http://repub.eur.nl/res/aut/10593/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/40016/ 2013-03-01T00:00:00Z Context: From the mid-1990s several countries have introduced elements of regulated competition in healthcare. The aim of this paper is to identify the most important preconditions for achieving efficiency and affordability under regulated competition in healthcare, and to indicate to what extent these preconditions are fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. These experiences can be worthwhile for other countries (considering) implementing regulated competition (e.g. Australia, Czech Republic, Ireland, Russia, Slovakia, US). Methods: We identify and discuss ten preconditions derived from the theoretical model of regulated competition and assess the extent to which each of these preconditions is fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. Findings: After more than a decade of healthcare reforms in none of these countries all preconditions are completely fulfilled. The following preconditions are least fulfilled: consumer information and transparency, contestable markets, freedom to contract and integrate, and competition regulation. The extent to which the preconditions are fulfilled differs substantially across the five countries. Despite substantial progress in the last years in improving the risk equalization systems, insurers are still confronted with substantial incentives for risk selection, in particular in Israel and Switzerland. Imperfect risk adjustment implies that governments are faced with a complex tradeoff between efficiency, affordability and selection. Conclusions: Implementing regulated competition in healthcare is complex, given the preconditions that have to be fulfilled. Moreover, since not all preconditions can be fulfilled simultaneously, tradeoffs have to be made with implications for the levels of efficiency and affordability that can be achieved. Therefore the optimal set of preconditions is not only an empirical question but ultimately also a matter of societal preferences. http://repub.eur.nl/res/pub/38998/ 2013-02-08T00:00:00Z This paper explores the goals and implementation of reforms introducing choice of and competition among insurers providing statutory health coverage in Belgium, Germany, the Netherlands and Switzerland. In theory, health insurance competition can enhance efficiency in health care administration and delivery only if people have free choice of insurer (consumer mobility), if insurers do not have incentives to select risks, and if insurers are able to influence health service quality and costs. In practice, reforms in the four countries have not always prioritised efficiency and implementation has varied. Differences in policy goals explain some but not all of the differences in implementation. Despite significant investment in risk adjustment, incentives for risk selection remain and consumer mobility is not evenly distributed across the population. Better risk adjustment might make it easier for older and less healthy people to change insurer. Policy makers could also do more to prevent insurers from linking the sale of statutory and voluntary health insurance, particularly where take-up of voluntary coverage is widespread. Collective negotiation between insurers and providers in Belgium, Germany and Switzerland curbs insurers' ability to influence health care quality and costs. Nevertheless, while insurers in the Netherlands have good access to efficiency-enhancing tools, data and capacity constraints and resistance from stakeholders limit the extent to which tools are used. The experience of these countries offers an important lesson to other countries: it is not straightforward to put in place the conditions under which health insurance competition can enhance efficiency. Policy makers should not, therefore, underestimate the challenges involved. http://repub.eur.nl/res/pub/38517/ 2012-11-27T00:00:00Z The Chinese government is considering a (regulated) competitive healthcare system. Sufficient consumer information is a crucial pre-condition to benefit from such a change. We conducted a survey on the level of consumer information regarding health insurance among the insured population in Nanjing, China in 2009. The results from descriptive analysis and binary logistic regression demonstrate that the current level of consumer information about health insurance is low. The level of consumer information is positively correlated with the subscribers' motivation to obtain the information and its availability. The level of searching for health insurance information is also low; moreover, even upon searching, the chance of finding relevant information is less than 25%. We conclude that the level of consumer information is currently insufficient in China. If the Chinese government is determined to adopt market mechanisms in the healthcare sector, it should take the lead in making valid and reliable information publicly available and easily accessible. http://repub.eur.nl/res/pub/38393/ 2012-10-05T00:00:00Z Het vervangen van het huidige eigen risico in de basisverzekering door een systeem van gepaste eigen betalingen, komt een gepast gebruik van zorg ten goede. In dit systeem varieert de eigen betaling met de ziektelast van de aandoening, de effectiviteit en doelmatigheid van de behandeling en de doelmatigheid van zorgaanbieders. http://repub.eur.nl/res/pub/32891/ 2012-05-01T00:00:00Z Het ex-ante vereveningsmodel van de Zorgverzekeringswet dient verzekeraars te compenseren voor voorspelbare, gezondheidsgerelateerde kostenverschillen tussen verzekerden. Zonder goed vereveningsmodel worden verzekeraars – vanwege het verbod op premiedifferentiatie – geconfronteerd met voorspelbare winsten op gezonde verzekerden en voorspelbare verliezen op chronisch zieken. Voorspelbare winsten en verliezen geven verzekeraars prikkels tot risicoselectie, indirecte premiedifferentiatie en productdifferentiatie. Bovendien kan sprake zijn van een ongelijk speelveld op de zorgverzekeringsmarkt wanneer chronisch zieken zich concentreren bij bepaalde verzekeraars. Het doel van dit artikel is inzicht te geven in 1) het effect van de verbeteringen die de afgelopen twee decennia in het vereveningsmodel zijn aangebracht en 2) de ontwikkeling van prikkels tot risicoselectie, indirecte premiedifferentiatie en productdifferentiatie. Hiertoe hebben wij schadegegevens van verzekeraars gekoppeld aan enqueˆtegegevens van het Permanent Onderzoek naar de Leefsituatie dat jaarlijks wordt uitgevoerd door het Centraal Bureau voor de Statistiek. Uit de resultaten blijkt dat het vereveningsmodel sinds de invoering in 1993 sterk is verbeterd: voor een brede set van subgroepen met een oververtegenwoordiging van chronisch zieken reduceert het ex-ante vereveningsmodel-2011 de voorspelbare verliezen met gemiddeld 70%; voor het exante vereveningsmodel-1993 was dat nog gemiddeld 40%. In dezelfde periode is het financieel risico voor verzekeraars verhoogd van gemiddeld 3% in 1993 naar 74% in 2011. Combineren we de modelverbeteringen met de stijging van het financieel risico dan blijkt dat de prikkels tot risicoselectie, indirecte premiedifferentiatie en productdifferentiatie per saldo zijn toegenomen. Kijken we naar de afgelopen vijf jaar dan zijn deze prikkels in 2011 ruim een derde groter dan in 2007. http://repub.eur.nl/res/pub/38161/ 2012-01-01T00:00:00Z In de Verenigde Staten kiezen miljoenen mensen voor zorgsparen in combinatie met een eigen risico. Ook voor Nederland is dit concept interessant omdat hiermee het zorggebruik kan worden afgeremd, de verzekerbaarheid van zorg buiten het basispakket kan worden vergroot en zowel de totale zorgkosten als het aandeel collectief gefinancierde zorgkosten kunnen worden verlaagd. http://repub.eur.nl/res/pub/38335/ 2012-01-01T00:00:00Z Het vroegtijdig gesneuvelde plan van het nieuwe kabinet voor een meer inkomensafhankelijke zorgpremie stuitte op felle kritiek. Naast de bekritiseerde koopkrachteffecten zou het concurrentie ontmoedigen, kostenbewustzijn beperken, werkgelegenheid verkleinen en leiden tot nationalisatie. Deze kritiek berust op misvattingen en mist onderbouwing. De voorgestelde premiestructuur kan concurrentie juist versterken en leidt tot lagere uitvoeringskosten, lagere collectieve uitgaven en een forse vermindering van het wanbetalersprobleem. Een gemiste kans. http://repub.eur.nl/res/pub/38389/ 2012-01-01T00:00:00Z In het ESB-artikel ‘Zorgsparen reduceert zorgkosten’ bespreken wij hoe zorgsparen in combinatie met een vrijwillig eigen risico interessant kan zijn voor zowel de basisverzekering als de aanvullende verzekering (Van Winssen et al., 2012). http://repub.eur.nl/res/pub/30787/ 2011-10-01T00:00:00Z Introduction: The aim of this study was to compare the reproducibility of epidermal growth factor receptor (EGFR) immunohistochemistry (IHC), EGFR gene amplification analysis, and EGFR and KRAS mutation analysis among different laboratories performing routine diagnostic analyses in pathology in The Netherlands, and to generate normative data. Methods: In 2008, IHC, in-situ hybridisation (ISH) for EGFR, and mutation analysis for EGFR and KRAS were tested. Tissue microarray sections were distributed for IHC and ISH, and tissue sections and isolated DNA with known mutations were distributed for mutation analysis. In 2009, ISH and mutation analysis were evaluated. False-negative and false-positive results were defined as different from the consensus, and sensitivity and specificity were estimated. Results: In 2008, eight laboratories participated in the IHC ring study. In only 4/17 cases (23%) a consensus score of ≥75% was reached, indicating that this analysis was not sufficiently reliable to be applied in clinical practice. For EGFR ISH, and EGFR and KRAS mutation analysis, an interpretable result (success rate) was obtained in ≥97% of the cases, with mean sensitivity ≥96% and specificity ≥95%. For small sample proficiency testing, a norm was established defining outlier laboratories with unsatisfactory performance. Conclusions: The result of EGFR IHC is not a suitable criterion for reliably selecting patients for anti-EGFR treatment. In contrast, molecular diagnostic methods for EGFR and KRAS mutation detection and EGFR ISH may be reliably performed with high accuracy, allowing treatment decisions for lung cancer. http://repub.eur.nl/res/pub/25800/ 2011-05-01T00:00:00Z As China explores new directions to reform its health care system, regulated competition among both insurers and providers of care might be one potential model. The Russian Federation in 1993 implemented legislation intended to stimulate such regulated competition in the health care sector. The subsequent progress and lessons learned over these 17 years can shed light on and inform the future evolution of the Chinese system. In this paper, we list the necessary pre-conditions for reaping the benefits of regulated competition in the health care sector. We indicate to what extent these conditions are being fulfilled in the post-reform Russian and current Chinese health care systems. We draw lessons from the Russian experience for the Chinese health care system, which shares a similar economic and political background with the pre-reform Russian health care system in terms of the starting point of the reform, and analyse the prospects for regulated competition in China. http://repub.eur.nl/res/pub/25880/ 2011-01-01T00:00:00Z http://repub.eur.nl/res/pub/26528/ 2011-01-01T00:00:00Z In this paper, we first deal with the rationale of risk adjustment and risk equalization in health insurance markets. Then we discuss the state of the art concerning the application of risk adjustment and risk equalization in practice. Finally, we focus on: What needs to be done? http://repub.eur.nl/res/pub/20199/ 2010-11-01T00:00:00Z http://repub.eur.nl/res/pub/20543/ 2010-11-01T00:00:00Z The paper summarises the conclusions for health policy from the experience of three countries who have introduced risk equalisation subsidies, in their voluntary health insurance (VHI) markets. The countries chosen are Australia, Ireland and South Africa. All of these countries have developed VHI markets and have progressed towards introducing risk equalisation. The objective of such subsidies is primarily to make VHI affordable while encouraging efficiency in health care production. The paper presents a conceptual framework to understand and compare risk equalisation subsidies in VHI markets. The paper outlines how such subsidies are organised in each of the countries and identifies problems that arise in their implementation. We conclude that the objectives of risk equalisation, in VHI markets are no different to those in countries with mandatory insurance systems. We find that the introduction of risk equalisation subsidies is complex and that countries seeking to introduce risk equalisation in VHI markets must carefully consider how such subsidies advance their overall health policy goals. Furthermore, we conclude that such subsidies must be structured correctly as otherwise incentives exist for risk selection which may threaten affordability and efficiency. Our overall conclusion is that also in voluntary health insurance markets risk equalisation has a role in meeting the related public policy objectives of risk solidarity and affordability, and without it these objectives are severely undermined. http://repub.eur.nl/res/pub/23187/ 2010-08-01T00:00:00Z Het voorstel om de AWBZ te laten uitvoeren door concurrerende zorgverzekeraars is niet verstandig. Zorgverzekeraars hebben geen financieel belang bij investeringen in goede AWBZ-zorg omdat AWBZ-zorggebruikers voorspelbaar verliesgevend zijn. Bovendien ontbreekt vooralsnog elk perspectief op adequate stimuli tot doelmatige zorginkoop. http://repub.eur.nl/res/pub/19659/ 2010-07-01T00:00:00Z In the 1990s, countries experimented with two models of health care reforms based on choice of provider and insurer. The governments of the UK, Italy, Sweden and New Zealand introduced relatively quickly 'internal market' models into their single-payer systems, to transform hierarchies into markets by separating 'purchasers' from 'providers', and enabling 'purchasers' to contract selectively with competing public and private providers so that 'money followed the patient'. This model has largely been abandoned where it has been tried. England, however, has implemented a modified 'internal market' model emphasising patient choice, which has so far had disappointing results. In the Netherlands, it took nearly 20 years to implement successfully the model in which enrollees choose among multiple insurers; but these insurers have so far only realised in part their potential to contract selectively with competing providers. The paper discusses the difficulties of implementing these different models and what England and the Netherlands can learn from each other. This includes exploration, as a thought experiment, of how choice of purchaser might be introduced into the English National Health Service based on lessons from the Netherlands. http://repub.eur.nl/res/pub/23185/ 2010-06-01T00:00:00Z Het kabinetsvoorstel om ziekenhuizen te laten concurreren binnen een macrobudget straft prijsconcurrentie af. De overheid moet een keuze maken tussen prijsconcurrentie zonder macrobudget of een macrobudget zonder prijsconcurrentie. http://repub.eur.nl/res/pub/23142/ 2010-05-01T00:00:00Z A new method is proposed to assess and improve the performance of risk equalization models in competitive markets for individual health insurance, where compensation is intended for variation in observed expenditures due to so-called S(ubsidy)-type risk factors but not for variation due to other, so-called N(onsubsidy)-type risk factors. Given the availability of a rich subsample of individuals for which normative expenditures, YNORM, can be accurately determined, we make two contributions: (a) any risk equalization scheme applied to the entire population, YREF, should be evaluated through its performance in the subsample, by comparing YREF with YNORM (not by comparing YREF with observed expenditures, Y, in the entire population, as commonly done); (b) conventional risk equalization schemes can be improved by the subsample regression of YNORM, rather than Y, on the risk adjusters that are observable in the entire population. This new method is illustrated by an application to the 2004 Dutch risk equalization model. http://repub.eur.nl/res/pub/23166/ 2010-05-01T00:00:00Z BACKGROUND: Current research on the added value of self-reported health measures for risk equalization modeling does not include all types of self-reported health measures; and/or is compared with a limited set of medically diagnosed or pharmacy-based diseases; and/or is limited to specific populations of high-risk individuals. OBJECTIVE: The objective of our study is to determine the predictive power of all types of self-reported health measures for prospective modeling of health care expenditures in a general population of adult Dutch sickness fund enrollees, given that pharmacy and diagnostic data from administrative records are already included in the risk equalization formula. RESEARCH DESIGN: We used 4 models of 2002 total, inpatient and outpatient expenditures to evaluate the separate and combined predictive ability of 2 kinds of data: (1) Pharmacy-based (PCGs) and Diagnosis-based (DCGs) Cost Groups and (2) summarized self-reported health information. Model performance is measured at the total population level using R2 and mean absolute prediction error; also, by examining mean discrepancies between model-predicted and actual expenditures (ie, expected over- or undercompensation) for members of potentially "mispriced" subgroups. These subgroups are identified by self-reports from prior-year health surveys and utilization and expenditure data from 5 preceding years. SUBJECTS: Subjects were 18,617 respondents to a health survey, held among a stratified sample of adult members of the largest Dutch sickness fund in 2002, with an overrepresentation of people in poor health. DATA: The data were extracted from a claims database and a health survey. The claims-based data are the outcomes of total, inpatient, and outpatient annualized expenditures in 2002; age, gender, PCGs, DCGs in 2001; and health care expenditures and hospitalizations during the years 1997 to 2001. The SF-36, Organization for Economic Cooperation and Development items, and long-term diseases and conditions were collected by a special purpose health survey conducted in the last quarter of 2001. RESULTS: Out-of-sample R2 equals 17.2%, 2.6%, and 32.4% for the models of total, inpatient and outpatient expenditures including PCGs, DCGs, and self-reported health measures. Self-reported health measures contribute less to predictive power than PCGs and DCGs. PCGs and DCGs also predict better than self-reported health measures for people with top 25% total expenditures or hospitalizations in each year during a 5-year period. On the other hand, self-reported health measures are better predictors than PCGs and DCGs for people without any top 25% expenditures during the 5-year period, for switchers, and for most subgroups of relatively unhealthy people defined by self-reported health measures. Among the set of self-reported health measures, the SF-36 adds most to predictive power in terms of R2, mean absolute prediction error, and for almost all studied subgroups. CONCLUSION: It is concluded that the self-reported health measures make an independent contribution to forecasting health care expenditures, even if the prediction model already includes diagnostic and pharmacy-based information currently used in Dutch risk equalization models. http://repub.eur.nl/res/pub/23203/ 2010-01-01T00:00:00Z Met de invoering van de Zorgverzekeringswet (Zvw) is het zorgverzekeringsstelsel fors veranderd. Een evaluatie van de Zvw wijst uit dat de eerste effecten overwegend positief kunnen worden beoordeeld, maar dat ook sprake is van belangrijke knelpunten en problemen. Deze hebben betrekking op de zorgtoeslag, de hoogte van de zorgpremie, het toenemend aantal wanbetalers, de ex ante risicoverevening, de zorgplicht, het eigen risico en de aanvullende verzekering. Mogelijke oplossingsrichtingen zoals het afschaffen van de zorgtoeslag, het verlagen van de zorgpremie en een verschoven eigen risico worden door het kabinet niet overgenomen. Dat is volgens de auteurs niet verstandig, omdat deze oplossingen niet alleen knelpunten en problemen aanpakken, maar ook kunnen leiden tot miljardenbesparingen op de collectieve uitgaven. http://repub.eur.nl/res/pub/23467/ 2010-01-01T00:00:00Z http://repub.eur.nl/res/pub/23468/ 2010-01-01T00:00:00Z http://repub.eur.nl/res/pub/16989/ 2009-10-01T00:00:00Z Objectives: China's government has decided to increase government funding by 1-1.5% of the Gross Domestic Products in the health care sector. However, it is still a question how to turn the new funding into efficient health care. Methods: To help to answer this question we analyze three prototype models of organizing the health care system that may be relevant for China, namely the "Government provision model", the "regulated market with non-competing third-party purchasers", and the "regulated market with competing third-party purchasers". The pre- and post-reform English health care system and the present Dutch health care system are used as examples of the three models. During the last 20 years these countries had, just as China, major health care reforms from a national centrally planned system to a market-based system. Based on the experiences in these countries we analyze the advantages and disadvantages of these three prototype models and discuss their relevance for China. Results and conclusions: We conclude that the creation of prudent third-party purchasers, who have the incentive and ability to act on behalf of individual consumers, is a critical success factor, whatever model China chooses to implement. http://repub.eur.nl/res/pub/23508/ 2009-09-01T00:00:00Z http://repub.eur.nl/res/pub/16286/ 2009-06-03T00:00:00Z http://repub.eur.nl/res/pub/17156/ 2009-01-07T00:00:00Z In this paper, we simulate several scenarios of the potential premium range for voluntary (supplementary) health insurance, covering benefits which might be excluded from mandatory health insurance (MI). Our findings show that, by adding risk-factors, the minimum premium decreases and the maximum increases. The magnitude of the premium range is especially substantial for benefits such as medical devices and drugs. When removing benefits from MI policymakers should be aware of the implications for the potential reduction of affordability of voluntary health insurance coverage in a competitive market. http://repub.eur.nl/res/pub/15067/ 2009-01-01T00:00:00Z In health insurance, a traditional deductible (i.e. with a deductible range [0,d]) is in theory not effective in reducing moral hazard for individuals who know (ex-ante) that their expenditures will exceed the deductible amount d, e.g. those with a chronic disease. To increase the effectiveness, this paper proposes to shift the deductible range to [si,si + d], with starting point si depending on relevant risk characteristics of individual i. In an empirical illustration we assume the optimal shift to be such that the variance in out-of-pocket expenditures is maximized. Results indicate that for the 10-percent highest risks in our data the optimal starting point of a €1000-deductible is to be found (far) beyond €1200, which corresponds with a deductible range of [1200,2200] or further. We conclude that, compared to traditional deductibles, shifted deductibles with a risk-adjusted starting point lower out-of-pocket expenditures and may further reduce moral hazard. http://repub.eur.nl/res/pub/16087/ 2009-01-01T00:00:00Z The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges. http://repub.eur.nl/res/pub/9767/ 2001-01-01T00:00:00Z In many countries, competing health plans receive capitation payments from a sponsor, whether government or a private employer. All capitation payment methods are far from perfect and have raised concerns about risk selection. Paying health plans partly on the basis of capitation and partly on the basis of actual costs ("risk sharing") reduces plans' incentives for selection but sacrifices some incentives for efficiency. This paper summarizes our empirical research on Dutch health plans with respect to various forms of risk sharing. All sponsors can improve their payment systems by either implementing or changing their form of risk sharing. http://repub.eur.nl/res/pub/31886/ 1994-01-01T00:00:00Z In 1988 the Dutch government launched a proposal for a national health insurance based on regulated competition. The mandatory benefits package should be offered by competing insurers and should cover both non-catastrophic risks (like hospital care, physician services and drugs) and catastrophic risks (like several forms of expensive long-term care). However, there are two arguments to exclude some of the catastrophic risks from the competitive insurance market, at least during the implementation process of the reforms. Firstly, the prospects for a workable system of risk-adjusted payments to the insurers that should take away the incentives for cream skimming are, at least during the next 5 years, more favorable for the non-catastrophic risks than for the catastrophic risks. Secondly, even if a workable system of risk-adjusted payments can be developed, the problem of quality skimping may be relevant for some of the catastrophic risks, but not for non-catastrophic risks. By 'quality skimping' we mean the reduction of the quality of care to a level which is below the minimum level that is acceptable to society. After 5 years of health care reforms in the Netherlands new insights have resulted in a growing support to confine the implementation of the reforms to the non-catastrophic risks. In drawing (and redrawing) the exact boundaries between different regulatory regimes for catastrophic and non-catastrophic risks, the expected benefits of a cost-effective substitution of care have to be weighted against the potential harm caused by cream skimming and quality skimping. http://repub.eur.nl/res/pub/8567/ 1994-01-01T00:00:00Z The market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that prevent plans from selecting the best health risks--are critical to the success of the reforms. In this paper we present an overview of the Dutch reforms and of our research concerning risk-adjusted capitation payments. Although we are optimistic about the technical possibilities for solving the problem of cream skimming, the implementation of good risk-adjusted capitation is a long-term challenge.