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Background: Health system in India is multifaceted and is influenced by a conglomeration of several factors. The diversity in the system coupled with disparities in the taxation system, makes it incredibly challenging to manage and consequently, the health system takes a toll. As a result, the infrastructure, as well as quality of healthcare, is in a poor state. Non-affordability of quality healthcare is another issue as many are not covered by insurance, and without it, they are susceptible to catastrophic health expenditures. This paper tries to explain the central role of these dual roadblocks: discrepancies in the taxation system and insufficient health insurance coverage as attributable factors of a number of issues in the Indian health system. Further, this paper analyses the health system of the Netherlands and draws ideas of implementing some ideas of the same in India. Although the two complexities threaten the healthcare system of the country, India can incorporate certain strategies that have yielded good results elsewhere for the betterment of the healthcare sector of the country [ABSTRACT FROM AUTHOR]

Most health insurers in the Netherlands apply community-rating and open enrolment for supplementary health insurance, although it is offered at a free market. Theoretically, this should result in adverse selection. There are four indications that adverse selection indeed has started to occur on the Dutch supplementary insurance market. The goal of this paper is to analyze whether premium differentiation would be able to counteract adverse selection. We do this by simulating the uptake and premium development of supplementary insurance over 25 years using data on healthcare expenses and background characteristics from 110,261 insured. For the simulation of adverse selection, it is assumed that only insured for whom supplementary insurance is expected not to be beneficial will consider opting out of the insurance. Therefore, we calculate for each insured the financial profitability (by making assumptions about the consumer's expected claims and the premium set by the insurer), the individual's risk attitude and the probability to opt out or opt in. The simulation results show that adverse selection might result in a substantial decline in insurance uptake. Additionally, the simulations show that if insurers were to differentiate their premium to 28 age and gender groups, adverse selection could be modestly counteracted. Finally, this paper shows that if insurers would apply highly refined risk-rating, adverse selection for this type of supplementary insurance could be counteracted completely. [ABSTRACT FROM AUTHOR]

State-of-the-art risk equalization models undercompensate some risk groups and overcompensate others, leaving systematic incentives for risk selection. A natural approach to reducing the under- or overcompensation for a particular group is enriching the risk equalization model with risk adjustor variables that indicate membership in that group. For some groups, however, appropriate risk adjustor variables may not (yet) be available. For these situations, this paper proposes an alternative approach to reducing under- or overcompensation: constraining the estimated coefficients of the risk equalization model such that the under- or overcompensation for a group of interest equals a fixed amount. We show that, compared to ordinary least-squares, constrained regressions can reduce under/overcompensation for some groups but increase under/overcompensation for others. In order to quantify this trade-off two fundamental questions need to be answered: "Which groups are relevant in terms of risk selection actions?" and "What is the relative importance of under- and overcompensation for these groups?" By making assumptions on these aspects we empirically evaluate a particular set of constraints using individual-level data from the Netherlands (N = 16.5 million). We find that the benefits of introducing constraints in terms of reduced under/overcompensations for some groups can be worth the costs in terms of increased under/overcompensations for others. Constrained regressions add a tool for developing risk equalization models that can improve the overall economic performance of health plan payment schemes. [ABSTRACT FROM AUTHOR]

Most countries that apply risk-equalization in their health insurance market(s) perform risk-equalization on medical claims but do not include other components of the insurance premium, such as administrative costs. Using fixed effects panel regressions from individual insurers in Australia, Germany, the Netherlands, Switzerland, and the US, we find evidence that health insurers with a high morbidity population on average have higher administrative costs. We argue that administrative costs should also be included in risk-equalization and we show that such equalization results in additional equalization payments nontrivial in size. Using examples from Germany and the US, we show how in practice policymakers can include administrative costs in risk-equalization. We are skeptical about applying risk-equalization to other components of the insurance premium, such as profits or costs related to solvency requirements of insurers. [ABSTRACT FROM AUTHOR]

Health insurers may use financial incentives to encourage their enrollees to choose preferred providers for medical treatment. Empirical evidence whether differences in cost-sharing rates across providers affects patient choice behavior is, especially from Europe, limited. This paper examines the effect of a differential deductible to steer patient provider choice in a Dutch regional market for varicose veins treatment. Using individual patients' choice data and information about their out-of-pocket payments covering the year of the experiment and 1 year before, we estimate a conditional logit model that explicitly controls for pre-existing patient preferences. Our results suggest that in this natural experiment designating preferred providers and waiving the deductible for enrollees using these providers significantly influenced patient choice. The average cross-price elasticity of demand is found to be 0.02, indicating that patient responsiveness to the cost-sharing differential itself was low. Unlike fixed cost-sharing differences, the deductible exemption was conditional on the patient's other medical expenses occurring in the policy year. The differential deductible did, therefore, not result in a financial benefit for patients with annual costs exceeding their total deductible. [ABSTRACT FROM AUTHOR]

Objective: Drug non-adherence in primary preventive cardiovascular therapy is one of the most important modifiable drivers of cardiovascular events. The effect of deductibles in healthcare cost-sharing plans (the amount that has to be paid for healthcare services before the insurance company starts to pay) on such non-adherence in a European setting is unknown. Therefore, we estimated the association between deductibles and the adherence to primary preventive antihypertensive and antihyperlipidemic medication. Methods: Using the claims database of Menzis Health Insurer in the Netherlands, we applied ordered beta regression mixed modelling to estimate the association between deductibles and adherence taking several demographic and social-economic factors, repeated measurements and within-patient variation into account. Results: All in all, 106,316 patients starting primary preventive antihypertensive or antihyperlipidemic monotherapy were eligible for analysis. At index date, mean age of the study population was 58 years and 52% were male. Reaching the deductible limit and no need to pay for medication anymore increased the adherence [relative adherence ratio (RAR) 1.03, 95% confidence interval (95% CI): 1.00–1.05] for antihyperlipidemic therapy and 1.02 (95% CI: 1.00–1.04) for antihypertensive therapy. A larger deductible amount decreases the adherence of antihyperlipidemic and antihypertensive therapy (RAR 0.83; 95% CI: 0.69–1.00 and RAR 0.85, 95% CI: 0.74–0.98, respectively). Conclusion: Independent of other risk factors for non-adherence, presence of deductibles in health insurance is associated with a small negative effect on the adherence to both primary preventive antihypertensive as well as antihyperlipidemic therapy. Further study is needed on the potential health-economic consequences. [ABSTRACT FROM AUTHOR]

Occupational health and safety research rarely makes use of data on employee healthcare utilization to gain insight into the physical and mental health of healthcare staff. This paper aims to fill this gap by examining the prevalence of two relevant types of healthcare utilization among staff working in healthcare organizations: physical therapy and mental healthcare utilization. The paper furthermore explores what role employee and organizational characteristics play in explaining differences in healthcare utilization between organizations. A Dutch healthcare insurance company provided healthcare utilization records for a sample of 417 organizations employing 136,804 healthcare workers in the Netherlands. The results showed that there are large differences between and within healthcare industries when it comes to employee healthcare utilization. Multivariate regression analyses revealed that employee characteristics such as age and gender distributions, and healthcare industry, explain some of the variance between healthcare organizations. Nevertheless, the results of the analyses showed that for all healthcare utilization indicators there is still a large amount of unexplained variance. Further research into the subject of organizational differences in employee healthcare utilization is needed, as finding possibilities to influence employee health and subsequent healthcare utilization is beneficial to employees, employers and society as a whole. [ABSTRACT FROM AUTHOR]

If consumers have a choice of health plan, risk selection is often a serious problem (e.g., as in Germany, Israel, the Netherlands, the United States of America, and Switzerland). Risk selection may threaten the quality of care for chronically ill people, and may reduce the affordability and efficiency of healthcare. Therefore, an important question is: how can the regulator show evidence of (no) risk selection? Although this seems easy, showing such evidence is not straightforward. The novelty of this paper is two-fold. First, we provide a conceptual framework for showing evidence of risk selection in competitive health insurance markets. It is not easy to disentangle risk selection and the insurers' efficiency. We suggest two methods to measure risk selection that are not biased by the insurers' efficiency. Because these measures underestimate the true risk selection, we also provide a list of signals of selection that can be measured and that, in particular in combination, can show evidence of risk selection. It is impossible to show the absence of risk selection. Second, we empirically measure risk selection among the switchers, taking into account the insurers' efficiency. Based on 2-year administrative data on healthcare expenses and risk characteristics of nearly all individuals with basic health insurance in the Netherlands (N > 16 million) we find significant risk selection for most health insurers. This is the first publication of hard empirical evidence of risk selection in the Dutch health insurance market. [ABSTRACT FROM AUTHOR]

This paper provides new field evidence on the role of probability numeracy in health insurance purchase. Our regression results, based on rich survey panel data, indicate that the expenditure on two out of three measures of health insurance first rises with probability numeracy and then falls again. This non-monotonic relationship suggests that probability numeracy affects health insurance decisions through several channels. In the third case-the obligatory Dutch basic health insurance-we find that high levels of probability numeracy coincide with a lower deductible choice. We discuss possible explanations for the patterns we find, including status quo bias and ambiguity aversion, and the related policy implications. [ABSTRACT FROM AUTHOR]

In health care systems with a competitive health insurance market, governments or other sponsors (e.g. employers) often subsidize premiums to encourage enrolment. These subsidies are typically independent of plan choice leaving the absolute premium differences in place so as not to distort consumer choice of plan. Such subsidies do, however, change the relative premium differences across plans, which, according to theories from behavioral economics, can affect choice. Consumers might be sensitive to differences relative to a reference premium ("relative thinking"). Furthermore, consumers might be particularly sensitive to a reference premium of zero ("zero-price effect"), a relevant range for some subsidized health insurance markets. This paper tests these ideas with two sources of evidence. We argue that observed equilibria in Germany and the U.S. Medicare Advantage markets are consistent with a powerful zero-price effect, resulting in an equilibrium focal pricing at zero. This contrasts with the Netherlands where equilibrium premiums are well above zero. In an empirical test using hypothetical questions in a web-based survey in these three countries, we also find evidence for both a relative thinking and a zero-price effect in the demand for health insurance. Our findings imply that well-designed subsidies can leverage relative thinking to increase demand elasticity for health plans. Creation of a powerful reference price (e.g., at zero), however, risks subverting price competition. [ABSTRACT FROM AUTHOR]

This paper considers consumer behavior in the Dutch market for health insurances, which is characterized by managed competition. We observe substantial price dispersion for the same basic insurance package. We describe the market by a simple consumer search model, which we empirically test using data from the Dutch Health Care Consumer Panel. We argue that insurers use group contracts to target discounts to better informed consumers, reducing their incentives to search. Since search is essential for competition, this increases premiums and premium dispersion. [ABSTRACT FROM AUTHOR]

Choice of insurer is an essential precondition for efficiency in healthcare systems based on regulated competition. However, supplementary insurance (SI) may restrict choice of insurer for basic health insurance (BI) due to a joint purchase of BI and SI. Roos and Schut (Eur J Health Econ 13(1):51-62, ) found that the belief in not being accepted by another insurer for SI was an important reason for not switching insurer for BI for 4 % of the non-switching Dutch population in 2006. This increased to approximately 7 % in 2009. In this paper, we provide evidence that in 2011 and 2012 approximately 10 % of the Dutch population expected that another insurer would not accept them for SI. An additional 20 % of the consumers expected to be accepted by another insurer, but only for a higher premium than other consumers with the same SI. About one-third of the elderly (55+) consumers, and more than half of the consumers with bad or moderate health status, expected their current insurer to offer them more favourable conditions for SI, in terms of acceptance and premium, than other insurers do for similar SI. However, if dissatisfied high-risk consumers, due to a joint purchase of BI and SI, do not switch insurer for BI, the disciplining effect of 'voting with one's feet' is substantially reduced. This is a serious problem that may increase in coming years. We discuss several potential solutions. Our conclusion is that the integration of BI and SI into one basic-plus-insurance is an effective solution under current EU legislation. This conclusion may also be relevant for other countries. [ABSTRACT FROM AUTHOR]

Background: Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders' reluctance to engage in what can be perceived as 'rationing'. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the 'Appropriate Care' program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work?Method: We conducted ethnographic research into the National Health Care Institute's epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants.Results: The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions.Conclusions: This case shows that - apart from the right data and adequate expertise - disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute's Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of 'waste' in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of 'waste' in public health expenditure. [ABSTRACT FROM AUTHOR]

Background: Although the promise of integrated neighborhood approaches, including the essential roles of communities and collaboration between the medical and social domains, has been widely acknowledged, the realization of such approaches in practice often remains difficult. To gain insight into the development of integrated neighborhood approaches, this case study describes the experiences of stakeholders involved in such an approach for health promotion and prevention in Rotterdam. Methods: Interviews with 18 stakeholders (including health and social care professionals, health insurance employees, and policymakers) were conducted, and stakeholders' statements were analyzed thematically. Results: The results reveal a lack of alignment among the professional, organizational, and system levels. Elements needed for collaboration between health and social care professionals are not supported at the organizational and system levels. The lack of integration at the policy and organizational levels encourages competition and self-interest instead of stimulating collaboration. Conclusions: Intersectoral collaboration and coordination must take place not only between professionals, but also at the organizational and policy levels. As long as integration at the organizational and system levels is lacking, professionals' ability to collaborate and provide coordinated support to neighborhood residents will be compromised. [ABSTRACT FROM AUTHOR]

In a healthcare system based on managed competition, health insurers are intended to be the prudent buyers of care on behalf of their enrollees. Equally, citizens are expected to be critical consumers when choosing a health insurance policy. The choice of a health insurance policy may be related to trust in the health insurer, as enrollees must believe that the health insurer will make the right choices for them when it comes to purchasing care. This study aims to investigate how enrollees' trust in health insurers is associated with their choice of a health insurance policy in the Netherlands. We will focus on the switching behaviour of enrollees and the choice of a policy with restrictive conditions. In February 2022, a questionnaire was sent to a representative sample regarding gender and age of the adult Dutch population. In total 1,125 enrollees responded, a response rate of 56%. Respondents were asked about the choices they made in choosing health insurance. Trust in health insurers was measured using the Health Insurer Trust Scale (HITS), a validated multiple item scale. Descriptive statistics, a paired t-test and logistic regression models were conducted to analyse the results. Of all respondents, 35% indicated that they agree, or completely agree, with the statement that they trust health insurers completely. In addition, trust in enrollees' own insurer is slightly higher than trust in other insurers (36.29 vs. 33.59, p<0.001). Furthermore, we found no significant associations between trust in health insurers, and whether enrollees have either switched health insurers or have chosen a policy with restrictive conditions. This study showed that enrollees' trust in health insurance in the Netherlands is relatively low and that trust in their own insurer is slightly higher than trust in other insurers. Furthermore, this study does not show a relationship between trust in health insurers and, either switching health insurers, or choosing a policy with restrictive conditions. Nevertheless, attention for increasing the trust in health insurers might still be important, as low trust may have negative consequences for other elements of the functioning of the healthcare system. [ABSTRACT FROM AUTHOR]

In several countries, citizens are expected to be critical consumers when choosing a health insurance policy. However, there are indications that citizens do not always have the sufficient skills, so called health insurance literacy (HIL), to do this. We investigated whether the level of HIL among Dutch citizens is related to the way in which they experience the process of choosing a policy, and furthermore whether it is related to their health insurance choices. We obtained information by sending questionnaires to members of the Nivel Dutch Health Care Consumer Panel in 2020. Of the 1,500 approached, 806 panel members participated (response rate 54%). Our results indicate that, compared to those with a high HIL, respondents with a low HIL more often find choosing a health insurance policy difficult, not interesting, and boring, and less often consider it important and worthwhile. Furthermore, they make less use of the opportunity to switch from one health insurer to another. However, they do still opt for a supplementary insurance policy and a voluntary deductible to the same extent as citizens with a high HIL. We conclude that the HIL level among Dutch citizens is related to the way in which they experience the process of choosing a health insurance policy and to the extent to which they switch from one insurer to another. But it is not related to their health insurance choices. Follow-up research should focus on how citizens with a low HIL can be better supported when choosing a health insurance policy. [ABSTRACT FROM AUTHOR]

Background Assessing quality of care from the patient's perspective has changed from patient satisfaction to the more general term patient experience, as satisfaction measures turned out to be less discriminative due to high scores. Literature describes four to ten dimensions of patient experience, tailored to specific conditions or types of care. Given the administrative burden on patients, less dimensions and items could increase feasibility. Ten dimensions of patient experiences with physical therapy (PT) were proposed in the Netherlands in a consensus-based process with patients, physical therapists, health insurers, and policy makers. The aim of this paper is to detect the number of dimensions from data of a field study using factor analysis at item level. Methods A web-based survey yielded data of 2,221 patients from 52 PT practices on 41 items. Principal component factor analysis at item level was used to assess the proposed distinction between the ten dimensions. Results Factor analysis revealed two dimensions: 'personal interaction' and 'practice organisation'. The dimension 'patient reported outcome' was artificially established. The three dimensions 'personal interaction' (14 items) (medianpractice level = 91.1;IQR = 2.4), 'practice organisation' (9 items) (medianpractice level = 88.9;IQR = 6.0) and 'outcome' (3 items) (medianpractice level = 80.6;IQR = 19.5) reduced the number of dimensions from ten to three and the number of items by more than a third. Conclusions Factor analysis revealed three dimensions and achieved an item reduction of more than a third. It is a relevant step in the development process of a quality measurement tool to reduce respondent burden, increase clarity, and promote feasibility. [ABSTRACT FROM AUTHOR]

The presence of undocumented migrants is increasing in many Western countries despite wide-ranging attempts by governments to increase border security. Measures taken to control the influx of immigrants include policies that restrict access to publicly funded health care for undocumented migrants. These restrictions to health care access are controversial, and evidence suggests they do not always have the intended effect. This study provides a comparative analysis of institutional, actor-related, and contextual factors that have influenced health care policy development on undocumented migrants in England and the Netherlands. For undocumented migrants, England restricts its access to care at the point of service, while the Netherlands restricts through the payment system for services. The study includes an analysis of policy papers and semistructured, in-depth interviews with various actors in both countries. Findings confirm the influence of such contextual factors as immigration considerations and cost concerns on health care policy making in this area. However, these factors cannot explain the differences between the two countries. Previously enacted policies, especially the organization of the health care system, affected the kind of restrictions for undocumented migrants. Concerns about the side effects of generous treatment of undocumented migrants on other groups played a substantial role in formulating restrictive policies in both countries. Evidently, policy development and implementation is critically affected by institutional rules, which govern the degree of influence that doctors and professional medical associations have on the policy process. [ABSTRACT FROM AUTHOR]

Like many other countries, the Netherlands has a health insurance system that combines mandatory basic insurance with voluntary supplementary insurance. Both types of insurance are founded on different principles. Since basic and supplementary insurance are sold by the same health insurers, both markets may interact. This paper examines to what extent basic and supplementary insurance are linked to each other and whether these links generate spillover effects of supplementary on basic insurance. Our analysis is based on an investigation into supplementary health insurance contracts, underwriting procedures and annual surveys among 1,700-2,100 respondents over the period 2006-2009. We find that health insurers increasingly use a variety of strategies to enforce a joint purchase of basic and supplementary health insurance. Despite incentives for health insurers to use supplementary insurance as a tool for risk selection in basic insurance, we find limited evidence of supplementary insurance being used this way. Only a minority of health insurers uses health questionnaires when people apply for supplementary coverage. Nevertheless, we find that an increasing proportion of high-risk individuals believe that insurers would not be willing to offer them another supplementary insurance contract. We discuss several strategies to prevent or to counteract the observed negative spillover effects of supplementary insurance. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, managed competition between health plans has been introduced. For Dutch health plans this implies that they need to collect data about their own performance and that of the care providers they contract. To that end, Consumer Assessment of Health Plan Surveys (CAHPS) instruments have recently been adopted by a large Dutch health plan. Objectives: This paper presents the results of a validation study of the Dutch version of the CAHPS Adult Commercial questionnaire. The questions addressed are as follows: Can this questionnaire be adapted for use in the context of the Dutch insurance system? and Can it generate valid information about the quality of health care and the performance of Dutch health plans? Methods: The translated questionnaire has been mailed to a sample of 977 enrollees. The psychometric properties of the translated instrument have been studied, and the results have been compared with those of other Dutch and American studies. Results: The net response rate was 51% (n = 500). In general, the questionnaires were filled out completely and consistently. Principal component analyses revealed a factor that can be labelled as patient-centredness in the primary process. It contains the domains that in the CAHPS literature are described as 'courteous/helpful staff' and 'doctors communicating well'. Conclusions: The translated version of the CAHPS Adult Commercial questionnaire is a promising tool for Dutch health plans. More research is needed on the external and the content validity of these questionnaires in the Dutch context. [ABSTRACT FROM AUTHOR]

In February 2005, a case-mix system based on 'diagnosis treatment combinations' (DBCs) was introduced in The Netherlands for the registration and reimbursement of hospital and medical specialist care. This paper describes the characteristics of the DBC system and how it is used for the reimbursement of hospitals. Prices for reimbursement are either based on fixed tariffs ('list A') or negotiated between health insurers and hospitals ('list B') and are partly based on information about unit costs of health care services. Because the DBC system is still under development we will describe the current situation (March 2006), but also focus on the most likely future developments. [ABSTRACT FROM AUTHOR]

In this paper, we examine the effects of the introduction of free choice and price competition in social health insurance in Germany and the Netherlands. Using panel data at the sickness fund level we estimate the price elasticity of sickness fund choice in both countries. We find that the price elasticity in Germany is high and rapidly increasing. Consistent with findings of other studies on health plan choice, the price elasticity is much lower for elderly than for non-elderly. In the Netherlands, by contrast, the price elasticity of fund choice is negligible. Only when people were forced to choose a sickness fund, they were quite sensitive to premium differences. Key factors in explaining the observed differences in switching behavior between both countries are the degree of financial risk for sickness funds, the features of the risk-adjustment mechanism and the role of employers. [ABSTRACT FROM AUTHOR]

This paper first describes the financial structure of the Dutch health care system and the costs of pharmaceutical services. The Dutch government has established three funding segments or 'compartments' in health care in 1998. The first is the chronic care in which both sickness funds and private health insurers administer the long term care insurance on behalf of their members. The second compartment (social and private health insurance) allow the sickness fund insurers to offer insurance to residents who can register with a fund of their own choice. The last compartment is private health insurance with a wide range of financial conditions, and various coverage, usually higher premiums for elderly. According to legislation, the Dutch reimbursement system for pharmacists is a 'fee-for-prescription' system. Dutch pharmacists have to prove their contribution to the health care system, for example for monitoring polypharmacy, smoking cessation programmes, drug utilization monitoring, development of formularies and supporting local therapeutic review committees. Together with a well developed ICT infrastructure in community pharmacy, this will support the development of a new reimbursement system for the provision of pharmaceutical care in the near future. Eventually this will allow pharmacists to provide the desired transparency and to install their role as health care provider. [ABSTRACT FROM PUBLISHER]

This article focuses on matters related to welfare effects of supplementary insurance. This issue of the Journal features two papers, Community Rating of Health Insurance and Different Benefit Packages by Matthias Kifman and Alternative Health Insurance Schemes: A Welfare Comparison that examines the welfare implications of permitting voluntary supplementary insurance in a regime with a community-rated, compulsory basic insurance package. This is a critical question in any country that either has adopted or is considering some mix of private and compulsory/public insurance, including Germany, the Netherlands and the US. The conclusions of these papers appear to be radically different. It has been concluded that a compulsory scheme with voluntary supplementation is likely to be welfare superior to the pure compulsory scheme, but that the compulsory scheme alone may also be welfare-dominated by a pure voluntary market insurance regime, using either a Hicksian or an average utility criterion of welfare improvement.

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Existing risk-equalization models in individual health insurance markets with premium-rate restrictions do not completely compensate insurers for predictable profits/losses, confronting insurers with risk selection incentives. To guide further improvement of risk-equalization models, it is important to obtain insight into the drivers of remaining predictable profits/losses. This article studies a specific potential driver: end-of-life spending (defined here as spending in the last 1–5 years of life). Using administrative (N = 16.9 m) and health survey (N = 384 k) data from the Netherlands, we examine the extent to which end-of-life spending contributes to predictable profits/losses for selective groups. We do so by simulating the predictable profits/losses for these groups with and without end-of-life spending while correcting for the overall spending difference between these two situations. Our main finding is that—even under a sophisticated risk-equalization model—end-of-life spending can contribute to predictable losses for specific chronic conditions. [ABSTRACT FROM AUTHOR]

Purpose Stress-related illnesses are prevalent in Western society, causing sick leave and putting a heavy economic burden on employers and society. For Dutch employers it is particularly relevant to have insight into the costs of absenteeism due to stress-related illness, as they are legally obligated to continue payment of wages. Therefore, this study assessed the duration and costs of an episode of sick leave due to stress-related illness for Dutch employers. Methods Data on sick leave due to various stress-related illnesses were obtained from a nationwide occupational health service database. Stress-related illnesses included tension complaints, burn-out, overexertion, and other reactions to stress. The duration per sick leave episode was estimated in working days, after which the average cost per sick leave period was estimated using age- and gender-specific price weights. Results During the study period, 16,676 employees took 17,338 episodes of sick leave due to stress-related illness. On average, one episode of sick leave lasted 101 working days, for which the costs for the employer were on average €19,151 per worker. Women were responsible for most episodes of sick leave and were on average 37 days more absent per episode compared to men. Moreover, of all kinds of stress-related illnesses, burn-out had the longest duration of sick leave with 313 calendar days and 163 working days, resulting in an average cost of €30,770. Conclusions Sick leave due to stress-related illness places a heavy burden on employers and thus society. Further research should be conducted on how to reduce this burden. [ABSTRACT FROM AUTHOR]

An important criterion for the proper functioning of a managed competition healthcare system, such as operates in the Netherlands, is that all citizens can make well-informed decisions regarding their health insurance policy. In order to achieve this, citizens need certain health insurance literacy skills. It is not known how far citizens in the Netherlands have these skills. The aim of this study is to provide a reliable instrument that measures the health insurance literacy of citizens in the Netherlands. It would be based upon an existing instrument developed in the US. We translated the US Health Insurance Literacy Measure (HILM) into Dutch. Furthermore, we established the psychometric properties of the Dutch version (HILM-NL), and we validated the HILM-NL in a general population sample by sending surveys to members of the Nivel Dutch Health Care Consumer Panel (DHCCP) in February and March 2020. The response rates were respectively 54% (n = 806) and 56% (n = 595). No insurmountable difficulties with equivalence were encountered throughout the translation process. The HILM-NL showed an acceptable level of internal consistency, good test-retest reliability, and a good construct validity. The HILM-NL is a reliable instrument for measuring health insurance literacy among citizens in the Netherlands. With this instrument, it is better possible both to assess how these citizens choose and use a health insurance policy, and also the difficulties they face. It enables citizens in the Netherlands to be supported better in making well-informed decisions on health insurance. [ABSTRACT FROM AUTHOR]

Background: A high percentage of people dying at home, and a low percentage of people being admitted to hospital and dying there are regarded as indicators of appropriate care at the end of life. However, performance standards for these quality indicators are often lacking, which makes it difficult to state whether an indicator score falls between the ranges of good or poor quality care. The aim of this study was to assess quality indicators concerning place of death and hospital care utilization in people with diseases relevant for palliative care, and to establish best practice performance standards based on indicator scores in 31 regions in the Netherlands. Methods: A retrospective nationwide population-based observational study was conducted, using routinely collected administrative data concerning persons who died in 2017 in the Netherlands with underlying causes relevant for palliative care (N = 109,707). Data from four registries were linked for analysis. Scores on eight quality indicators concerning place of death and hospital care utilization were calculated, and compared across 31 healthcare insurance regions to establish relative benchmarks. Results: On average, 36.4% of the study population died at home (range between regions 30.5%-42.6%) and 20.4% in hospital (range 16.6%-25.5%). Roughly half of the population who received hospital care at any time in the last year of life were found to (also) receive hospital care in the last month of life. In the last month, 32.0% of the study population were admitted to hospital (range 29.4-36.4%), 5.3% to an Intensive Care Unit (range 3.2-6.9%) and 23.9% visited an Emergency Department (range 21.0-27.4%). In the same time period, less than 1% of the study population was resuscitated in hospital or received tube or intravenous feeding in hospital. Conclusions: The variation between regions points towards opportunities for practice improvement. The best practice performance standards as set in this study serve as ambitious but attainable targets for those regions that currently do not meet the standards. Policymakers, healthcare providers and researchers can use the suggested performance standards to further analyze causes of variance between regions and develop and test interventions that can improve practice. [ABSTRACT FROM AUTHOR]

Abstract: The Dutch risk equalization scheme has been improved over the years by including health related risk adjusters. The purpose of the Dutch risk equalization scheme is to prevent risk selection and to correct for predictable losses and gains for insurers. The objective of this paper is to explore the financial incentives for risk selection under the Dutch risk equalization scheme. We used a simulation model to estimate lifetime health care costs and risk equalization contributions for three cohorts (a smoking; an obese; and a healthy living cohort). Financial differences for the three cohorts were assessed by subtracting health care costs from risk equalization contributions. Even under an elaborate risk equalization system, the healthy living cohort was still most financially attractive for insurers. Smokers were somewhat less attractive, while the obese cohort was least attractive. Lifetime differences with healthy living individuals (revenues minus costs) were modest: €4840 for obese individuals and €1101 for smokers. Under a simple form of risk equalization these differences were higher, €8542 and €4620 respectively. Improvement of the risk equalization scheme reduced the gap between costs and revenues. Incentives for undesirable risk selection were reduced, but simultaneously incentives for health promotion were weakened. This highlights a new prevention paradox: improving the level playing field for health insurers will inevitably limit their incentives for promoting the health of their clients. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

Context: Since the 1990s, the EU's influence over national health care policy has been limited to European internal market law or social policy coordination mechanisms. The introduction of EU competition law into health care is more recent and underdeveloped; however, its introduction would potentially be much more far-reaching and disruptive. Methods: Three EUcompetition law(state-aid) cases are used and comprise both Court of Justice and European Commission decisions. One is from Ireland, one is from the Netherlands, and the third is from Belgium. Findings: The Belgian (Iris-H) case sees EU institutions scrutinize a clearly "social" (nonmarket) health care model with EU competition law for the first time. This is a highly significant development. It is clear, however, that the European Commission is more reluctant to use EU competition law to scrutinize health care systems than the European courts are. Conclusions: This intent on the part of EU institutions will have to be assessed in future cases, as considerable uncertainty about its shape and outer contours remains. However, EU competition law, and the EU's state-aid investigation apparatus, encroaching into the national health care systems for the first time is highly significant. [ABSTRACT FROM AUTHOR]

This paper examines the right to health care. Various expressions of this right may be distinguished. These include both individual rights and social rights which could be based upon international treaties and constitutional rights. They may be found in national health legislation and, in some cases, in jurisprudence. To analyze the consequences of limiting the right to health care, a framework for judicial review has been developed which encompasses these expressions of the right to health care. The framework was used to examine legal and health policy developments in three Western and two Eastern European countries. In Italy and the Netherlands the right to health care is protected constitutionally (but on differing legal bases) while the United Kingdom does not have a written constitution. In contrast, Hungary and Poland have for many years seen the state take responsible for the provision, administration and allocation of health care services and the right to health care was guaranteed theoretically but not in practice because of the lack of (financial) means. However, the Polish Constitution explicitly anticipates possible limitations of the right to health care. What all these countries have in common is a cost containment perspective where the future will bring even tighter limits on what resources patients may consume. Despite differences in legal structure between these countries, where they seem to converge is on the consequences of putting limitations on the right to health care. The courts in Italy, the Netherlands and the UK have formulated conditions drawn from the acceptance that this right has to be judged within the context of limited resources. It may be concluded that finding a compromise between the right to health care and cost containment policies could also be an issue, Eastern European countries will have to face in the future. [ABSTRACT FROM AUTHOR]

The use of health care facilities in the Netherlands has increased substantially during the past years. In this paper two large cross-section surveys are used to analyze the changes in the use of medical services. Further, differences in use by type of health care insurance are analyzed. The findings show that the increase in medical consumption is largely due to a change in the propensity to use medical services. Further, the findings do not suggest that social health care insurance leads to less efficient use of medical services than private insurance. [ABSTRACT FROM AUTHOR]

Objective: Cancer imposes a substantial economic burden on society, health and social care systems, patients and their families. This study aims to examine the out‐of‐pocket spending of cancer patients in their last year of life, in six countries with health insurance system hat have a defined benefits package. Methods: Data from SHARE and SHARE End‐of‐Life surveys among people aged +50 were analysed. Family members of deceased persons were interviewed in order to learn about the circumstances of their relative's death. Results: The average out‐of‐pocket spending for health and social services during the last year of life was 4.5% of the total household income, 2.2% in the Netherlands, 4.3% in Israel, 5% in Germany, 5.1% in Austria, 5.1% in Belgium and 8.2% in Switzerland. Whereas the out‐of‐pocket spending on nursing home care was 7.8% of the total household income in Switzerland, in the Netherlands and in Israel it was negligible. In contrast, the out‐of‐pocket spending for home care due to disability surged to 5.6% in Israel and 3.7% in Austria, whereas in other countries it was very low. Conclusion: This information is important to health and social policymakers, in order to better adapt the benefits package to the patients' needs. [ABSTRACT FROM AUTHOR]

This paper employs the method of Aronson et al. (1994) to decompose the redistributive effect of the Dutch health care financing system into three components: a progressivity component, a classical horizontal equity component and a reranking component. Results are presented for the health care financing system as a whole, as well as for its constituent parts. A final section sets out to uncover the relative importance (in terms of their effects on progressivity, horizontal equity and reranking) of the key institutional features of one component of the Dutch system-the AWBZ social insurance scheme. [ABSTRACT FROM AUTHOR]

This article’s aim is to reintroduce the teleological approach formulated by professor Karel Engliš hundred years ago indicating it as a valuable analytical tool for social systems, including the health one. Engliš enriched the positive and normative approach of scientific analysis with teleological one, using postulates based on the principle of finality, and distinguished it both from positive causality and narrow normative measures or legal norms. Because health economics has been often struggling with managing the plurality of health systems, it is worth searching in theory for approaches that may improve this deficit and Engliš’s approach has shown as perfectly suitable for this purpose. We therefore subsequently explain its logic, which was thoroughly defended by Engliš in the literature in 1920s and 1930s. Then we look for specific attributes of four different health systems (the USA, the Netherlands, Germany, Great Britain) from teleological point of view and sum them up into a table which briefly combines social models, fiscal and tax policy measures, and ideals/postulates that those systems are based on. The result is better understanding of the health systems configuration and solid theoretical knowledge behind it, easing the need for finding the optimal or “most effective” health system by recognizing that more important is to know which properties and characteristics it ought to have and which principles it is built on. [ABSTRACT FROM AUTHOR]

In contemporary healthcare policies the logic of Evidence-based Medicine (EBM) is typically proposed as a way of addressing a demand to explicitly justify policy decisions. Policymakers' use of 'evidence' is presumed to pertain to ideals of justice in decision-making. However, according to some, EBM is liable to generate 'epistemic injustice' because it prefers quantitative types of evidence and – as a result of that – potentially undervalues the qualitative testimonies of doctors and patients. Miranda Fricker's concept of 'epistemic injustice' refers to a wrong done to a person in their capacity as a knower. This paper explores the usefulness and limits of this concept in the context of public decision-making. How is evidence-based policymaking intertwined with questions of 'epistemic injustice'? Drawing from ethnographic research conducted at the National Health Care Institute, we analyze two cases of EBM-inspired policy practices in Dutch social health insurance: 1) the use of the principles of EBM in making a public reimbursement decision, and 2) private insurers' use of quantitative performance indicators for the practice of selective contracting on the Dutch healthcare market. While the concept of 'epistemic injustice' misses some key processes involved in understanding how 'knowing gets done' in public policy, it does shed new light on priority-setting processes. Patients or medical professionals who are not duly recognized as credible and intelligible epistemic agents, subsequently, lack the social power to influence priority-setting practices. They are thus not merely frustrated in their capacity to be heard and make themselves understood, they are potentially deprived of a fair share in collective financial and medical resources. If we fail to recognize inequalities in credibility and intelligibility between diverse groups of knowers, there is a chance that these epistemic inequalities are being reproduced in our system of health insurance and our ways of distributing healthcare provisions. • The concept of 'epistemic injustice' sheds new light on priority-setting processes. • Not all patients or professionals are credited equal status as epistemic agent. • Participation in priority-setting requires that agents are credibly understood. • Lack of recognition as epistemic agent means less influence on priority-setting. • Structural epistemic inequalities can be reproduced in allocating public resources. [ABSTRACT FROM AUTHOR]

Background In market-based systems, the possibility to switch is an important precondition for a well-functioning health insurance market. To assess whether such a market works as intended, insight into the considerations and perceived barriers of insured is needed. This study examines the rates and reasons for not switching health insurer in the Netherlands, and whether these reasons differ between the general population and the population of people with a chronic illness. Methods We made use of survey data collected in 2017 among two panels representing the general population (n  = 659, response 44%) and the chronically ill population (n  = 1593, response 86%). Results We found differences regarding the reasons for not switching insurer. The chronically ill population seems to attach more importance to reasons related to the coverage of the health plan, whereas the general population is more focused on the level of service. Some people who considered switching experienced barriers, however, these barriers were not significantly more experienced by the chronically ill population. Conclusions This study reveals differences between the general population and the chronically ill population when examining reasons for not switching related to quality and coverage. A subset from the people who initially considered to switch experienced barriers which might have altered their decision. Further research is recommended to include questions about information search behaviour to examine which consumers make an informed decision for not switching, and for whom barriers limit switching. [ABSTRACT FROM AUTHOR]

Background: HIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania. Methods: Data are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January–March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers' HIV status disclosure being the outcome variable was conducted. Results: The analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16–1.28); unmarried (OR = 1.12, 95% CI 1.03–1.23); widowed (OR = 1.12, 95% CI 1.07–1.18); those without health insurance (OR = 1.36, 95% CI 1.28–1.45); age 61 + years (OR = 1.72, 95% CI 1.59–1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04–1.25); and rural residents (OR = 1.58, 95% CI 1.34–1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001). Conclusion: While improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population. [ABSTRACT FROM AUTHOR]

Most health insurance markets with premium-rate restrictions include a risk equalization system to compensate insurers for predictable variation in spending. Recent research has shown, however, that even the most sophisticated risk equalization systems tend to undercompensate (overcompensate) groups of people with poor (good) self-reported health, confronting insurers with incentives for risk selection. Self-reported health measures are generally considered infeasible for use as an explicit 'risk adjuster' in risk equalization models. This study examines an alternative way to exploit this information, namely through 'constrained regression' (CR). To do so, we use administrative data (N = 17 m) and health survey information (N = 380 k) from the Netherlands. We estimate five CR models and compare these models with the actual Dutch risk equalization model of 2016 which was estimated by ordinary least squares (OLS). In the CR models, the estimated coefficients are restricted, such that the under-/overcompensation for groups based on self-reported general health is reduced by 20, 40, 60, 80, or 100%. Our results show that CR can improve outcomes for groups that are not explicitly flagged by risk adjuster variables, but worsens outcomes for groups that are explicitly flagged by risk adjuster variables. Using a new standardized metric that summarizes under-/overcompensation for both types of groups, we find that the lighter constraints can lead to better outcomes than OLS. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background There have been contributions to quantify the volume of low-value care practices in the USA, Canada and Australia but we have no knowledge about the volume in Europe. The purpose of this study was to assess the volume and variation of Dutch low-value care practices. Methods We conducted a cross-sectional study with data of a Dutch healthcare insurance company from general practioners (GP's) and hospitals in the Netherlands from 2016. We used all billing claims made by healthcare providers of 3.5 million Dutch inhabitants. We studied Choosing Wisely recommendations in order to select low-value care practices. We used the percentage low-value care practices per hospital and number of low-value care practices per GP as outcomes. Results We assessed the volume of low-back imaging by GPs, screening of patients over 75 years for colorectal cancer and diagnosing varices with Doppler or Plethysmography. We found that 0.4% (range 0–7%) of the eligible patients received low-value screening for colorectal cancer and 8.0% (range 0–88%) of eligible patients received low-value diagnosing of varices. About 52.4% of the GPs ordered X-rays and 11.2% ordered magnetic resonance imagings of the lumbosacral spine. Most healthcare providers did not provide the measured low-value care practices. However, 1 in 12 GPs ordered at least one low-back X-ray a week. Conclusions The three Choosing Wisely recommendations showed a lot of practice variation; many healthcare providers did not order these low-value diagnostic tests; a minor part did order a substantial amount, low-back spine radiology in particular. These healthcare providers should start reducing these activities. [ABSTRACT FROM AUTHOR]

Aims: To obtain more insight into differences in sick leave assessments of workers with subjective health complaints, we studied sick leave assessments among Dutch occupational and insurance physicians, and explored possible determinants for these differences. Methods: A cross-sectional study was conducted among 50 occupational and 43 insurance physicians in the Netherlands. They all assessed sick leave (complete, partial or no) of nine video case vignettes of workers with subjective health complaints and gave their opinion on the complaints, sick leave and health status. Data were analyzed via a multinomial regression approach, using generalized estimating equations in SPSS. Results: Compared to occupational physicians, complete sick leave was less likely to be assessed by insurance physicians (odds ratio 0.74, 95% confidence interval 0.56–0.97). For occupational physicians, psychological diagnoses, private issues and reduced work ability had more influence on the outcome of the sick leave assessment than for insurance physicians. Conclusion: There are differences in sick leave assessments for workers with subjective health complaints between physicians working in the same occupational health system; insurance physicians are stricter in assessing complete sick leave than occupational physicians. These differences may be explained by differences in roles, tasks and perspectives of the physician in occupational health care. Sick leave assessments of workers with subjective health complaints. • The current study showed that there are differences between occupational physicians and insurance physicians in sick leave assessments for workers with subjective health complaints. • These differences may be based on different perspectives, roles and tasks of physicians. • Physicians working in the rehabilitation and occupational health system should be more aware of the impact of these differences on their assessments and advices. • Better communication and collaboration between physicians, and more insight into and clarification of the perspectives may result in more agreement between physicians' sick leave assessment and advice towards workers. [ABSTRACT FROM AUTHOR]

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