Managed competition in health
care in the Netherlands
The displacement of public
responsibility
Romke van der Veen
1
Changes in health care
• Universal and comprehensive health
insurance
• Introduction of market-principles in healthinsurance and health provision
• Goals of managed care:
– cost control
– maintenance of quality
– less central steering
2
Transformation of the
Welfare State
•
•
•
•
From public to private provision
From protection to promoting participation
From universality to selectivity
From citizenship to membership
3
…. 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)
4
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
5
…. in Health Care
• Private insurance companies
• Insurance
– nominal premium
– no-claim
– supplementary insurance
• Heath care provision
– competition (between care providers)
– contracts (providers-insurers)
6
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
7
Conditions of managed care
8
Field/actor:
Systemrationality:
Conditional:
Insurance-market and
Care provision market (1)
Homogeneity
Transparency
Atomistic
Competion
Information
(=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)
Economic actor
Citizen (2)
Patient
Competition
Transparency
(Professional) trust
9
Systemlogic requires
•
•
•
•
Competition
Transparency
Professionalism
Management
10
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
11
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
12
Professionalism
• Contradictory forces working on
professionals?
• Dominance of one of the three:
– overconsumption
– low quality
– low cooperation
• Dominance of professional?
• Risk of decoupling
13
Management
• Taylorisation
• No machine bureaucracy, difficult to
standardize
• Manager highly dependent
• Management = managing conflicting
interests
14
Displacement of public
responsibility
• Privatization
– of risks: decollectivization
– of administration
• Decentralization
– of regulatory and administrative respoinsibility
• Europeanization
– upward displacement
15