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Managed competition in health care in the Netherlands

The displacement of public responsibility

Romke van der Veen

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Changes in health care

• Universal and comprehensive health insurance

• Introduction of market-principles in health-insurance and health provision

• Goals of managed care:– cost control– maintenance of quality– less central steering

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Transformation of the Welfare State

• From public to private provision

• From protection to promoting participation

• From universality to selectivity

• From citizenship to membership

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…. in Health Care

• System still collective and solidaristic:– Insurance obligation– Allowance– Risk equalisation

• Market limited:– Basic package (90%)– Acceptance obligation– Care obligation (in kind/reimbursement)

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From public bureaucracy to public management

• From hierarchy to freedom for managers

• From state to market

• From rules to incentives

• From normconformity to output/results

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…. in Health Care

• Private insurance companies• Insurance

– nominal premium– no-claim– supplementary insurance

• Heath care provision– competition (between care providers)– contracts (providers-insurers)

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3 domains, 3 logics

• Economic domain – logic of the market

• Public domain – logic of the state: rules and solidarity

• Professional domain – professional logic: knowledge and cooperation

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Conditions of managed care

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Field/actor: Systemrationality: Conditional:

Insurance-market and

Care provision market (1)

HomogeneityTransparencyAtomistic

CompetionInformation (=Transparency)

Care provision market (2) Cooperation Profesionalism

Insurance company and

Care provider (1)

Economic actor Competition Management

Transparency

Care provider (2) Cooperation

Care

Professionalism

Professional Care Professionalism

Citizen (1)

Citizen (2)

Economic actor

Patient

Competition

Transparency

(Professional) trust

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Systemlogic requires

• Competition

• Transparency

• Professionalism

• Management

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Competition

• Market– scarcity; local dominance; market contraction

• Insurer-provider: no managed care• In kind/reimbursement:

– no in kind --- no managed care

• Professionals:– make no distinction in treatment– functioning in chain hinders competition

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Transparency

• Costly and complex

• Not all actors interested in transparency– conflicts with competition– conflicts with professional autonomy

• Gathering information can produce unwanted and unintended consequences

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Professionalism

• Contradictory forces working on professionals?

• Dominance of one of the three: – overconsumption– low quality– low cooperation

• Dominance of professional?• Risk of decoupling

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Management

• Taylorisation

• No machine bureaucracy, difficult to standardize

• Manager highly dependent

• Management = managing conflicting interests

Displacement of public responsibility

• Privatization– of risks: decollectivization– of administration

• Decentralization– of regulatory and administrative respoinsibility

• Europeanization– upward displacement

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