RESUMEN

Health systems' insurance/funding can be organised in several ways. Some countries have adopted systems with a mixture of public-private involvement (e.g. Australia, Chile, Ireland, South Africa, New Zealand) which creates two-tier health systems, allowing consumers (groups) to have preferential access to the basic standard of care (e.g. skipping waiting times). The degree to which efficiency and equity are achieved in these types of systems is questioned. In this paper, we consider integration of the two tiers by means of a managed competition model, which underpins Social Health Insurance (SHI) systems. We elaborate a two-part conceptual framework, where, first, we review and update the existing pre-requisites for the model of managed competition to fit a broader definition of health systems, and second, we typologise possible roadmaps to achieve that model in terms of the insurance function, and focus on the consequences on providers and governance/stewardship.

RESUMEN

This paper considers whether and how managed competition arrangements could be introduced into the Aotearoa health and disability system. The paper describes the key features of the system, including new organisational arrangements established from 1 July 2022. It discusses major reforms and managed competition plans that were developed in the 1990s, with the managed competition plans abandoned fairly early on, as a result of major issues with the reforms that had been implemented and with problems in designing a fair payment system for competing health plans. The paper goes on to argue that the development of capitated, risk-bearing and competing Primary Health Organisations set up in the 2000s should be considered in terms of managed competition, and the paper points to the issues that have arisen in Aotearoa due to a lack of regulations that would have better supported the better achievement of effectiveness, efficiency, and equity goals over the past 20 years. Finally, the paper also looks ahead to whether and how managed competition might again be considered in Aotearoa and the extent to which the system currently includes key pre-conditions to support such arrangements.

RESUMEN

Managed competition frameworks aim to control healthcare costs and promote access to high-quality health insurance and services through a combination of public policies and market forces. In the United States, managed competition delivery systems are varied and diffused across a patchwork of divided markets and populations. This, coupled with extremely high national health spending per capita, makes a more unified managed competition strategy an appealing alternative to a currently struggling healthcare system. We examine the relative effectiveness of three existing programmes in the U.S. that each rely upon some principles of managed competition: health insurance exchanges instituted by the Affordable Care Act, Medicaid managed care organisations, and Medicare Advantage plans. Although each programme leverages some competitive features, each faces significant hurdles as a candidate for expansion. We highlight these challenges with a survey of academic health economists, and find that provider and insurer consolidation, highly segmented markets, and failing to incentivise competitive efficiencies all dampen the success of existing programmes. Although managed competition for all is a potentially desirable framework for future health reform in the U.S., successful expansion relies on addressing fundamental issues revealed by imperfect existing programmes.

RESUMEN

The Dutch health system is based on the principles of managed (or regulated) competition, meaning that competing risk bearing insurers and providers negotiate contracts on the price, quantity and quality of care. The COVID-19 pandemic caused a huge external shock to the health system which potentially distorted the conditions required for fair competition. Therefore, an important question is to what extent was the competitive Dutch health system resilient to the financial shock caused by the pandemic? Overall, the Dutch competitive health system proved to be sufficiently flexible and resilient at absorbing the financial shock caused by the COVID-19 pandemic in 2020 and 2021 due to an effective combination of regulatory and self-regulatory measures. However, based on the overall experiences in the Netherlands, from the health policy perspective improvements are needed aimed at (i) refining the catastrophic costs clause included in the Health Insurance Act, (ii) reducing the vulnerability of the Dutch risk equalisation system to distortions due to unforeseen catastrophic health care costs, and (iii) establishing more equal financial risk sharing between health insurers and health care providers. These improvements are also relevant for other countries with a health system based on the principles of managed (or regulated) competition.

Asunto(s)

RESUMEN

Systems of managed competition naturally seek the middle ground between competition and regulation. This debate essay makes the case for adjusting the level of regulation according to the characteristics of the submarket in question. We first develop a theoretical framework that can be used to identify the services in which relatively free competition will be beneficial. The framework is grounded in the economic literature and consists of eight criteria. Targeted regulatory tools are then discussed that can be used to structure submarkets in which these criteria are not (fully) met. Applying this framework and targeted interventions, regulators gain the flexibility to react to potential market failures, without foregoing the benefits of managed competition where it works well. This analysis is highly relevant for countries in transition to managed competition. Regulators can identify potential failure in submarkets for medical services, and apply the necessary regulatory tools to prepare for a smooth transition.

RESUMEN

Over the past decade, many health care systems across the Global North have implemented elements of market mechanisms while also dealing with the consequences of the financial crisis. Although effects of these two developments have been researched separately, their combined impact on the governance of health care organizations has received less attention. The aim of this study is to understand how health care reforms and the financial crisis together shaped new roles and interactions within health care. The Netherlands - where dynamics between health care organizations and their financial stakeholders (i.e., banks and health insurers) were particularly impacted - provides an illustrative case. Through semi-structured interviews, additional document analysis and insights from institutional change theory, we show how banks intensified relationship management, increased demands on loan applications and shifted financial risks onto health care organizations, while health insurers tightened up their monitoring and accountability practices towards health care organizations. In return, health care organizations were urged to rearrange their operations and become more risk-minded. They became increasingly dependent on banks and health insurers for their existence. Moreover, with this study, we show how institutional arenas come about through both the long-term efforts of institutional agents and unpredictable implications of economic and societal crises.

Asunto(s)

RESUMEN

BACKGROUND: In a healthcare system based on managed competition, it is important that health insurers are able to channel enrollees to preferred providers. This results in incentives for healthcare providers to improve the quality and reduce the price of care. One of the instruments to guide enrollees to preferred providers is by providing healthcare advice. In order to use healthcare advice as an effective instrument, it is important that enrollees accept the health insurer as a healthcare advisor. As trust in health insurers is not high, this may be an obstacle for enrollees to be receptive to the health insurer's advice. This study aims to investigate the association between trust in the health insurer and the willingness to receive healthcare advice from the health insurer in the Netherlands. In terms of receiving healthcare advice, we examine both enrollees' willingness to approach the health insurer themselves and their willingness to be approached by the health insurer. METHODS: In February 2021, a questionnaire was sent to a representative sample of the Dutch population. The questionnaire was completed by 885 respondents (response rate 59%). Respondents were asked about their willingness to receive healthcare advice, and trust in the health insurer was measured using a validated multiple item scale. Logistic regression models were conducted to analyse the results. RESULTS: Enrollees with more trust in the health insurer were more willing to approach their health insurer for healthcare advice (OR = 1.07, p = 0.00). In addition, a higher level of trust in the health insurer is significantly associated with the odds that enrollees would like it/really appreciate it if their health insurer actively approached them with healthcare advice (OR = 1.07, p = 0.00). The role of trust in the willingness to receive healthcare advice is not proven to differ between groups with regard to educational levels, health status or age. CONCLUSIONS: This study confirms that trust plays a role in the willingness to receive healthcare advice from the health insurer. The association between the two emphasizes the importance to increase enrollees' trust in the health insurer. As a result, health insurers may be better able to fulfil their role as healthcare advisor.

Asunto(s)

RESUMEN

In healthcare systems with a purchaser-provider split, contracts are an important tool to define the conditions for the provision of healthcare services. Financial risk allocation can be used in contracts as a mechanism to influence provider behavior and stimulate providers to provide efficient and high-quality care. In this paper, we provide new insights into financial risk allocation between insurers and hospitals in a changing contracting environment. We used unique nationwide data from 901 hospital-insurer contracts in The Netherlands over the years 2013, 2016, and 2018. Based on descriptive and regression analyses, we find that hospitals were exposed to more financial risk over time, although this increase was somewhat counteracted by an increasing use of risk-mitigating measures between 2016 and 2018. It is likely that this trend was heavily influenced by national cost control agreements. In addition, alternative payment models to incentivize value-based health care were rarely used and thus seemingly of lower priority, despite national policies being explicitly directed at this goal. Finally, our analysis shows that hospital and insurer market power were both negatively associated with financial risk for hospitals. This effect becomes stronger if both hospital and insurer have strong market power, which in this case may indicate a greater need to reduce (financial) uncertainties and to create more cooperative relationships.

Asunto(s)

RESUMEN

BACKGROUND: Purchasing systems aim to improve resource allocation in healthcare markets. The Netherlands is characterized by four different purchasing systems: managed competition in the hospital market, a non-competitive single payer system for long-term care (LTC), municipal procurement for home care and social services, and self-procurement via personal budgets. We hypothesize that managed competition and competitive payer reforms boost reallocations of provider market share by means of active purchasing, ie, redistributing funds from high-quality providers to low-quality providers. METHODS: We define a Market Activity Index (MAI) as the sum of funds reallocated between providers annually. Provider expenditures are extracted from provider financial statements between 2006 and 2019. We compare MAI in six healthcare sectors under four different purchasing systems, adjusting for reforms, and market entry/exit. Next, we perform in-depth analyses on the hospital market. Using multivariate linear regressions, we relate reallocations to selective contracting, provider quality, and market characteristics. RESULTS: No difference was found between reallocations in the hospital care market under managed competition and the non-competitive single payer LTC (MAI between 2% and 3%), while MAI was markedly higher under procurement by municipalities and personal budget holders (between 5% and 15%). While competitive reforms temporarily increased MAI, no structural effects were found. Relatively low hospital MAI could not be explained by market characteristics. Furthermore, the extent of selective contracting or hospital quality differences had no significant effects on reallocations of funds. CONCLUSION: Dutch managed competition and competitive purchaser reforms had no discernible effect on reallocations of funds between providers. This casts doubt on the mechanisms advocated by managed competition and active purchasing to improve allocative efficiency.

Asunto(s)

RESUMEN

BACKGROUND: In insurance-based healthcare systems, healthcare insurers are interested in engaging citizens in care procurement to contract healthcare services that matter to people. In the Netherlands, an amendment to the Health Insurance Act was set forth in 2021 to formalize and strengthen the engagement of the insured population with healthcare insurers' procurement cycles. This study explores the role of Dutch healthcare insurers in operationalizing citizen engagement in procurement cycles before changes occur linked to the amendment to the Health Insurance Act. METHODS: A phenomenological qualitative design was employed in two phases: (1) we consulted academics and policy experts on the role of healthcare insurers regarding citizen engagement; (2) we conducted focus groups with representatives of healthcare insurers to understand how citizens' engagement is being operationalized. Transcripts of the interviews with experts and detailed notes of focus group meetings were analysed using a qualitative inductive approach. Selected excerpts were analysed on discourse and content and organized by a coding scheme following a rigorous and accelerated data reduction technique. RESULTS: We identified four strategies used by healthcare insurers to operationalize citizen engagement: (1) broadening their population health orientation; (2) developing and improving mechanisms for engaging citizens; (3) strengthening features of data governance for effective use of value-driven data; (4) implementing financial and incentive mechanisms among healthcare providers in support of value-based healthcare. However, regulated market mechanisms and low institutional trust in healthcare insurers undermine their transition from merely funding healthcare towards becoming people-centred value-based healthcare purchasers. CONCLUSION: Dutch healthcare insurers seem to be strengthening the community orientation of their functioning while enhancing the end-to-end experience of the insured. The expected practical effects of the amendment to the Health Insurance Act include broadening the role of the council of insurees in decision-making processes and systematically documenting the efforts set forth by healthcare insurers in engaging citizens. Further research is needed to better understand how the regulated competitive market could be hampering the engagement of citizens in healthcare procurement decision-making and value creation from the citizens' perspective.

Asunto(s)

RESUMEN

BACKGROUND: Since 2006, business principles have been introduced to foster efficient healthcare by way of managed competition. Managed competition is expressed by a contract between a health insurer and a physiotherapy primary healthcare organisation (PTPHO). In such a managed environment, PTPHOs have to attain treatment service quality and financial PTPHO-centred outcomes Research shows that business model designs may enhance organisation-centred outcomes. A business model is a design (efficiency or novelty) of how a firm transacts with customers, partners, and vendors; how it connects with markets. However, research on managed competition contract and business model designs, in relation to PTPHO-centred outcomes is new to the healthcare literature. PTPHOs may not know how business model designs enhance outcomes. This study aims to delineate the relations between business model efficiency and novelty, and PTPHO-centred outcomes, while accounting for managed competition contract in Dutch healthcare. METHODS: A quantitative cross-sectional design was adopted. Using a questionnaire, the relations between managed competition, business model efficiency and novelty, and PTPHO-centred outcomes were investigated among PTPHO managers (n = 138). Theory-based expectations were set up and multiple linear regression analyses were applied. RESULTS: Managed competition and business model efficiency show no relation with PTPHO-centred outcomes. Moderation of the business model efficiency and PTPHO-centred outcomes relation by managed competition contract is not detected. Business model novelty shows a positive relation with PTPHO-centred outcomes. Moderation of the business model novelty and PTPHO-centred outcomes relation by managed competition contract is found. CONCLUSIONS: There seem to be positive relations between business model novelty and PTPHO-centred outcomes on its own and moderated by managed competition contract. No relations seem to exist with business model efficiency. This implies that the combination of persistent use of health insurer-driven managed competition contracts and a naturally efficient PTPHOs may have left too few means for these organisations to contribute to healthcare reforms and attain PTPHO-centred outcomes. Organisation-driven innovation could stretch system-level regulations and provide room for new business models. Optimising contracts towards organisation-driven healthcare reform, including novelty requirements and corresponding reimbursements is suggested. PTPHO managers may want to shift their attitudes towards novel business models.

Asunto(s)

RESUMEN

BACKGROUND: Within the Dutch healthcare system of managed competition, health insurers can contract healthcare providers selectively. Enrollees who choose a health insurance policy with restrictive conditions will have to make a co-payment if they consult a non-contracted provider. This study aims to gain insight into enrollees' awareness of the conditions of such health insurance policies. METHODS: In August 2020, an online questionnaire was sent out via health insurers to their enrollees with restrictive health plans. In total 13,588 enrollees responded. RESULTS: One fifth of the respondents appeared to be totally unfamiliar with the policy conditions. Men, younger people, people with a low level of education, a lower income, a poorer health status and non-care users were found to be less familiar with the conditions. Of those who have been in the situation that they wanted to visit a healthcare provider whose care was not fully reimbursed, 62% went to that provider. Of those who had to pay extra because hospital care was not fully reimbursed, 62% did not know this in advance and 30% indicated that paying extra was a serious problem. CONCLUSIONS: Not all enrollees who choose a policy with restrictive conditions are aware of the consequences of receiving care from non-contracted providers. Increased awareness among enrollees will benefit the functioning of the healthcare system based on managed competition.

Asunto(s)

RESUMEN

In the last decades, several European health systems have abandoned their vertically integrated health care in favour of some form of managed competition (MC), either in a centralised or decentralised format. However, during a pandemic, MC may put health systems under additional strain as they are designed to follow some form of 'organisational self-interest', and hence face reduced incentives for both provider coordination (e.g. temporary hospital close down, change in the case-mix), and information sharing. We illustrate our argument using evidence for the Covid-19 pandemic outbreak in Italy during March and April 2020, which calls for the development of 'coordination mechanisms' at times of a health emergency.

Asunto(s)

RESUMEN

The burden of registrations for professionals should be more firmly on the policy agenda. In a rigorous study, Marieke Zegers and colleagues make a compelling argument why that should be the case. In Dutch hospitals, the average professional spends 52.3 minutes a day on quality registries and monitoring instruments. Many more administrative duties exist. These represent substantial resources and ultimately could become a drag on the intrinsic motivation of the care professions. We agree with Zegers et al that we are in need for more operational efficiency. However, the issue at hand is very complex and also intensely connected to the entire healthcare system and its different levels. More operational efficiency alone will not solve this problem. We are also in need for better governance of data-issues at the macro-system level.

Asunto(s)

RESUMEN

In health care systems based upon managed competition, insurers are expected to negotiate with providers about price and quality of care. The Dutch experience, however, shows that quality plays a limited role in insurer-provider negotiations. It has been suggested that this is partly due to a lack of cooperation among insurers. This raises the question whether cooperation amongst insurers is a precondition or a substitute for quality-based competition. To answer this question, we mapped insurers' cooperating activities to enhance quality of care using a six-stage continuum. The first three stages (defining, designing and measuring quality indicators) may enhance competition, whereas the next three stages (setting benchmarks, steering patients and selective contracting) may reduce it. We investigated which types of insurer cooperation currently take place in the Netherlands. Additionally, we organized focus groups among insurers, providers and other stakeholders to examine their perceptions on insurer cooperation. We find that all stakeholders see advantages of cooperation amongst insurers in the first stages of the continuum and sometimes cooperate in this domain. Cooperation in the next stages is almost absent and more controversial because without adequate quality information, it is difficult to assess whether the benefits outweigh the cost associated with reduced competition.

Asunto(s)

RESUMEN

BACKGROUND: In 2006 a major healthcare reform was introduced in the Netherlands, implying managed competition. This study explored the level of consensus on the outcomes and desired changes of this new system, and differences between stakeholder groups. METHODS: A three-round Delphi-study was conducted among Dutch healthcare insurers, health economists, and professionals in general practice (GP) care and mental health (MH) care. In the first round, 20 experts indicated the most important advantages and disadvantages of the Dutch managed competition, and desired changes. Experts in the second (n = 106) and third round (N = 88) rated the importance of the 88 factors identified in the first round. RESULTS: Only healthcare insurers reached consensus on important advantages (i.e. improved efficiency; room for choice). Health economists reached almost no consensus on any factors. GP and MH-care professionals reached most consensus on disadvantages (i.e. focus on price over quality, increased bureaucracy) and desired changes (i.e. reduce bargaining power of healthcare insurers; increase attention for care of complex patients); half of them suggested abolishment of managed competition. CONCLUSION: GP and MH-care professionals were most dissatisfied and suggested several changes or even abolishment of the 2006 reform; healthcare insurers mentioned some benefits. This level of dissatisfaction among health care professionals indicates that there is room for improvement, preferably developed in conjunction with stakeholders.

Asunto(s)

RESUMEN

OBJECTIVE: To assess how beneficiary premiums, expected out-of-pocket costs, and plan finances in the Medicare Advantage (MA) market are related to coding intensity. DATA SOURCES/STUDY SETTING: MA plan characteristics and administrative records from the Centers for Medicare and Medicaid Services (CMS) for the sample of beneficiaries enrolled in both MA and Part D between 2008 and 2015. Medicare claims and drug utilization data for Traditional Medicare (TM) beneficiaries were used to calibrate an independent measure of health risk. STUDY DESIGN: Coding intensity was measured by comparing the CMS risk score for each MA contract with a contract level risk score developed using prescription drug data. We conducted regressions of plan outcomes, estimating the relationship between outcomes and coding intensity. To develop prescription drug scores, we assigned therapeutic classes to beneficiaries based on their prescription drug utilization. We then regressed nondrug spending for TM beneficiaries in 2015 on demographic and therapeutic class identifiers for 2014 and used the coefficients to predict relative risk. PRINCIPAL FINDINGS: We found that, for each $1 increase in potential revenue resulting from coding intensity, MA plan bid submissions declined by $0.10 to $0.19, and another $0.21 to $0.45 went toward reducing plans' medical loss ratios, an indication of higher profitability. We found only a small impact on beneficiary's projected out-of-pocket costs in a plan, which serves as a measure of the generosity of plan benefits, and a $0.11 to $0.16 reduction in premiums. As expected, coding intensity's effect on bids was substantially larger in counties with higher levels of MA competition than in less competitive counties. CONCLUSIONS: While coding intensity increases taxpayers' costs of the MA program, enrollees and plans both benefit but with larger gains for plans. The adoption of policies to more completely adjust for coding intensity would likely affect both beneficiaries and plan profits.

Asunto(s)

RESUMEN

Introduction. Las compras estratégicas son un componente importante del financiamiento del sistema de salud. Puede mejorar la productividad, la justicia y la responsabilidad en la prestación de atención médica en caso de considerar la calidad. Este estudio, que se realizó como una revisión sistemática, tuvo como objetivo investigar el estado de la calidad en cinco dominios de compras estratégicas en el sistema de salud para responder qué, para quién, de quién, cómo comprar y cuánto comprar. Material y Métodos: Este estudio revisó sistemáticamente los artículos publicados en las bases de datos de Web of Sciences (WOS), Scopus, PubMed, Medline vía Ovid, Embase desde 2000 hasta octubre de 2019. Las palabras clave utilizadas para la búsqueda en las bases de datos incluyeron las siguientes: Sector Salud, Entrega de atención médica, garantía de calidad, mejora de la calidad y compras estratégicas. Un total de 182 artículos fueron seleccionados y revisados ​​por cuatro investigadores. Se excluyeron los artículos con contenido irrelevante. Los datos de los artículos seleccionados se analizaron mediante el método de análisis de contenido. Resultados: De los 182 artículos recopilados mediante la búsqueda en las bases de datos seleccionadas, se analizaron 16 artículos. Con base en los resultados de este estudio, las compras estratégicas en el sistema de salud resultan en la entrega de servicios con mayor calidad. Conclusión: Las compras estratégicas pueden mejorar el desempeño del sistema de salud al elegir el proveedor más apropiado y el método de pago más apropiado, junto con la equidad en la prestación de servicios de atención médica de calidad

Introducction. Strategic purchasing is an important component of financing in the health system. It can enhance productivity, justice, and accountability in the health care delivery in case of considering the quality. This study, which was conducted as a systematic review, was aimed at investigating the status of quality in five domains of strategic purchasing in the health system to answer what, for whom, from whom, how to buy, and how much to buy. Material and Methods: This study systematically reviewed the articles published in the databases of Web of Sciences (WOS), Scopus, PubMed, Medline via Ovid, Embase from 2000 to October 2019. The keywords used to search the databases included the following: Health Care Sector, Delivery of Health Care, Quality Assurance, Quality Improvement, and Strategic Purchasing. A total of 182 articles were selected and reviewed by four researchers. Articles with irrelevant content were excluded. Data of the selected articles were analyzed using the content analysis method. Results: Of the 182 articles collected through searching the selected databases, 16 articles were analyzed. Based on the results of this study, strategic purchasing in the health system results in the delivery of services with higher quality. Conclusion: Strategic purchasing can enhance the performance of the health system through choosing the most appropriate provider and the most appropriate payment method, along with equity in providing quality health care services

RESUMEN

Our article deals with pricing strategies in Swiss health insurance markets and focuses on the relationship between basic and supplementary insurance. We analyzed how firms' pricing strategies (i.e., pricing of basic and supplementary products) can create switching costs in basic health insurance markets, thereby preventing competition in basic insurance from working properly. More specifically, using unique market and survey data, we investigated whether firms use bundling strategies or supplementary products as low-price products to attract and retain basic insurance consumers. To our knowledge, this is the first paper to analyze these pricing strategies in the context of insurance/health insurance. We found no evidence of bundling in the Swiss setting. We did however observe that firms used low-price supplementary products that contributed to lock in consumers. A majority of firms offered at least one of such product at a low price. None offered low-price products in both basic and supplementary markets. Low-price insurance products differed across firms. When buying a low-price supplementary product, consumers always bought their basic contract from the same firm. Furthermore, those who opted for low-price supplementary products were less likely to declare an intention to switch basic insurance firms in the near future. This result was true for all risk category levels.

Asunto(s)

RESUMEN

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.

Asunto(s)