Sociale ziektekostenverzekering en doelmatigheid

REDE uitgesproken bij de openbare aanvaarding van het ambt van bijzonder hoogleraar sociale ziektekostenverzekering, vanwege de Vereniging van Nederlandse Ziekenfondsen, in de Faculteit Geneeskunde en Gezondheidswetenschappen van de Erasmus Universiteit Rotterdam op donderdag 15 oktober 198

Improving access to essential health care services: The case of Israel

In a recent article in this journal Simon-Tuval, Horev and Kaplan argue that in order to improve the protection of consumers there might be a need to impose a threshold on the medical loss ratio (MLR) for voluntary health insurance (VHI) in Israel [1]. Their argument is that VHI in Israel covers several essential services that are not covered by the mandatory benefits package due to budget constraints, while there are market failures in the VHI market that justify regulation to assure consumer protection such as high accessibility to high quality coverage. In this commentary it will be argued that in addition to market failures there are also government failures. It is doubtful whether imposing a threshold on MLR is effective because of government failures. It can be even counter-productive. Therefore, alternative regulatory measures are discussed to promote the protection of the beneficiaries. If essential services covered by VHI are unaffordable for some low-income people, government can extend the current mandatory basic health insurance so that it covers all essential services. If there is a budget restriction, the amount of government funds could be increased, or the health plans could be allowed to request an additional flat rate premium, set by them and to be paid by the consumer directly to their health plan. Also, effective out-of-pocket payments could be introduced. Subsidies could be given to low-income people to compensate for their additional expenses under the mandatory health insurance. If these changes are adopted, then the government would no longer be held responsible for access to benefits outside the mandatory health insurance. Accordingly, all VHI could be sold on the normal free insurance market, just as other types of indemnity insurance. In addition, the Israeli health insurance and healthcare markets could be made more competitive by introducing procompetitive regulation. This would increase the efficiency and affordability of healthcare

Is de Zorgverzekeringswet een succes?

Met de invoering van de Zorgverzekeringswet (Zvw) is het zorgverzekeringsstelsel fors veranderd. Een evaluatie van de Zvw wijst uit dat de eerste effecten overwegend positief kunnen worden beoordeeld, maar dat ook sprake is van belangrijke knelpunten en problemen. Deze hebben betrekking op de zorgtoeslag, de hoogte van de zorgpremie, het toenemend aantal wanbetalers, de ex ante risicoverevening, de zorgplicht, het eigen risico en de aanvullende verzekering. Mogelijke oplossingsrichtingen zoals het afschaffen van de zorgtoeslag, het verlagen van de zorgpremie en een verschoven eigen risico worden door het kabinet niet overgenomen. Dat is volgens de auteurs niet verstandig, omdat deze oplossingen niet alleen knelpunten en problemen aanpakken, maar ook kunnen leiden tot miljardenbesparingen op de collectieve uitgaven

Should catastrophic risks be included in a regulated competitive health insurance market?

In 1988 the Dutch government launched a proposal for a national health insurance based on regulated competition. The mandatory benefits package should be offered by competing insurers and should cover both non-catastrophic risks (like hospital care, physician services and drugs) and catastrophic risks (like several forms of expensive long-term care). However, there are two arguments to exclude some of the catastrophic risks from the competitive insurance market, at least during the implementation process of the reforms. Firstly, the prospects for a workable system of risk-adjusted payments to the insurers that should take away the incentives for cream skimming are, at least during the next 5 years, more favorable for the non-catastrophic risks than for the catastrophic risks. Secondly, even if a workable system of risk-adjusted payments can be developed, the problem of quality skimping may be relevant for some of the catastrophic risks, but not for non-catastrophic risks. By 'quality skimping' we mean the reduction of the quality of care to a level which is below the minimum level that is acceptable to society. After 5 years of health care reforms in the Netherlands new insights have resulted in a growing support to confine the implementation of the reforms to the non-catastrophic risks. In drawing (and redrawing) the exact boundaries between different regulatory regimes for catastrophic and non-catastrophic risks, the expected benefits of a cost-effective substitution of care have to be weighted against the potential harm caused by cream skimming and quality skimping

Uitvoering AWBZ door zorgverzekeraars onverstandig

Het voorstel om de AWBZ te laten uitvoeren door concurrerende zorgverzekeraars is niet verstandig. Zorgverzekeraars hebben geen financieel belang bij investeringen in goede AWBZ-zorg omdat AWBZ-zorggebruikers voorspelbaar verliesgevend zijn. Bovendien ontbreekt vooralsnog elk perspectief op adequate stimuli tot doelmatige zorginkoop

Supplementary physicians' fees: a sustainable system?

In Belgium and France, physicians can charge a supplementary fee on top of the tariff set by the mandatory basic health insurance scheme. In both countries, the supplementary fee system is under pressure because of financial sustainability concerns and a lack of added value for the patient. Expenditure on supplementary fees is increasing much faster than total health expenditure. So far, measures taken to curb this trend have not been successful. For certain categories of physicians, supplementary fees represent one-third of total income. For patients, however, the added value of supplementary fees is not that clear. Supplementary fees can buy comfort and access to physicians who refuse to treat patients who are not willing to pay supplementary fees. Perceived quality of care plays an important role in patients’ willingness to pay supplementary fees. Today, there is no evidence that physician

Towards a capitation formula for competing health insurers. An empirical analysis

__Abstract__ In many countries the concept of capitating health care insurers is receiving increasing attention. The main reason is, that capitation may induce health care insurers in a competitive environment to concentrate more on cost containment. However, if the adjusters on which capitation payments are based, are too global, there may be ample room for risk selection by the insurers whilst also an unfair distribution of funds over the insurers may result, thereby undermining the objectives of capitation. The prime motivation for the present study is, that the Dutch government, as part of proposals for a new, market oriented structure of health care system, is considering to capitate insurers on the basis of global parameters like age, gender and location. Our analysis based on panel data of some 35,000 individuals, shows that the proportion of variance in annual health care expenditures that can be predicted (R2) by such a global capitation formula, is only 0.024. This is less than of our estimate of the theoretically maximum achievable R2 which amounts to 0.138, implying the existence of abundant selection oppurtunities, e.g. on the basis of past expenditures or other health indicators. Alternative capitation formulae incorporating prior-year's costs and reaching about of the maximum obtainable R2, effectively remove the profitableness of selection on the basis of past expenditures. The findings suggest, however, that selection via (chronic) health status may still be profitable to some extent. Therefore, we also analyzed data from the Dutch Health Interview Survey (N ≈ 20,000) which comprised better health indicators. It appeared that a capitation formula based on the global adjusters mentioned above as well as three health status indicators and several background characteristics, yields an R2 of about 0.114, which probably accounts for of our estimate of the maximum obtainable R2. The main conclusion is, that in the short term information on prior expenditures, which is available in the files of most insurers and thus may be used for risk selection, should be included in the capitation formula. For the more distant duture, the formula should be expanded with indicators of chronic health status, possibly based on diagnostic information from previous, non-discretionary hospitalizations