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From the mid-1990s several countries have introduced elements of the model of regulated competition in healthcare. In 2012 we assessed the extent to which in five countries ten important preconditions for achieving efficiency and affordability in competitive healthcare markets were fulfilled. In this paper we assess to what extent the fulfilment of these preconditions has changed ten years later. In 2022, as in 2012, in none of the five countries all preconditions are completely fulfilled. In the period 2012-2022 on balance there have been some improvements in the fulfillment of the preconditions, although to a different extent in the five countries. The only preconditions that were improved in most countries were 'consumer information and transparency' and 'cross-subsidies without incentives for risk selection'. On balance the Netherlands and Switzerland made most progress in the number of better fulfilled preconditions. For Belgium these preconditions no longer seem relevant because the idea of regulated competition has been completely abandoned. In Germany, Israel and Switzerland, the preconditions 'effective competition policy' and 'contestability of the markets' are not sufficiently fulfilled in 2022, just as in 2012. In Germany and Switzerland this also holds for the precondition 'freedom to contract and integrate'. Overall, the progress towards realizing the preconditions has been limited., Competing Interests: Declarations of competing interest None., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

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., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

In health care systems based on managed competition, enrolees can choose between insurers who are positioned as prudent buyers of care on their behalf. To avoid risk selection, insurers are compensated through a system of risk equalisation. The Dutch system of risk equalisation is generally considered to be one of the most sophisticated in the world. Empirical evidence, however, shows there are still consumer segments that are profitable for insurers. To examine whether insurers use target marketing for attracting these segments, we assessed promotional material used by Dutch insurers during the switching season of 2019. Our findings provide preliminary evidence that large insurers with different brands primarily use their sub brands as strategic vehicles to improve their competitive positions by targeting these brands at financially favourable groups and price sensitive buyers. By contrast, the more visible main brands are targeted at a much broader spectrum of consumer groups to display the insurer's social character. Only a minority of insurers' marketing expressions are targeted at actual users of care. Despite continuous improvements in the risk equalisation system, on average this group is still unprofitable for insurers. From a health policy perspective, further improvements are key to motivate health insurers to target their efforts at improving care for the chronically ill and to eliminate incentives for risk selection., Competing Interests: Declaration of Competing Interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Karel Stolper was employed at CZ Groep at the time of the study. This research, however, was conducted independently outside the employment of CZ Groep but with their consent, (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

With the reform in 2015 of the system of long-term care (LTC) in the Netherlands, responsibilities for the provision of social support and assistance were delegated from the central government to the municipalities. Unintentionally, the way municipalities are financed created incentives to shift cost from the local level back to central level. In this paper we examine whether municipalities respond to the prevailing financial incentives by shifting costs to the public LTC insurance scheme. Using data on almost all Dutch municipalities over the period 2015-2019, we estimate that municipalities with a solvency rate below 20% have a 2.5% higher admission rate to the public LTC scheme. Furthermore, we show that the tightening municipal budgets for social care since 2017 were accompanied with about 14% higher admission rates in 2018 and 2019 compared to 2015. The results point to strategic cost shifting by municipalities that can be counteracted by changing the financial incentives for municipalities and by reducing the existing overlap between the local and central care domains., Competing Interests: Declaration of Competing Interest Peter Alders is also working at the Ministry of Health, Welfare and Sport. The views presented here are those of the authors and should not be attributed to the Ministry of Health, Welfare and Sport., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

In health care the assessment of patients' needs is typically entrusted to health care providers. By contrast, in publicly financed long-term care (LTC) needs assessment is often delegated to an independent assessor. One rationale offered for independent needs assessment in LTC is to limit the scope for moral hazard and supplier-induced demand, which may be particularly strong in case of public LTC insurance. We study whether independent needs assessment restricts use of publicly financed LTC at the intensive margin (i.e. after people are being assessed to be eligible for receiving care). Therefore, we link nationwide Dutch administrative datasets about individual LTC use and eligibility decisions by the independent assessment agency in 2012. We find for virtually all types of care, all population subgroups, and all regions that LTC use by patients was substantially less than the maximum amount of care allowed by the independent assessor. This suggests that in the Netherlands independent needs assessment in LTC does not impose a binding constraint on use once a person is considered eligible for care. Still, independent needs assessment may have reduced LTC use at the extensive margin. A significant proportion of the applications for care (16 %) was rejected. In addition, the independent assessment may deter some people from applying., Competing Interests: Declaration of competing interest Part of the research was done while Pieter Bakx performed contract research for the CPB. Pieter Bakx and Erik Schut acknowledge support through the NETSPAR grant on “Optimal saving and insurance for old age: the role of public long-term care insurance”. These funding sources were not involved in the research., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

In health care systems based on managed competition, insurers are expected to negotiate with providers about price, quantity, and quality of care. The Dutch experience shows that this expectation may be justified with regard to price and quantity, but for quality the results are less conclusive. To examine the incentives insurers face for enhancing quality of care, we conducted in-depth interviews with CEOs and organised separate focus groups with purchasers and marketers of five Dutch health insurers. Jointly these insurers account for more than 90 percent of the market. We distinguished three categories of both positive and negative incentives to steer on quality: social, competitive and financial incentives. The overall picture emerging is that insurers are caught in a struggle between positive and negative incentives, with CEOs being more positive about the incentives to steer on quality than purchasers and marketers. At present, the social mission perceived by insurers seems to be their most important driver to invest in quality enhancement. However, whether or not the role of the social mission is sustainable in a competitive market remains unclear. Improving publicly available information on quality therefore seems to be crucially important for reinforcing the positive as well as counteracting the negative incentives insurers face with respect to enhancing quality of care., (Copyright © 2018 Elsevier B.V. All rights reserved.)

In 2015 the system of long-term care (LTC) financing and provision in the Netherlands was profoundly reformed. The benefits covered by the former comprehensive public LTC insurance scheme were split up and allocated to three different financing regimes. The objectives of the reform were to improve the coordination between LTC, medical care and social care, and to reinforce incentives for an efficient provision of care by making risk-bearing health insurers and municipalities responsible for procurement. Unintentionally, the reform also created a number of major incentive problems, however, resulting from the way: (i) LTC benefits were split up across the three financing regimes; (ii) the various third party purchasers were compensated; and (iii) co-payments for the beneficiaries were designed. These incentive problems may result in cost shifting, lack of coordination between various LTC providers, inefficient use of LTC services and quality skimping. We discuss several options to get the financial incentives better aligned with the objectives of the reform., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

In the Netherlands in 2006 a major health care reform was introduced, aimed at reinforcing regulated competition in the health care sector. Health insurers were provided with strong incentives to compete and more room to negotiate and selectively contract with health care providers. Nevertheless, the bargaining position of health insurers vis-à-vis both GPs and hospitals is still relatively weak. GPs are very well organized in a powerful national interest association (LHV) and effectively exploit the long-standing trust relationship with their patients. They have been very successful in mobilizing public support against unfavorable contracting practices of health insurers and enforcement of the competition act. The rapid establishment of multidisciplinary care groups to coordinate care for patients with chronic diseases further strengthened their position. Due to ongoing horizontal consolidation, hospital markets in the Netherlands have become highly concentrated. Only recently the Dutch competition authority prohibited the first hospital merger. Despite the highly concentrated health insurance market, it is unclear whether insurers will have sufficient countervailing buyer power vis-à-vis GPs and hospitals to effectively fulfill their role as prudent buyer of care, as envisioned in the reform. To prevent further consolidation and anticompetitive coordination, strict enforcement of competition policy is crucially important for safeguarding the potential for effective insurer-provider negotiations about quality and price., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

This paper reviews the impact of health policies on hospital waiting times in the Netherlands over the last two decades. During the 1990s hospital waiting times increased as a result of the introduction of fixed budgets and capacity constraints for specialists, in addition to the fixed global hospital budgets that were already in place since the 1980s. To tackle these increased waiting times over the years 2000-2011 several policies were implemented, including a change from fixed budgets to activity-based funding--for both hospitals and specialists--and increased competition among hospitals. All together these measures resulted in a strong reduction of waiting times. In 2011 mean expected waiting times for almost all surgical procedures varied from 2 to 6 weeks, well below the broadly accepted specified maximum waiting times. Hence, in the Netherlands hospital waiting times are currently not an important policy concern. Since the waiting time reduction was achieved at the expense of rapidly growing hospital costs, these have become now the primary policy concern. This has triggered the introduction of new powerful supply-side constraints in 2012, which may cause waiting times to increase for the coming years., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)