De marktwerking in de zorg heeft de hooggespannen verwachtingen nog niet waargemaakt, maar hoe kan het beter? Dat is een centraal thema in het proefschrift van Karel Stolper (Erasmus School of Health Policy & Management) die werkt voor zorgverzekeraar CZ.
Competition in health care has not yet lived up to the high expectations, but how can it be improved? That is a central theme in the thesis of Karel Stolper (Erasmus School of Health Policy & Management) who works for health insurer CZ.
Among other things, you researched how Dutch people think about health insurers. What stands out?
''I was curious if people understand the role of health insurers. Health insurers buy care on behalf of the insured, which is an important premise of the system. Do people know that at all, or do they just buy a policy for a certain price? Research participants mostly knew this, more than I thought beforehand. But then I got back in focus groups and the survey that policyholders are not good at judging whether insurers are buying care properly. You also see that there is little trust in health insurers.''
What does that indicate to you?
''The main issue is that people don't have enough information to judge insurers. That's already not a tasty start to making the system work well. The ability to switch between health insurers was meant to incentivize insurers to buy the best possible care. But if insureds cannot judge that, the system is not working as intended. Low trust, I think, is something health insurers have to learn to live with. They don't have such a rewarding job because they have to guard the wallet. That means they sometimes have to tell a practitioner that a certain treatment can no longer be done.''
You also talked to numerous health insurance companies. What do you get out of that?
''What came back very strongly is that health insurers experience the incentive to control costs, but not to control quality. In fact, health insurers experience negative incentives to do so. Suppose they no longer want to contract a particular health care provider because it provides poor care. Then you have a chance that people will choose another insurer. One CEO literally said, “This could cost us 100,000 customers. Health insurers do feel a social mission to manage for quality, but the system does not motivate them to actually do so.''
''It's problematic when the system only drives by price because then the conversations are just about care being too expensive''
Karel Stolper
PhD candidate
Why is that problematic?
''The idea behind the current system was that there would be an optimum by weighing quality and price. If you then get a system that steers only by price and not by quality, that is problematic. The conversations are then only about whether care is too expensive and whether it can't be a little cheaper.''
So has the current healthcare system had its prime?
''You can say that competition has not fully lived up to expectations. The system is not perfect, but then what are the alternatives? You can give the government a bigger role and let the minister decide what care will be purchased. Or you give the consultation model more space and leave it to the consultation table.''
Based on your thesis, can you say what works best?
''My main plea is that you have to look at what mechanism works best for each healthcare domain. I think we have to get rid of the idea that there is one mechanism that works for all of healthcare. In physical therapy, where there are more than 20,000 providers, regulated market forces can work well, for example. If you organize this well and you provide consumers with good information about quality and price considerations, then the health insurer can do a good job. If you look at complex specialist medical care, of which there are only a handful of providers, think of oncology, the minister can tie the knot just fine.''
''My plea to let go of competition for some sectors may be a bit uncomfortable for some insurers''
Karel Stolper
PhD candidate
And just when is collaboration important?
''These are sectors where the minister cannot properly oversee the decision and where the market does not work well. For example, because consumers do not properly understand the trade-offs made by the insurer. Here I am thinking of GP care and complex mental health care. You have to think carefully about how you organize that cooperation and with which parties. There are also some legal snags. Collaboration has been the magic word for years, but I also see that healthcare managers are fed up with the endless consultation tables where no decisions are taken.''
You yourself work for a health insurance company. How do they look at the conclusions from your research?
''I think they can endorse the empirical findings pretty quickly. There will be more discussion about where it should go. My plea to let go of competition for some sectors may be a bit uncomfortable for some insurers. In doing so, you are basically telling health insurers that they have to give up some of their power in favor of the government or the consultation table.''
- PhD student
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