Less – or no – market forces in healthcare, what then?

“Health care is not a market!” It has been the slogan of the SP for years. But now that the next cabinet hardly seems to be able to avoid tampering with market forces in healthcare, the SP is on the sidelines with five seats. Pickles? “You can say: we’ll get it credits not in favor,” says MP Jimmy Dijk, healthcare spokesperson for the SP. “But I prefer to think: it finally worked. Please let them take over all our plans.”

In many election manifestos, parties, from left to right, write about tackling regulated market forces. This has “gone crazy”, say BBB and GroenLinks-PvdA. “Market forces have led to a waste of money,” says the Party for the Animals. And NSC writes: “Care for people is not a market.”

The current system of regulated market forces was introduced in 2006 by then minister Hans Hoogervorst (Public Health, VVD), under the Balkenende II cabinet with CDA, VVD and D66. It replaced the health insurance fund system (for lower incomes and compulsory) and private health insurance (for higher incomes and not compulsory). From now on, all Dutch people aged 18 and over had to take out compulsory basic insurance and health insurers started to compete with each other, just like healthcare providers. The idea was that insurers could keep healthcare providers competitive and command lower prices. It was all supposed to lead to less rapidly rising costs, higher quality and better accessibility of care.

“That system has worked very well to control costs. They could have been much higher,” says professor of healthcare affordability Patrick Jeurissen of Radboud University Medical Center in Nijmegen. “The accessibility of care is also good, the quality has improved boost received, although it is difficult to say whether this is due to the system or, for example, due to new technology.” His conclusion: “All in all, the system is not functioning badly.”

In 2021, Jeurissen, together with emeritus professor of policy science in healthcare Hans Maarse (Maastricht University), wrote the book The market reform in Dutch health care, about fifteen years of market forces in healthcare. It contained roughly the same conclusions. But, it then became clear, the administrative burden for healthcare staff has increased enormously. And that has not changed yet, as it turned out last week new figures from the Nivel research institute. Despite many plans and reports, healthcare workers still spend an average of more than ten hours per week completing paperwork and reporting. Almost half of healthcare professionals call the amount of administrative work “unreasonable”.

Greater role for commercial chains

There are more problems with market forces. For example, commercial chains are playing an increasingly important role through takeovers in, for example, oral care (Dental Clinics) and general practitioner care (Centric Health, Co-Med). In general practitioner care, the inspection regularly finds shortcomings, with doors that remain closed and patients who do not receive care. The chains receive a fixed amount per patient from the health insurer every quarter, even if a practice is temporarily closed or difficult to reach. That can make money.

In youth care, many parties are active that focus on ‘lighter’ (cheaper) cases such as exam stress, while children waiting for more serious help are often on long waiting lists. The same goes for mental health care. What has also not worked out well, says Jeurissen, is “active healthcare purchasing” by insurers: “Rewarding good healthcare providers by using them more and calling on the bad ones less often. You don’t see much of that anymore.”

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Germany during the corona crisis. Competing health insurers means: expensive marketing campaigns. The SP points to lagging wages and increasing workload – the outflow from healthcare is a major problem. “Where market forces have taken hold, you definitely have to do something about it,” concludes Marco Varkevisser, professor of market regulation in healthcare at Erasmus University Rotterdam.

professor of affordability of healthcare at Radboud university medical centerPatrick Jeurissen Market forces were successful in controlling healthcare costs. They could have been much higher

But do parties offer the right solutions? Varkevisser previously called it “valid” to look at what does and does not fit within the system of regulated market forces, referring to the PVV’s proposal to remove acute care from that system. In emergency care and complex mental health care, for example, competition adds little. GroenLinks-PvdA wants the same for elderly care.

But the professor – and other experts with him – also views some of the plans with some skepticism. For example, PVV and GroenLinks-PvdA, and possibly also BBB, want a complete ban on profit distribution – which will cause investors to drop out. Currently, such a ban only applies to hospitals, large elderly care institutions and large mental health institutions. NSC also wants to reduce the influence of commercial investors on general practices, dental practices, pharmacies, nursing homes, physiotherapy chains and private clinics. The SP wants to get rid of those investors completely.

‘Set strict criteria’

There is indeed a risk of “wrong investors” in certain healthcare sectors, such as general practitioner care, says Varkevisser. You must keep them out, for example by setting strict criteria. But a generic ban prevents all private investors, while he believes they are necessary: ​​“In any case, investments must be made in healthcare, for example in technological innovation that can alleviate labor shortages. If you sideline private investors, financing will have to come largely from taxes and premiums.”

The role of the insurer is also changing – ergo: shrinking – if it is up to most parties. NSC wants the judgment of healthcare professionals to become ‘leading’, BBB wants insurers to make agreements with ‘collectives’ (such as interest groups), the SP wants a National Healthcare Fund and GroenLinks-PvdA would prefer to see healthcare insurers become public healthcare funds, in which patient organizations, healthcare providers and professional groups draw up one care plan for each region with its own care budget. But changing private insurers into public funds “is not without a fight,” says Professor Jeurissen. “They will also want compensation. And that money is not there.”

What it is mainly about, says Varkevisser: “It sounds good, it scores electorally, because there is less confidence in the insurer than in the professional. But changing the purchasing role of the insurer puts the control in the hands of the healthcare professional, who is not confronted with the costs. It is the insurer’s public duty to control the pot of premium money, in the interests of all of us.”

‘Legalization of cartel formation’

He is particularly critical of BBB’s plan to make agreements with collectives. “It is legalization of cartel formation. If you think a little further, what remains is that all power lies with the healthcare providers, meaning that the insurer can no longer argue against overly expensive contract proposals, unnecessary care or too little quality improvement.”

Healthcare economist Indya Duivenbode agrees. However, she does see the need for more cooperation between health insurers and healthcare providers, including among themselves – and therefore less competition: “Although the question is how far you go. Letting go of market forces is possible, but in addition to the positive consequences, it also has negative consequences.” According to Duivenbode, the proposal for healthcare funds, for example, from GroenLinks-PvdA, resembles the health insurance fund system from before 2006. “The current system has disadvantages, but so did the public system with health insurance funds.” The problems of that time – sharply rising healthcare costs and ever-growing waiting lists – are comparable to those of today.

Duivenbode points to the British healthcare system, the public National Health Service, without market forces. “The waiting lists there are no less and the quality of care is no better. And you still see a market emerging, but only for the rich: if you can afford it, you go to a private clinic. In the Netherlands you cannot just go to a private cardiologist. We have one of the most inclusive healthcare systems in the world.” But, she adds: “That does not alter the fact that you should always look carefully at what can be improved within a system.”

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The initiators of the current system, VVD, CDA and D66, are more cautious in their proposals. For example, D66 believes that healthcare “requires more control from the government in matters that we have previously left to the market.” The CDA writes that “more cooperation (and less market forces) is important in both primary care and in secondary and tertiary care.” The VVD does not mention any adjustments in its election manifesto and only states: “Let us not waste our time on system discussions.”

The question is also whether all political plans must lead to a completely new system. Jeurissen and Duivenbode say that such a major change costs a lot of money. Moreover, says Jeurissen, “what will be the robust and well-thought-out alternative? I haven’t seen that framework yet.” Although he is also realistic: “The truth is that this is now a political fact. I have never experienced such broad support. The limits of market forces in healthcare have apparently been reached.”