aversion, probably because ambiguity attitudes are richer than aversion alone.Supplementary Information: The online version contains supplementary material available at 10.1007/s11166-021-09364-7.

Zorgverzekeraars worden financieel gecompenseerd voor verzekerden met hoge zorgkosten om te voorkomen dat chronisch zieken onaantrekkelijk zijn voor verzekeraars. Deze ‘risicoverevening’ is echter onvolledig omdat ze geen rekening houdt met de hogere bedrijfskosten van verzekeraars met veel chronisch zieken.

Een bekend doel van risicoverevening op de zorgverzekeringsmarkt is om prikkels tot risicoselectie te verminderen. De relatie tussen risicoverevening en doelmatigheid is echter complex. Het is de vraag of doelmatigheid van zorg ook als doel van risicoverevening moet worden gezien.

We study whether two groups of mental health care providers—each paid according to a different payment scheme—adjusted the duration of their patients' treatments after they faced an exogenous 20% drop in the number of patients. For the first group of providers, self-employed providers, we find that they did not increase treatment duration to recoup their income loss. Treatment duration thresholds in the stepwise fee-for-service payment function seem to have prevented these providers to treat patients longer. For the second group of providers, large mental health care institutions who were subject to a budget constraint, we find an average increase in treatment duration of 8%. Prior rationing combined with professional uncertainty can explain this increase. We find suggestive evidence for overtreatment of patients as the longer treatments did not result in better patient outcomes, i.e. better General Assessment of Functioning scores.

Inter-organizational collaboration plays a pivotal role in the provision of care for patients and clients. Yet, questions on how and why healthcare providers collaborate, how collaboration coexists with competition policy and how collaboration contributes to patient outcomes were largely unexplored. Therefore, this thesis studies inter-organizational collaboration between providers within the setting of regulated competition. The results show that objectives for collaboration differ between hospitals and long-term care organizations. Competition enforcement aims to safeguard competition when collaborators are also competitors. The findings of this dissertation reveal a distinct shift in enforcement approach, from punitive enforcement to providing informal guidance. Collaboration in oncological care often aims to meet minimum volume standards or increase volume of care. Analysis breast cancer surgery outcomes shows that most variation is explained by differences in treatment types as well as patient and tumor characteristics, while hospital volume and regional competition seem to play a limited role. A preliminary evaluation of a centralization agreement for high-complex tumors does not demonstrate clear differences in price and travel time.

Survival rates of adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL) are inferior to those of pediatric ALL patients. In part, this may be caused by differences in treatment setting. Generally, children are treated in specialized pediatric hemato-oncology settings, whereas AYAs are treated in adult hemato-oncology settings. Since 2005, adult treatment protocols have included pediatric-inspired chemotherapy, which has been the standard of care for AYAs from 2008 onwards. This study aims to assess whether, despite protocols in both settings having become more similar, there remains an effect of treatment in specialized pediatric hemato-oncology settings on 5-year survival for ALL patients in the Netherlands. We used nationwide registry data (2004–2013) on 472 ALL patients aged between 10 and 30 years old. A fuzzy regression discontinuity design was applied to estimate the treatment effect using two-stage least squares regression with the treatment threshold at 17 years and 7 months of age, adjusting for sex, age at diagnosis, and immunophenotype. We found a risk difference of 0.419 (p = 0.092; 95% CI = −0.0686; 0.907), meaning a 41.9 percentage point greater probability of surviving five years after diagnosis for ALL patients treated in specialized pediatric hemato-oncology settings. Our results suggest that ALL patients around the threshold could benefit from increased collaboration between pediatric and adult hemato-oncology in terms of survival.

Health insurance markets with community-rated premiums typically include risk adjustment (RA) to mitigate selection problems. Over the past decades, RA systems have evolved from simple demographic models to sophisticated morbidity-based models. Even the most sophisticated models, however, tend to overcompensate people with persistently low spending and undercompensate those with persistently high spending. This paper compares three methods that exploit spending-level persistence for improving health plan payment systems: (1) implementation of spending-based risk adjustors, (2) implementation of high-risk pooling for people with multiple-year high spending, and (3) indirect use of spending persistence via constrained regression. Based on incentive measures for risk selection and cost control, we conclude that a combination of the last two options can substantially outperform the first, which is currently used in the health plan payment system in the Netherlands.

Introduction Various statistical approaches can be used to deal with unmeasured confounding when estimating treatment effects in observational studies, each with its own pros and cons. This study aimed to compare treatment effects as estimated by different statistical approaches for two interventions in observational stroke care data. Patients and methods We used prospectively collected data from the MR CLEAN registry including all patients (n = 3279) with ischemic stroke who underwent endovascular treatment (EVT) from 2014 to 2017 in 17 Dutch hospitals. Treatment effects of two interventions – i.e., receiving an intravenous thrombolytic (IVT) and undergoing general anesthesia (GA) before EVT – on good functional outcome (modified Rankin Scale ≤2) were estimated. We used three statistical regression-based approaches that vary in assumptions regarding the source of unmeasured confounding: individual-level (two subtypes), ecological, and instrumental variable analyses. In the latter, the preference for using the interventions in each hospital was used as an instrument. Results Use of IVT (range 66–87%) and GA (range 0–93%) varied substantially between hospitals. For IVT, the individual-level (OR ~ 1.33) resulted in significant positive effect estimates whereas in instrumental variable analysis no significant treatment effect was found (OR 1.11; 95% CI 0.58–1.56). The ecological analysis indicated no statistically significant different likelihood (β = − 0.002%; P = 0.99) of good functional outcome at hospitals using IVT 1% more frequently. For GA, we found non-significant opposite directions of points estimates the treatment effect in the individual-level (ORs ~ 0.60) versus the instrumental variable approach (OR = 1.04). The ecological analysis also resulted in a non-significant negative association (0.03% lower probability). Discussion and conclusion Both magnitude and direction of the estimated treatment effects for both interventions depend strongly on the statistical approach and thus on the source of (unmeasured) confounding. These issues should be understood concerning the specific characteristics of data, before applying an approach and interpreting the results. Instrumental variable analysis might be considered when unobserved confounding and practice variation is expected in observational multicenter studies.

Identifying prognostic factors (PFs) is often costly and labor-intensive. Routinely collected hospital data provide opportunities to identify clinically relevant PFs and construct accurate prognostic models without additional data-collection costs. This multicenter (66 hospitals) study reports on associations various patient-level variables have with outcomes and costs. Outcomes were in-hospital mortality, intensive care unit (ICU) admission, length of stay, 30-day readmission, 30-day reintervention and in-hospital costs. Candidate PFs were age, sex, Elixhauser Comorbidity Score, prior hospitalizations, prior days spent in hospital, and socio-economic status. Included patients dealt with either colorectal carcinoma (CRC, n = 10,254), urinary bladder carcinoma (UBC, n = 17,385), acute percutaneous coronary intervention (aPCI, n = 25,818), or total knee arthroplasty (TKA, n = 39,214). Prior hospitalization significantly increased readmission risk in all treatments (OR between 2.15 and 25.50), whereas prior days spent in hospital decreased this risk (OR between 0.55 and 0.95). In CRC patients, women had lower risk of in-hospital mortality (OR 0.64), ICU admittance (OR 0.68) and 30-day reintervention (OR 0.70). Prior hospitalization was the strongest PF for higher costs across all treatments (31–64% costs increase/hospitalization). Prognostic model performance (c-statistic) ranged 0.67–0.92, with Brier scores below 0.08. R-squared ranged from 0.06–0.19 for LoS and 0.19–0.38 for costs. Identified PFs should be considered as building blocks for treatment-specific prognostic models and information for monitoring patients after surgery. Researchers and clinicians might benefit from gaining a better insight into the drivers behind (costs) prognosis.

Across OECD countries, healthcare organizations increasingly rely on inter-organizational collaboration (IOC). Yet, systematic insight into the relations across different healthcare sectors is lacking. The aim of this explorative study is twofold. First, to understand how IOC differs across healthcare sectors with regards to characteristics, motives and the role of health policy. Second, to understand which potential effects healthcare executives consider prior to the establishment of the collaborations. For this purpose, a survey was conducted among a representative panel of Dutch healthcare executives from medium-sized or large healthcare organizations. Almost half (n = 344, 48%) of the invited executives participated. Our results suggest that differences in policy changes and institutional developments across healthcare sectors affect the scope and type of IOC: hospitals generally operate in small horizontal collaborations, while larger and more complex mixed and non-horizontal collaborations are more present among nursing homes, disability care and mental care organizations. We find that before establishing IOCs, most healthcare executives conduct a self-assessment including the potential effects of the collaboration. The extensive overview of policy developments, collaboration types and intended outcomes presented in our study offers a useful starting point for a more in-depth assessment of the effectiveness of collaborations among healthcare organizations.

In health care systems with a competitive health insurance market, governments or other sponsors (e.g. employers) often subsidize premiums to encourage enrolment. These subsidies are typically independent of plan choice leaving the absolute premium differences in place so as not to distort consumer choice of plan. Such subsidies do, however, change the relative premium differences across plans, which, according to theories from behavioral economics, can affect choice. Consumers might be sensitive to differences relative to a reference premium (“relative thinking”). Furthermore, consumers might be particularly sensitive to a reference premium of zero (“zero-price effect”), a relevant range for some subsidized health insurance markets. This paper tests these ideas with two sources of evidence. We argue that observed equilibria in Germany and the U.S. Medicare Advantage markets are consistent with a powerful zero-price effect, resulting in an equilibrium focal pricing at zero. This contrasts with the Netherlands where equilibrium premiums are well above zero. In an empirical test using hypothetical questions in a web-based survey in these three countries, we also find evidence for both a relative thinking and a zero-price effect in the demand for health insurance. Our findings imply that well-designed subsidies can leverage relative thinking to increase demand elasticity for health plans. Creation of a powerful reference price (e.g., at zero), however, risks subverting price competition.

In health care the assessment of patients' needs is typically entrusted to health care providers. By contrast, in publicly financed long-term care (LTC) needs assessment is often delegated to an independent assessor. One rationale offered for independent needs assessment in LTC is to limit the scope for moral hazard and supplier-induced demand, which may be particularly strong in case of public LTC insurance. We study whether independent needs assessment restricts use of publicly financed LTC at the intensive margin (i.e. after people are being assessed to be eligible for receiving care). Therefore, we link nationwide Dutch administrative datasets about individual LTC use and eligibility decisions by the independent assessment agency in 2012. We find for virtually all types of care, all population subgroups, and all regions that LTC use by patients was substantially less than the maximum amount of care allowed by the independent assessor. This suggests that in the Netherlands independent needs assessment in LTC does not impose a binding constraint on use once a person is considered eligible for care. Still, independent needs assessment may have reduced LTC use at the extensive margin. A significant proportion of the applications for care (16 %) was rejected. In addition, the independent assessment may deter some people from applying.

Non-take-up of means-tested benefits is a widespread phenomenon which undermines the effectiveness and fairness of social policies. The digitalisation of the welfare state creates new opportunities for proactively contacting people who are potentially entitled to benefits, but do not take up their social rights. In this study, we report on how new data flows were used to reach out to potential beneficiaries of the Increased Reimbursement of health care, a programme targeted at low-income households in Belgium. By randomizing the period in which potential beneficiaries were contacted, we were able to identify a three- to four-fold increase in take-up among those contacted as a result of the outreaching activities. Households that did not respond to the intervention, the never takers, have lower pre-intervention healthcare expenditures. This suggests that non-take-up was reduced primarily among those who would expect to benefit most from receiving the Increased Reimbursement. Exploiting the combination of rich administrative data with experimental evidence, we also find that early responders are mostly older and have higher historic health expenditures than late responders. Furthermore, results point to the need for balancing well the inclusiveness of the intervention with an increased number of applications by ineligible people.

Ondanks de uitdagingen die het gevolg zijn van de coronapandemie staan de goede prestaties van de Nederlandse gezondheidszorg buiten kijf. Met het oog op de toekomst zijn er echter ook zorgen. Onlangs concludeerde de WRR (2021) dat de grenzen van de financiële, personele en maatschappelijke houdbaarheid van de zorg in zicht komen. Het nieuwe kabinet van VVD, D66, CDA en ChristenUnie heeft deze boodschap ter harte genomen en kondigt “stevige keuzes” aan. Maar maakt het nieuwe kabinet-Rutte IV deze keuzes ook echt?

Background: Despite a lack of supporting evidence, hospitals continue to merge in pursuit of quality improvements. Purpose: We seek to develop a more thorough understanding of the quality effects of hospital mergers by integrating various theoretical perspectives using a mixed-methods design. Methodology: Quantitatively, we tested the quality effect of all consummated hospital mergers in the Netherlands between 2008 and 2014 on 15 quality indicators (with 82 measurements at hospital, department, and disease levels) using a difference-in-difference approach with Bonferroni correction. Qualitatively, we conducted three comparative case studies to examine how hospital executives, managers, and medical professionals perceive the quality impact of hospital mergers. Results: Our quantitative results reveal few significant effects of hospital mergers on quality of care at all levels. After applying Bonferroni correction, two quality indicators are negatively associated with hospital mergers. However, the qualitative results indicate that hospital staff have positive perceptions of the mergers’ quality implications, resulting from scale and shock effects. Conclusion: The perceptions of hospital staff regarding mergers diametrically oppose their measurable effects. However, the operationalization of quality by hospital staff members differs considerably from the way it is quantitatively measured. The positive perceptions of hospital staff toward mergers could further contribute to the institutionalization of mergers as a quality improvement strategy. Practice Implications: Hospital managers seeking measurable quality improvements should be wary of merging, despite potential positive perceptions toward it within the organization. In case they do decide to merge, mitigating difficulties in the postmerger integration processes seem most pertinent to achieve measurable effects

In the Dutch healthcare system, provider competition is used as a tool to improve efficiency. From a competition policy perspective, little is known about how collaboration among healthcare providers contributes to overall patient welfare, and how a balance is achieved between scale benefits and preventing anti-competitive collusion. This paper examines the ex-post effects of a Dutch case study in which three competing hospitals have collaborated to provide high-complexity low-volume cancer surgery, an arrangement that tests the limits of permissibility under the Dutch cartel prohibition. Our preliminary empirical research demonstrated only a modest increase in price and travel time for some of the tumour surgeries. Volume analysis showed that the intended centralization of surgical procedures has not been fully realized. Our findings highlight the importance of a comprehensive self-assessment by the collaborating hospitals to ex-ante assess (potential) efficiencies and antitrust risks. Such self-assessments could benefit from research focused on which collaborations are most appropriate to achieve quality gains. For the ex-post assessment by competition authorities following the cartel prohibition, a more thorough insight into the (long-term) changes in hospital prices, profitability, and quality after collaboration is needed.

textabstractWith aging populations, the role of private insurance in financing late-in-life risks is likely to grow. Yet, demand for long-term care insurance (LTCI) and life annuities (hereafter annuities) is very limited and lags behind economic projections. This systematic literature review surveys the large number of theoretical and empirical studies analyzing this contradiction. We examine the LTCI and annuity puzzles separately and show which factors limit demand for insurance against both late-in-life risks. Our systematic search rendered 3,945 unique hits and findings of 187 studies were integrated in our analyses. Results hereof suggest that holding of both insurance products is systematically impeded by substitution by social security, adverse selection, nonstandard preferences and limited rationality due to low financial literacy and risk unawareness. Furthermore, insurance holding is concentrated among wealthier and subjectively healthier individuals. A comprehensive approach addressing all four reasons for low uptake may increase insurance holding most effectively and may particularly empower people with lower socio-economic status to make well-informed decisions.

Background Consumer mobility is an important aspect of a health insurance system based on managed competition. Both the general population and insured with a chronic illness should enjoy an equal opportunity to switch their insurer every year. We studied possible differences in the rates of switching between these two groups in the Netherlands. Methods A structured questionnaire was sent to 1500 members of Nivel’s Dutch Health Care Consumer Panel (response rate: 47%) and to 1911 chronically ill members of the National Panel of the Chronically ill and Disabled (response rate: 84%) in February 2016. Associations between switching and background characteristics were estimated using logistic regression analyses with interaction effects. Results In general, we did not find significant differences in switching rates between the general population and chronically ill population. However, a combination of the population and background characteristics demonstrated that young insured with a chronic illness switched significantly less often than young insured from the general population (1% versus 17%). Conclusions Our results demonstrated that the group of young people with a chronic illness is less inclined to switch insurer. This observation suggests that this group might either face difficulties or barriers which prevents them from switching, or that they experience a high level of satisfaction with their current insurer. Further research should therefore focus on unravelling the mechanisms which explain the differences in switching rates.

In 2015 werd een deel van de langdurige zorg gedecentraliseerd naar de gemeenten om beter passende zorg te bieden en de zorgkosten te verlagen. Een onbedoeld effect van deze decentralisatie was dat gemeenten een financiële prikkel kregen om zorg­kosten te verschuiven naar de Wet langdurige zorg. Als dit ook gebeurt, dan staat dat het halen van het oorspronkelijke doel in de weg.

Sinds 2015 wordt de ouderenzorg gefinancierd via drie systemen. Het overkoepelende doel is goede en toegankelijke ouderenzorg op de juiste plek en tegen de juiste prijs. Samenhangende financiële prikkels voor preventie en het inkopen op kwaliteit zijn hiervoor onontbeerlijk. Maar in de praktijk werken ze onvoldoende.

Verplaatsing van zorg van het ziekenhuis naar huisartsen kan bijdragen aan passende zorg. Maar loont een dergelijke zorgverplaatsing wel voor verzekeraars, als inkopers van zorg?

Reducing free-riding is an important challenge for educators who use group projects. In this study, we measure students’ preferences for group project characteristics and investigate if characteristics that better help to reduce free-riding become more important for students when stakes increase. We used a discrete choice experiment based on 12 choice tasks in which students chose between two group projects that differed on five characteristics of which each level had its own effect on free-riding. A different group project grade weight was presented before each choice task to manipulate how much there was at stake for students in the group project. Data of 257 student respondents were used in the analysis. Based on random parameter logit model estimates we find that students prefer (in order of importance) assignment based on schedule availability and motivation or self-selection (instead of random assignment), the use of one or two peer process evaluations (instead of zero), a small team size of three or two students (instead of four), a common grade (instead of a divided grade), and a discussion with the course coordinator without a sanction as a method to handle free-riding (instead of member expulsion). Furthermore, we find that the characteristic team formation approach becomes even more important (especially self-selection) when student stakes increase. Educators can use our findings to design group projects that better help to reduce free-riding by (1) avoiding random assignment as team formation approach, (2) using (one or two) peer process evaluations, and (3) creating small(er) teams.

De Zorgverzekeringswet (Zvw) biedt verzekerden de mogelijkheid om jaarlijks te wisselen van zorgpolis. Dit moet verzekeraars aansporen om in te spelen op de wensen van verzekerden, en het liefst op de wensen van alle verzekerden. Dat laatste is echter niet vanzelfsprekend. De Zvw verplicht verzekeraars om per zorgpolis een uniforme premie te hanteren (afgezien van de mogelijkheid om korting te geven voor een vrijwillig eigen risico, collectiviteit en jaarlijkse vooruitbetaling).

Background Since the Global Burden of Disease study (GBD) has become more comprehensive, data for hundreds of causes of disease burden, measured using Disability Adjusted Life Years (DALYs), have become increasingly available for almost every part of the world. However, undergoing any systematic comparative analysis of the trends can be challenging given the quantity of data that must be presented. Methods We use the GBD data to describe trends in cause-specific DALY rates for eight regions. We quantify the extent to which the importance of ‘major’ DALY causes changes relative to ‘minor’ DALY causes over time by decomposing changes in the Gini coefficient into ‘proportionality’ and ‘reranking’ indices. Results The fall in regional DALY rates since 1990 has been accompanied by generally positive proportionality indices and reranking indices of negligible magnitude. However, the rate at which DALY rates have been falling has slowed and, at the same time, proportionality indices have tended towards zero. These findings are clearest where the focus is exclusively upon non-communicable diseases. Notably, large and positive proportionality indices are recorded for sub-Saharan Africa over the last decade. Conclusion The positive proportionality indices show that disease burden has become less concentrated around the leading causes over time, and this trend has become less prominent as the DALY rate decline has slowed. The recent decline in disease burden in sub-Saharan Africa is disproportionally driven by improvements in DALY rates for HIV/AIDS, as well as for malaria, diarrheal diseases, and lower respiratory infections.

Several regulated health insurance markets include the option for consumers to choose a voluntary deductible. An important motive for this option is to reduce moral hazard. In return for a voluntary deductible, consumers receive a premium rebate, which is typically community rated. Under community rating, voluntary deductibles are particularly attractive for low-risk consumers. Since these people use relatively little medical care, the total moralhazard reduction might be relatively small compared to the total healthcare spending. This paper examines the potential moralhazard reduction under risk-rated premiums. We use Chile as a case study due to institutional features that make it a valid benchmark for other countries. Our simulations show that in the presence of self-selection and under a uniform percentage moral hazard reduction across risk types, the absolute moral hazard reduction from a voluntary deductible is indeed expected to be larger in a system with risk-rated premiums than in a system with community-rated premiums. Nevertheless, sensitivity checks show that this conclusion might no longer hold as the percentage moral hazard reduction is lower for high-risk individuals compared to low-risk individuals.

In the Dutch health care system of managed competition, insurers and mental health providers negotiate on prices for mental health services. Contract prices are capped by a regulator who sets a maximum price for each mental health service. In 2013, the majority of the contract prices equaled these maximum prices. We study price setting after a major policy change in 2014. In 2014, mental health care providers had to negotiate prices with each individual health insurer separately, instead of with all insurers collectively as in 2013. Moreover, after a cost‐price revision, the regulator increased in 2014 maximum prices by about 10%. Insurers and mental health providers reacted to this policy change by setting most contract prices below the new maximum prices. We find that in 2014 mental health providers with more market power, that is, a higher willingness‐to‐pay measure, contracted significantly higher prices. Some insurers negotiated significantly lower prices than other insurers but these differences are unrelated to an insurers' market share.

Summary We assess the relative importance of demand and supply factors as determinants of regional variation in healthcare expenditures in the Netherlands. Our empirical approach follows individuals who migrate between regions. We use individual data on annual healthcare expenditures for the entire Dutch population between the years 2006 and 2013. Regional variation in healthcare expenditures is mostly driven by demand factors, with an estimated share of around 70%. The relative importance of different causes varies with the groups of regions being compared.

Background: In several OECD countries the percentage of people over 80 in LTC institutions has been declining for more than a decade, despite population ageing. The standard model to explain healthcare utilization, the Andersen model, cannot explain this trend. We extend the Andersen model by including proxies for the relative attractiveness of community living compared to institutional care. Using longitudinal data on long-term care use in the Netherlands from 1996 to 2012, we examine to what extent a decline in institutional care is associated with changes in perceived attractiveness of institutional LTC care compared to community living. Methods: With a Blinder–Oaxaca decomposition regression, we decomposed the difference in admission to LTC institutions between the period 1996–1999 and 2009–2012 into a part that accounts for differences in predictors of the Andersen model and an “unexplained” part, and investigate whether the perceived attractiveness of institutional care reduces the size of the unexplained part. Results: We find that factors related to the perceived attractiveness of institutional care compared to community living explains 12.8% of the unexplained negative time trend in admission rates over the total period (1996–2012), and 19.1–19.2% over shorter time frames. Discussion: Our results show that changes in the perceived attractiveness of institutional LTC may explain part of the decline in demand for institutional care. Our findings imply that policies to encourage community living may have a self-reinforcing effect.

markdownabstractAlweer bijna negen jaar geleden schreven wij in dit tijdschrift een kritisch artikel over het toenmalige toezicht op zorgfusies en de voorgenomen invoering van een extra zorgspecifieke fusietoets. Onze belangrijkste conclusies van destijds kunnen als volgt worden samengevat:1 ‘De effectiviteit van het huidige toezicht op zorgfusies staat volop ter discussie. Het kabinetsvoornemen om [voorafgaand aan de toets op grond van de Mededingingswet] een zorgspecifieke fusietoets in te voeren is echter overbodig en ongewenst. Er zijn vooralsnog namelijk geen criteria waarmee kwaliteitsverlagende effecten van schaalvergroting vooraf kunnen worden vastgesteld. (…) Voor het toezicht op zorgfusies belooft 2011 een spannend jaar te worden. Het afgelopen jaar heeft de NMa, samen met de NZa, bij drie voorgenomen zorgfusies haar tanden laten zien. De komende periode moet duidelijk worden of de mededingingsautoriteit op het gebied van zorgfusies, indien nodig, ook durft te bijten.’ In aanloop naar het tweede lustrum van dit tijdschrift heeft de redactie ons gevraagd om met de kennis van nu nogmaals naar dit onderwerp te kijken. Met dit artikel, waarin wij terug- en vooruitblikken, gaan wij graag op deze uitnodiging in. In de terugblik zullen we achtereenvolgens de ervaringen met de zorgspecifieke fusietoets en het mededingingstoezicht op zorgfusies bespreken. Vervolgens zullen we in de vooruitblik op basis van deze ervaringen voor beide vormen van fusietoezicht lessen trekken voor de toekomst.

In 2015 the system of long-term care (LTC) financing and provision in the Netherlands was profoundly reformed. The benefits covered by the former comprehensive public LTC insurance scheme were split up and allocated to three different financing regimes. The objectives of the reform were to improve the coordination between LTC, medical care and social care, and to reinforce incentives for an efficient provision of care by making risk-bearing health insurers and municipalities responsible for procurement. Unintentionally, the reform also created a number of major incentive problems, however, resulting from the way: (i) LTC benefits were split up across the three financing regimes; (ii) the various third party purchasers were compensated; and (iii) co-payments for the beneficiaries were designed. These incentive problems may result in cost shifting, lack of coordination between various LTC providers, inefficient use of LTC services and quality skimping. We discuss several options to get the financial incentives better aligned with the objectives of the reform.