http://repub.eur.nl/res/aut/12336/ 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/38749/ 2013-01-17T00:00:00Z When public long-term care (LTC) insurance is provided by insurers, they typically lack incentives for purchasing cost-effective LTC. Providing insurers with appropriate incentives for efficiency without jeopardizing access for high-risk individuals requires, among other things, an adequate system of risk adjustment. While risk adjustment is now widely adopted in health insurance, it is unclear whether adequate risk adjustment is feasible for LTC because of its specific features. We examine the feasibility of risk adjustment for LTC insurance using a rich set of linked nationwide Dutch administrative data. Prior LTC use and demographic information are found to explain much of the variation, while prior health care expenditures are important in reducing predicted losses for subgroups of health care users. Nevertheless, incentives for risk selection against some easily identifiable subgroups persist. Moreover, using prior utilization and expenditure as risk adjusters dilutes incentives for efficiency, but using multiyear data may reduce this disadvantage. http://repub.eur.nl/res/pub/37330/ 2012-07-01T00:00:00Z In markets where hospitals are expected to compete, preventive merger control aims to prohibit anticompetitive mergers. In the hospital industry, however, the standard method for defining the relevant market (SSNIP) is difficult to apply and alternative approaches have proven inaccurate. Experiences from the United States show that courts, by identifying overly broad geographic markets, have underestimated the anticompetitive effects of hospital mergers. We examine how geographic hospital markets are defined in Germany and the Netherlands where market-oriented reforms have created room for hospital competition. For each country, we discuss a landmark case where definition of the geographic market played a decisive role. Our findings indicate that defining geographic hospital markets in both countries is less complicated than in the United States, where antitrust analysis must take managed care organisations into account. We also find that different methods result in much more stringent hospital merger control in Germany than in the Netherlands. Given the uncertainties in defining hospital markets, the German competition authority seems to be inclined to avoid the risk of being too permissive; the opposite holds for the Dutch competition authority. We argue that for society the costs of being too permissive with regard to hospital mergers may be larger than the costs of being too stringent. http://repub.eur.nl/res/pub/37342/ 2012-03-01T00:00:00Z A necessary condition for competition to promote quality in hospital markets is that patients are sensitive to differences in hospital quality. In this paper we examine the relationship between hospital quality, as measured by publicly available quality ratings, and patient hospital choice for angioplasty using individual claims data from a large health insurer. We find that Dutch patients have a high propensity to choose hospitals with a good reputation, both overall and for cardiology, and a low readmission rate after treatment for heart failure. Relative to a mean readmission rate of 8.5% we find that a 1%-point lower readmission rate is associated with a 12% increase in hospital demand. Since readmission rates are not adjusted for case-mix they may not provide a correct signal of hospital quality. Insofar patients base their hospital choice on such imperfect quality information, this may result in suboptimal choices and risk selection by hospitals. http://repub.eur.nl/res/pub/38367/ 2012-02-01T00:00:00Z In 2010 a bundled payment system for diabetes care, chronic obstructive pulmonary disease care, and vascular risk management was introduced in the Netherlands. Health insurers now pay a single fee to a contracting entity, the care group, to cover all of the primary care needed by patients with these chronic conditions. The initial evaluation of the program indicated that it improved the organization and coordination of care and led to better collaboration among health care providers and better adherence to care protocols. Negative consequences included dominance of the care group by general practitioners, large price variations among care groups that were only partially explained by differences in the amount of care provided, and an administrative burden caused by outdated information and communication technology systems. It is too early to draw conclusions about the effects of the new payment system on the quality or the overall costs of care. However, the introduction of bundled payments might turn out to be a useful step in the direction of risk-adjusted integrated capitation payments for multidisciplinary provider groups offering primary and specialty care to a defined group of patients. 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/38366/ 2012-01-01T00:00:00Z De marktordening in de zorg kent belangrijke tekortkomingen. De extra ruimte voor concurrentie draagt nog niet aantoonbaar bij aan een meer gepast gebruik van zorg. De huidige marktordening kan worden verbeterd door zorgaanbieders, verzekeraars en gebruikers meer te prikkelen tot gepast gebruik van zorg. http://repub.eur.nl/res/pub/38434/ 2012-01-01T00:00:00Z http://repub.eur.nl/res/pub/26521/ 2011-03-01T00:00:00Z In this paper we examine the pricing behaviour of nonprofit health insurers in the Dutch social health insurance market. Since for-profit insurers were not allowed in this market, potential spillover effects from the presence of for-profit insurers on the behaviour of nonprofit insurers were absent. Using a panel data set for all health insurers operating in the Dutch social health insurance market over the period 1996-2004, we estimate a premium model to determine which factors explain the price setting behaviour of nonprofit health insurers. We find that financial stability rather than profit maximisation offers the best explanation for health plan pricing behaviour. In the presence of weak price competition, health insurers did not set premiums to maximize profits. Nevertheless, our findings suggest that regulations on financial reserves are needed to restrict premiums. http://repub.eur.nl/res/pub/25880/ 2011-01-01T00:00:00Z http://repub.eur.nl/res/pub/21887/ 2010-12-02T00:00:00Z We investigate the impact of the transition towards managed competition in the Dutch health care system on health insurers' contracting behaviour. Specifically, we examine whether insurers have been able to take up their role as prudent buyers of care and examine consumers' attitudes towards insurers' new role. Health insurers' contracting behaviour is investigated by an extensive analysis of available information on purchasing practices by health insurers and by interviews with directors of health care purchasing of the four major health insurers, accounting for 90% of the market. Consumer attitudes towards insurers' new role are investigated by surveys among a representative sample of enrollees over the period 2005-2009. During the first four years of the reform, health insurers were very reluctant to engage in selective contracting and preferred to use 'soft' positive incentives to encourage preferred provider choice rather than engaging in restrictive managed care activities. Consumer attitudes towards channelling vary considerably by type of provider but generally became more negative in the first two years after the reform. Insurers' reluctance to use selective contracting can be at least partly explained by the presence of a credible-commitment problem. Consumers do not trust that insurers with restrictive networks are committed to provide good quality care. The credible-commitment problem seems to be particularly relevant to the Netherlands, since Dutch enrollees are not used to restrictions on provider choice. Since consumers are quite sensitive to differences in provider quality, more reliable information about provider quality is required to reduce the credible-commitment problem. http://repub.eur.nl/res/pub/21589/ 2010-10-01T00:00:00Z Context. To effectively bargain about the price and quality of health services, health insurers need to successfully channel their enrollees. Little is known about consumer sensitivity to different channeling incentives. In particular, the impact of status quo bias, which is expected to differ between different provider types, can play a large role in insurers' channeling ability. Objective. To examine consumer sensitivity to channeling strategies and to analyze the impact of status quo bias for different provider types. Data Sources/Study Design. With a large-scale discrete choice experiment, we investigate the impact of channeling incentives on choices for pharmacies and general practitioners (GPs). Survey data were obtained among a representative Dutch household panel (n=2,500). Principal Findings. Negative financial incentives have a two to three times larger impact on provider choice than positive ones. Positive financial incentives have a relatively small impact on GP choice, while the impact of qualitative incentives is relatively large. Status quo bias has a large impact on provider choice, which is more prominent in the case of GPs than in the case of pharmacies. Conclusion. The large impact of the status quo bias makes channeling consumers away from their current providers a daunting task, particularly in the case of GPs 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/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/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/20171/ 2009-12-15T00:00:00Z http://repub.eur.nl/res/pub/15562/ 2009-12-01T00:00:00Z Efficient contracting of health care requires effective consumer channeling. Little is known about the effectiveness of channeling strategies. We study channeling incentives on pharmacy choice using a large scale discrete choice experiment. Financial incentives prove to be effective. Positive financial incentives are less effective than negative financial incentives. Channeling through qualitative incentives also leads to a significant impact on provider choice. While incentives help to channel, a strong status quo bias needs to be overcome before consumers change pharmacies. Focusing on consumers who are forced to choose a new pharmacy seems to be the most effective strategy. http://repub.eur.nl/res/pub/19405/ 2009-11-01T00:00:00Z Sinds de invoering van het nieuwe zorgstelsel in 2006 hebben verzekeraars een belangrijke rol als zorginkoper gekregen. Zij worden geacht, in naam van hun verzekerden, te onderhandelen met zorgaanbieders over de prijs en kwaliteit van de zorg. Een cruciale conditie voor verzekeraars om effectief te kunnen onderhandelen met zorgaanbieders is dat zij verzekerden naar geselecteerde zorgaanbieders kunnen sturen. Want alleen dan moet een zorgaanbieder er serieus rekening mee houden dat een verzekeraar en zijn verzekerden niet naar de concurrent overstappen (Varkevisser et al., 2006) ... etc. http://repub.eur.nl/res/pub/19450/ 2009-10-01T00:00:00Z To contain expenditures in an increasingly demand driven health care system, in 2005 a no-claim rebate was introduced in the Dutch health insurance system. Since demand-side cost sharing is a very controversial issue, the no-claim rebate was launched as a consumer friendly bonus system to reward prudent utilization of health services. Internationally, the introduction of a mandatory no-claim rebate in a social health insurance scheme is unprecedented. Consumers were entitled to an annual rebate of 255 eruos if no claims were made. During the year, all health care expenses except for GP visits and maternity care were deducted from the rebate until the rebate became zero. In this article, we discuss the rationale of the no-claim rebate and the available evidence of its effect. Using a questionnaire in a convenience sample, we examined people's knowledge, attitudes, and sensitivity to the incentive scheme. We find that only 4% of respondents stated that they would reduce consumption because of the no-claim rebate. Respondents also indicated that they were willing to accept a high loss of rebate in order to use a medical treatment. However, during the last month of the year many respondents seemed willing to postpone consumption until the next year in order to keep the rebate of the current year intact. A small majority of respondents considered the no-claim rebate to be unfair. Finally, we briefly discuss why in 2008 the no-claim rebate was replaced by a mandatory deductible. http://repub.eur.nl/res/pub/23508/ 2009-09-01T00:00:00Z http://repub.eur.nl/res/pub/20169/ 2009-08-01T00:00:00Z http://repub.eur.nl/res/pub/16286/ 2009-06-03T00:00:00Z http://repub.eur.nl/res/pub/19440/ 2009-06-01T00:00:00Z Voorwoord In dit rapport wordt verslag gedaan van een onderzoek naar de mogelijke gevolgen van aanvullende en collectieve verzekeringen voor risicoselectie en verzekerdenmobiliteit in de basisverzekering. De analyse heeft betrekking op het jaar 2009. Tevens worden de ontwikkelingen in 2009 vergeleken met de bevindingen van evaluatiestudies over eerdere jaren. Het onderzoek is uitgevoerd in opdracht van de Nederlandse Patiënten Consumenten Federatie (NPCF). De auteurs danken prof. dr. W.P.M.M. van de Ven voor zijn waardevolle commentaar op een eerdere versie van dit rapport. Tevens danken zij drs. P.J. Schout van de NPCF voor haar inzet voor de totstandkoming van dit onderzoeksproject en haar betrokkenheid en commentaar. http://repub.eur.nl/res/pub/17100/ 2009-01-01T00:00:00Z Health care reforms in several European countries provide health insurers with incentives and tools to become prudent purchasers of health care. The potential success of this strategy crucially depends on insurers' bargaining leverage vis-à-vis health care providers. An important determinant of insurers' bargaining power is the willingness of consumers to consider alternative providers. In this paper we examine to what extent consumers are willing to switch hospitals when they are fully covered for hospital services, which is typical for many European countries. Since prices do not matter to these patients, we estimate time-elasticities to assess hospital substitutability. Using data from a large Dutch health insurer on non-emergency neurosurgical outpatient hospital visits in 2003, we estimate a conditional logit model of patient hospital choice taking both patient heterogeneity and hospital characteristics into account. We use the parameter estimates to simulate the demand effect of an artificial increase in travel time by 10% for every patient, holding all other hospital attributes constant. Overall, the resulting point estimates of hospitals' time-elasticities are fairly high, although variation is substantial (-2.6 to -1.4). Sensitivity tests reveal that these estimates are very robust and differ significantly across individual hospitals. This implies that all hospitals in our study sample have at least one close substitute which is an important precondition for effective hospital competition. http://repub.eur.nl/res/pub/22601/ 2009-01-01T00:00:00Z In s&d 2009/4 bekritiseerden Margo Trappenburg en Martin Buijsen het nieuwe zorgstelsel: marktwerking zou ongelijkheid in de hand werken. Erik Schut betoogt het tegenovergestelde: meer doelmatigheid gaat juist samen met een grotere toegankelijkheid. Curatieve, langdurige en welzijnszorg zijn verschillend georganiseerd. Is de markt te veel ruimte gegund? ‘Die vraag is niet met een volmondig “ja” of “nee” te beantwoorden.’ http://repub.eur.nl/res/pub/14458/ 2008-08-18T00:00:00Z Aim: To estimate the price sensitivity of consumer choice of health insurance firm. Method: Using paneldata of the flows of insured betweenpairs of Dutch sickness funds during the period 1993-2002, we estimate the sensitivity of these flows to differences in insurance premium. Results: The price elasticity of residual demand for health insurance was low during the period 1993-2002, confirming earlier findings based on annual changes in market share. We find small but significant elasticities for basic insurance but insignificant elasticities for supplementary insurance. Young enrollees are more price sensitive than older enrollees. Conclusion: Competition was weak in the market for health insurance during the period under study. For the market-based reforms that are currently under way, this implies that measures to promote competition in the health insurance industry may be needed. http://repub.eur.nl/res/pub/30203/ 2008-06-15T00:00:00Z Purpose: To assess efficacy of the novel, selective poly(ADP-ribose) polymerase-1 (PARP-1) inhibitor AZD2281 against newly established BRCA2-deficient mouse mammary tumor cell lines and to determine potential synergy between AZD2281 and cisplatin. Experimental Design: We established and thoroughly characterized a panel of clonal cell lines from independent BRCA2-deficient mouse mammary tumors and BRCA2-proficient control tumors. Subsequently, we assessed sensitivity of these lines to conventional cytotoxic drugs and the novel PARP inhibitor AZD2281. Finally, in vitro combination studies were done to investigate interaction between AZD2281 and cisplatin. Results: Genetic, transcriptional, and functional analyses confirmed the successful isolation of BRCA2-deficient and BRCA2-proficient mouse mammary tumor cell lines. Treatment of these cell lines with 11 different anticancer drugs or with γ-irradiation showed that AZD2281, a novel and specific PARP inhibitor, caused the strongest differential growth inhibition of BRCA2-deficient versus BRCA2-proficient mammary tumor cells. Finally, drug combination studies showed synergistic cytotoxicity of AZD2281 and cisplatin against BRCA2-deficient cells but not against BRCA2-proficient control cells. Conclusion: We have successfully established the first set of BRCA2-deficient mammary tumor cell lines, which form an important addition to the existing preclinical models for BRCA-mutated breast cancer. The exquisite sensitivity of these cells to the PARP inhibitor AZD2281, alone or in combination with cisplatin, provides strong support for AZD2281 as a novel targeted therapeutic against BRCA-deficient cancers. http://repub.eur.nl/res/pub/29490/ 2008-06-01T00:00:00Z Legislation that came into effect in 2006 has dramatically altered the health insurance system in the Netherlands, placing greater emphasis on consumer choice and competition among insurers. The potential for such competition depends largely on consumer preferences for price and quality of service by insurers and quality of affiliated providers. This study provides initial evidence on the preferences of Dutch consumers and how they view trade-offs between various aspects of health insurance product design. A key feature of the analysis is that we compare the responses of high and low risk individuals, where risk is defined by the presence of a costly chronic condition. This contrast is critically important for understanding incentives facing insurers and for identifying potential unanticipated consequences of market competition. The results from our conjoint analysis suggest that not only high risk but also low risk individuals are willing to pay substantially more for insurance products that can be shown to provide better health outcomes. This suggests that insurance products that are more expensive and provide better quality of care may also attract low risk individuals. Therefore, development and dissemination of good, reliable and understandable health plan performance indicators may effectively reduce the problem of adverse selection. http://repub.eur.nl/res/pub/12637/ 2008-05-31T00:00:00Z In dit rapport wordt verslag gedaan van een onderzoek naar de mogelijke gevolgen van aanvullende en collectieve verzekeringen voor risicoselectie en verzekerdenmobiliteit in de basisverzekering. De analyse heeft betrekking op het jaar 2008. Tevens worden de ontwikkelingen in 2008 vergeleken met de bevindingen van voorafgaande evaluatiestudies over eerdere jaren. Het onderzoek is uitgevoerd in opdracht van de Nederlandse Patiënten Consumenten Federatie (NPCF). http://repub.eur.nl/res/pub/23531/ 2008-05-01T00:00:00Z http://repub.eur.nl/res/pub/14237/ 2008-03-01T00:00:00Z Consumer channeling is an important element in the insurer-provider bargaining process. Health insurers can influence provider choice by offering insurance contracts with restricted provider networks. Alternatively, they can offer contracts with unrestricted access and use incentives to motivate consumers to visit preferred providers. Little is known, however, about the effectiveness of this alternative strategy of consumer channeling. Using data from two natural experiments in the Dutch pharmacy market, we examine how consumers respond to incentives used by health insurers to influence their choice of provider. We find that consumers are sensitive to rather small incentives and that temporary incentives may sort a long-term effect on provider choice. In addition, we find that both consumer and provider characteristics determine whether consumers are willing to switch to preferred pharmacies. http://repub.eur.nl/res/pub/15767/ 2004-01-01T00:00:00Z De economische ordening van de Nederlandse gezondheidszorg staat aan de vooravond van drastische veranderingen, waarbij prijsvorming en toetreding aanzienlijk zullen worden geliberaliseerd. Deze veranderingen nopen tot een herziening van de relaties tussen en binnen de (organisaties van) zorgvragers, zorgverzekeraars en zorgaanbieders. In dit artikel geven wij een aanzet om te komen tot een systematische indeling van mogelijke beheerstructuren voor de relaties tussen zorgverzekeraars, ziekenhuizen en medische specialisten. Doel van een dergelijke indeling is te komen tot een selectie van beheersstructuren die geschikt zijn voor de gewijzigde verantwoordelijkheidsverdeling in het nieuwe zorgstelsel. http://repub.eur.nl/res/pub/7284/ 2003-05-09T00:00:00Z http://repub.eur.nl/res/pub/11032/ 2001-01-01T00:00:00Z Editors and authors should be complimented for their impressive attempt to provide a fair account of the state-of-the-art in health economics. To review such an extensive work in a short time span, we decided to select certain chapters for more in depth study. This selection was based on our areas of expertise under the restriction that all major research areas distinguished in the handbook should be covered. Before turning to the review of the separate chapters, let us first make some general comments about the handbook. An important first question is whether all relevant research areas are covered and whether this has been done in a balanced way. Of course, exhaustive coverage in one book is unattainable for a large area like health economics. Rather the question is that regarding balance and possible lack of bias. In that respect, the book focuses on the US literature and health care system with 24 chapters written by US authors and only 11 by European and Canadian authors. The more traditional economic areas are generally covered by the US authors, emphasising a neo-classical rather than an institutional paradigm, and boundary topics like ‘equity’ and the ‘measurement of health’ are covered by the non-US authors. This structure both reflects the contributions in the health economics literature and the large variation in US health care institutions, and is only troublesome in some chapters as suggested below. http://repub.eur.nl/res/pub/11396/ 2000-01-01T00:00:00Z Focuses on the reformation of the health systems in the Netherlands and Belgium. Level of the systems' regulation in both countries; Objective in introducing managed competition; Comparison between the health care systems of the two countries. http://repub.eur.nl/res/pub/11407/ 1999-07-01T00:00:00Z This article describes some recent developments in health insurance in Belgium and the Netherlands. Both countries are moving towards greater financial responsibility of health insurers by means of risk-adjusted capitation payment systems. Although for the unwary observer it would appear as if both countries were following similar paths towards a common model, the authors make clear that rather different underlying rationales are driving these trends. In the Netherlands, the grand design ‘Dekker proposal’ for regulated competition has been replaced by a more gradual implementation of reforms with more limited scope. The ultimate goal remains a system of managed competition, albeit only for part of the health care services. In Belgium, prospective risk-adjusted capitation payment has always been at the heart of the original system in principle since its inception, but non-enforcement led to retrospective and inequitable financing in practice. Although the rhetoric of managed competition has never been used explicitly in any Belgian official government policy document, it seems unlikely that putting the insurers at financial risk without simultaneously also reinforcing their agency role by providing instruments for care management—like, for example, selective contracting—is viable in the longer run without jeopardizing the solvency of the insurers. The authors conclude that although the logic of the managed competition model is appealing, the lack of conclusive empirical evidence of success elsewhere makes governments reluctant to surrender their traditional cost containment tools. But making insurers financially accountable without simultaneously providing them with tools to take on the accountability seems useless and illogical. http://repub.eur.nl/res/pub/21510/ 1995-04-19T00:00:00Z For more than two decades, Dutch health policy has been marked by a search for a suitable market order in health care. Suitable in the sense of maintaining universal access, containing the growth of health care expenditure and improving the technical and allocative efficiency of health care delivery. This search was spurred by the seemingly uncontrollable escalation of health care expenditure during the early 1970s. The solution initially put forward to control health care cost inflation was that of comprehensive government planning. Although the envisioned sophisticated health planning largely failed, the government did manage to gain substantial control over total health care expenditure by unilaterally imposing restrictions on the capacity and operating expenses of inpatient care institutions. However, the adverse consequences of such a top-down rationing strategy were the subject of growing criticism. Health care was thought to be too inefficient due to detailed government regulations which impeded cost-effective substitution of care (technical efficiency), provision of 'tailor-made' care to consumers (allocative efficiency) and quality-improving and cost-reducing innovations in the organization and delivery of care (dynamic efficiency). Since in many industries the market mechanism is seen as the most successful device for enhancing efficiency it is not surprising that the search continued in the direction of a more marketoriented health care system. Therefore, since the mid-1980s, competition has become the new 'buzzword' in health policy. This change of direction was in accordance with a much broader international reorientation of social policy under the banner of 'more market, less government' which is steadily undermining the Dutch corporatist welfare state. For a long time, however, competition was widely regarded as an unsuitable mechanism for determining resource allocation in health care. Competition was generally considered as having adverse effects on not only access and equity but also on efficiency, due to the presence of pervasive information problems. This raises the question of why the expectations on the role of competition in health care have changed and whether there is some reason behind this rhetoric. In this thesis the role and feasibility of competition in the Dutch market for health insurance and medical care are investigated. Competition is an elusive term, one which is used to describe either a particular market structure or a certain type of conduct. In the latter case, competition may cover all aspects of a commodity but could also be restricted to specific aspects, non-price competition for instance. In this thesis the term competition will be used to denote rivalry among sellers of a commodity for the patronage of potential buyers where rivalry concerns both price and non-price aspects of that commodity. 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/21536/ 1986-01-01T00:00:00Z It is generally asserted that price discrimination is a common feature of the international pharmaceutical market, resulting in unnecessarily high medical costs to developing countries, since it is pharmaceuticals that are the largest component of their health care expenditures. However, little comprehensive empirical research has been carried out to test this hypothesis.