Managed competition in the Netherlands - out of fashion or work in progress? A study on the role of insurers as third-party purchasers of healthcare

Since 2006, the Netherlands has had a healthcare system based on managed competition, where health insurers purchase care on behalf of their insured clients. At the end of each year, policyholders are free to choose the insurer they believe performs this task best. This dissertation examines whether competition among Dutch health insurers functions as originally intended and, if not (fully), what can be done to improve the healthcare system. This is explored in four separate but closely related studies using both quantitative and qualitative research methods. These studies consecutively examine i) the perspective of consumers, ii) the perspective of insurers, iii) the behaviour of insurers, and iv) the willingness and ability of insurers to collaborate. In summary, the studies show that the Dutch healthcare system functions partly as originally intended but falls short in several other respects. Insurers are primarily and effectively incentivized to control the growth of healthcare costs, but they are insufficiently encouraged to incorporate quality considerations in their purchasing decisions, while the system legally obstructs collaboration aimed at improving care quality. This conclusion could raise the question of whether the current system is adequate for the challenges in healthcare. The dissertation therefore also discusses alternative coordination mechanisms. It demonstrates that there is no 'one size fits all' solution for all healthcare sectors. Overall, the dissertation first shows that the current system could work better by improving publicly available information on how insurers fulfil their purchasing role. Additionally, it shows how a future system can be shaped by employing specific criteria to determine the most appropriate coordination mechanisms for the different healthcare domains. For some sectors, this could imply a shift from regulated market competition to regulated cooperation or more direct government control.