Adverse selection and consumer inertia:empirical evidence from the Dutch health insurance market

This paper examines to what extent consumer inertia can reduce adverse selection in health insurance markets. To this end, we investigate consumer choice of deductible in the Dutch health insurance market over the period 2013–2018, using panel data based on a large random sample (266 k) of all insured individuals in the Netherlands. The Dutch health insurance market offers a unique setting for studying adverse selection, because during annual open enrollment periods all adults are free to choose an extra deductible up to 500 euro per year. By focusing on deductible choices of those who do not switch health plans, we are able to examine the ‘pure’ adverse selection effect (i.e., not distorted by other health plan attributes). We estimate a dynamic logit model to examine individuals’ deductible choice. We find evidence of adverse selection, as people with higher previous health care cost are substantially less likely to take up or keep a 500-euro deductible. We also find that adverse selection is counteracted by a high level of consumer inertia, as the average partial effect on deductible choice of the previous selected deductible level is much larger than the average partial effect of a change in health care costs.</p

Competition and quality indicators in the health care sector: empirical evidence from the Dutch hospital sector

textabstractThere is much debate about the effect of competition in healthcare and especially the effect of competition on the quality of healthcare, although empirical evidence on this subject is mixed. The Netherlands provides an interesting case in this debate. The Dutch system could be characterized as a system involving managed competition and mandatory healthcare insurance. Information about the quality of care provided by hospitals has been publicly available since 2008. In this paper, we evaluate the relationship between quality scores for three diagnosis groups and the market power indicators of hospitals. We estimate the impact of competition on quality in an environment of liberalized pricing. For this research, we used unique price and production data relating to three diagnosis groups (cataract, adenoid and tonsils, bladder tumor) produced by Dutch hospitals in the period 2008–2011. We also used the quality indicators relating to these diagnosis groups. We reveal a negative relationship between market share and quality score for two of the three diagnosis groups studied, meaning that hospitals in competitive markets have better quality scores than those in concentrated markets. We therefore conclude that more competition is associated with higher quality scores

Collaboration and competition policy in a market-based hospital system: a case-study from The Netherlands

In the Dutch healthcare system, provider competition is used as a tool to improve efficiency. From a competition policy perspective, little is known about how collaboration among healthcare providers contributes to overall patient welfare, and how a balance is achieved between scale benefits and preventing anticompetitive collusion. This paper examines the ex-post effects of a Dutch case study in which three competing hospitals have collaborated to provide highcomplexity low-volume cancer surgery, an arrangement that tests the limits of permissibility under the Dutch cartel prohibition. Our preliminary empirical research demonstrated only a modest increase in price and travel time for some of the tumour surgeries. Volume analysis showed that the intended centralization of surgical procedures has not been fully realized. Our findings highlight the importance of a comprehensive self-assessment by the collaborating hospitals to ex-ante assess (potential) e

Multilevel modeling and policy development: guidelines and applications to medical travel

Medical travel has expanded rapidly in recent years, resulting in new markets and increased access to medical care. Whereas several studies investigated the motives of individuals seeking healthcare abroad, the conventional analytical approach is limited by substantial caveats. Classical techniques as found in the literature cannot provide sufficient insight due to the nested nature of data generated. The application of adequate analytical techniques, specifically multilevel modeling, is scarce to non-existent in the context of medical travel. This study introduces the guidelines for application of multilevel techniques in public health research by presenting an application of multilevel modeling in analyzing the decision-making patterns of potential medical travelers. Benefits and potential limitations are discussed

Diclofenac Prolongs Repolarization in Ventricular Muscle with Impaired Repolarization Reserve

Background: The aim of the present work was to characterize the electrophysiological effects of the non-steroidal anti- inflammatory drug diclofenac and to study the possible proarrhythmic potency of the drug in ventricular muscle. Methods: Ion currents were recorded using voltage clamp technique in canine single ventricular cells and action potentials were obtained from canine ventricular preparations using microelectrodes. The proarrhythmic potency of the drug was investigated in an anaesthetized rabbit proarrhythmia model. Results: Action potentials were slightly lengthened in ventricular muscle but were shortened in Purkinje fibers by diclofenac (20 mM). The maximum upstroke velocity was decreased in both preparations. Larger repolarization prolongation was observed when repolarization reserve was impaired by previous BaCl 2 application. Diclofenac (3 mg/kg) did not prolong while dofetilide (25 mg/kg) significantly lengthened the QT c interval in anaesthetized rabbits. The addition of diclofenac following reduction of repolarization reserve by dofetilide further prolonged QT c . Diclofenac alone did not induce Torsades de Pointes ventricular tachycardia (TdP) while TdP incidence following dofetilide was 20%. However, the combination of diclofenac and dofetilide significantly increased TdP incidence (62%). In single ventricular cells diclofenac (30 mM) decreased the amplitude of rapid (I Kr ) and slow (I Ks ) delayed rectifier currents thereby attenuating repolarization reserve. L-type calcium current (I Ca ) was slightly diminished, but the transient outward (I to ) and inward rectifier (I K1 ) potassium currents were not influenced. Conclusions: Diclofenac at therapeutic concentrations and even at high dose does not prolong repolarization markedly and does not increase the risk of arrhythmia in normal heart. However, high dose diclofenac treatment may lengthen repolarization and enhance proarrhythmic risk in hearts with reduced repolarization reserve

The Incremental Cooperative Design of Preventive Healthcare Networks

This document is the Accepted Manuscript version of the following article: Soheil Davari, 'The incremental cooperative design of preventive healthcare networks', Annals of Operations Research, first published online 27 June 2017. Under embargo. Embargo end date: 27 June 2018. The final publication is available at Springer via http://dx.doi.org/10.1007/s10479-017-2569-1.In the Preventive Healthcare Network Design Problem (PHNDP), one seeks to locate facilities in a way that the uptake of services is maximised given certain constraints such as congestion considerations. We introduce the incremental and cooperative version of the problem, IC-PHNDP for short, in which facilities are added incrementally to the network (one at a time), contributing to the service levels. We first develop a general non-linear model of this problem and then present a method to make it linear. As the problem is of a combinatorial nature, an efficient Variable Neighbourhood Search (VNS) algorithm is proposed to solve it. In order to gain insight into the problem, the computational studies were performed with randomly generated instances of different settings. Results clearly show that VNS performs well in solving IC-PHNDP with errors not more than 1.54%.Peer reviewe

Residual C-peptide is associated with new and persistent impaired awareness of hypoglycaemia in type 1 diabetes

Aims: To describe the change in impaired awareness of hypoglycaemia (IAH) over time and to identify factors associated with this change in the Dutch Type 1 Diabetes biomarkers cohort (NCT04977635).Methods: A prospective cohort of type 1 diabetes patients, with C-peptide &lt;300 pmol/L, who had completed the Clarke questionnaire, to determine IAH status, at baseline and after 2 years. Changes in awareness status were defined and compares as follows: unchanged normal awareness (NAH) versus unchanged IAH, new IAH versus reversal of IAH. Multivariate logistic regression models were fitted using forward and backward stepwise selection using a 0.10 P-value cut-off, and stepwise backward selection using AIC criteria.Results: A total of 431 out of 611 participants were included. The baseline prevalence of IAH was 17 % and 20 % after 2 years. The incidence proportion of new IAH and reversal of IAH were, 9.5 % and 31 %, respectively. For every 2.7-fold increase in C-peptide, the odds of IAH decrease by 58 %. A 1-unit increase in BMI over the 2-year follow-up period is associated with a 5.27-fold increase in the odds of reversing IAH.Conclusions: Higher C-peptide levels are protective against new IAH, and an increase in BMI over time is associated with the reversal of IAH.</p

Differences in lipid and blood pressure measurements between individuals with type 1 diabetes and the general population:a cross-sectional study

OBJECTIVES: Cardiovascular disease (CVD) is a precarious complication of type 1 diabetes (T1D). Alongside glycaemic control, lipid and blood pressure (BP) management are essential for the prevention of CVD. However, age-specific differences in lipid and BP between individuals with T1D and the general population are relatively unknown.DESIGN: Cross-sectional study.SETTING: Six diabetes outpatient clinics and individuals from the Lifelines cohort, a multigenerational cohort from the Northern Netherlands.PARTICIPANTS: 2178 adults with T1D and 146 22 individuals without diabetes from the general population.PRIMARY AND SECONDARY OUTCOME MEASURES: Total cholesterol, low-density lipoprotein cholesterol (LDL-cholesterol), systolic BP (SBP) and diastolic BP (DBP), stratified by age group, glycated haemoglobin category, medication use and sex.RESULTS: In total, 2178 individuals with T1D and 146 822 without diabetes were included in this study. Total cholesterol and LDL-cholesterol were lower and SBP and DBP were higher in individuals with T1D in comparison to the background population. When stratified by age and medication use, total cholesterol and LDL-cholesterol were lower and SBP and DBP were higher in the T1D population. Men with T1D achieved lower LDL-cholesterol levels both with and without medication in older age groups in comparison to women. Women with T1D had up to 8 mm Hg higher SBP compared with the background population, this difference was not present in men.CONCLUSIONS: Lipid and BP measurements are not comparable between individuals with T1D and the general population and are particularly unfavourable for BP in the T1D group. There are potential sex differences in the management of LDL-cholesterol and BP.</p