Wynand van de Ven - Academia.edu (original) (raw)

Papers by Wynand van de Ven

Health Affairs the Policy Journal of the Health Sphere, May 1, 2004

Health Affairs, 1994

Prologue: "Americans know too little about the implementation of market-reform strategies in othe... more Prologue: "Americans know too little about the implementation of market-reform strategies in other countries," says Alain Enthoven, whose work on managed competition has formed the underpinnings of the most recent health system reforms in the Netherlands. In fact, he continues, "the Dutch are further down the road to managed competition than we [Americans] are." In this paper four leading Dutch researchers bring the American policy audience up to date on how managed competition is being implemented in their country. What is critical to the sucess of reforms, both in the Netherlands and in the United States, are risk adjustment mechanisms to prevent cream skimming-that is, to prevent plans from selecting the best health risks and avoiding those predicted to cost more. In a health system bused on up-front capitation, health plans see it in their interest to attract persons whose costs will not exceed the amount paid to the plan for their care. Wynund van de

Health Policy, 2016

Germany, the Netherlands, and Switzerland have taken steps toward regulated competition on the he... more Germany, the Netherlands, and Switzerland have taken steps toward regulated competition on the health insurance market to enhance efficiency and consumer responsiveness. The rationale of giving the consumer a periodic choice of health insurer is that individual risk-bearing insurers are stimulated to effectively purchase and manage the care on behalf of their enrollees. For Europe this is largely a terra incognita, while the United States have at least fifty years of relevant experience. Twenty years ago the United States were confronted with a substantial backlash against managed care. Based on the US experience we come to the following lessons for Europe. First, the greatest backlash against managed care can be expected from the healthcare providers. Second, consumers are willing to give up to some extent their free choice of healthcare provider in return for a lower premium. Third, insurers should (be allowed to) offer consumers a choice between an insurance product with free choice of provider and lower-priced products with restricted reimbursement for non-contracted providers. Fourth, insurers should use input from consumers, provide them in a timely manner with relevant information about the (non-) contracted providers, and reassure consumers that in-network providers offer good quality care. Fifth, the development of national guidelines and quality indicators, with input from the medical profession, can increase the acceptance of managed care.

Health Econometrics and Data Group Working Papers, 2006

Many cou ntries are consid ering the option of red u cing the share of m and atory health insu ra... more Many cou ntries are consid ering the option of red u cing the share of m and atory health insu rance (MH I) and to increasingly rely on volu ntary (su pplementary) health insu rance (VH I) schem es to cover health care expend itu res. It is w ell-know n that com petitive m arkets for VH I tend to risk-rated prem iu m s. After d iscu ssing the d eterm inants of riskrating in com petitive VH I m arkets, w e provid e em pirical evid ence of the potential reduction of (risk-) solidarity caused by the transfer of benefits from MHI to VHI coverage.

Expert Review of Pharmacoeconomics Outcomes Research, Jun 1, 2013

The Netherlands relies on risk equalization to compensate competing health insurers for predictab... more The Netherlands relies on risk equalization to compensate competing health insurers for predictable variation in individual medical expenses. Without accurate risk equalization insurers are confronted with incentives for risk selection. The goal of this study is to evaluate the improvement in predictive accuracy of the Dutch risk equalization model since its introduction in 1993. Based on individual-level claims data (n = 15.6 million), we estimate the risk equalization models that have been successively applied in The Netherlands since 1993. Using individual-level survey data (n = 8735), we examine the average under-/ overcompensation by these models for several relevant subgroups in the population. We find that in the course of years, the risk equalization model has been substantially improved. Even the current model (2012), however, does not eliminate incentives for risk selection completely. To achieve the public objectives, further improvement of the Dutch risk equalization model is crucial.

Economisch Statistische Berichten, 2012

Health Economics, Policy and Law, 2015

All consumer groups with specific preferences must feel free to easily switch insurer in order to... more All consumer groups with specific preferences must feel free to easily switch insurer in order to discipline insurers to be responsive to consumers' heterogeneous preferences. This paper provides insight into the switching behaviour of low-risks (i.e. young or healthy consumers) and high-risks (i.e. elderly or unhealthy consumers) in the Netherlands in the period 2009-2012. We analysed: (1) administrative data with objective health status information (i.e. medically diagnosed diseases and pharmaceutical use) and information on health care expenses of nearly the entire Dutch population (n=15.3 million individuals) and (2) three-year sample data (n=1152 individuals). Our findings indicate that switching rates strongly decrease with age. For example, in 2009, consumers aged 25-44 switched 10 times more than consumers aged 75 or older. Another finding is that switching rates decrease as the predicted health care expenses increase. Although healthy consumers switch twice as much as unhealthy consumers, this difference becomes much smaller after adjusting for age. We conclude that our findings can be explained by higher perceived switching costs by elderly consumers than by young consumers. Consequently, insurers have low incentives to act as quality-conscious purchasers of care for the elderly consumers. Therefore, strategies should be developed to increase the choice of insurer of elderly consumers.

TSG, 2008

ABSTRACT Risicoverevening is een noodzakelijke voorwaarde voor het goed functioneren van het zorg... more ABSTRACT Risicoverevening is een noodzakelijke voorwaarde voor het goed functioneren van het zorgstelsel. Uit eerder onderzoek is gebleken dat de risicoverevening in Nederland nog niet alle prikkels voor risicoselectie wegneemt. Het doel van voorliggend onderzoek is het evalueren van de risicovereveningsformule-2006 in Nederland. Voor dit onderzoek beschikken wij over een gegevensbestand waarin de resultaten van een gezondheidsenquête op individueel niveau zijn gekoppeld aan de schadegegevens uit de administratie van hun zorgverzekeraar. De conclusie is dat voor specifieke groepen verzekerden met een substantiële omvang (veelal meer dan 10% van de bevolking), ondanks het vereveningsysteem, forse voorspelbare verliezen (gemiddeld honderden euro’s per persoon per jaar) worden geleden. Deze subgroepen kunnen op eenvoudige wijze door de zorgverzekeraars worden onderscheiden. Zonder een wezenlijke verbetering van de risicoverevening kan het niet worden uitgesloten dat de beoogde effecten van de stelselwijziging, te weten verbetering van kwaliteit en doelmatigheid van de zorgverlening, niet zullen worden gerealiseerd. Dit rechtvaardigt een herbezinning op het overheidsstandpunt om de huidige ex-post compensaties in de risicoverevening snel af te bouwen.

Health policy (Amsterdam, Netherlands), Jan 29, 2014

Competitive health insurance markets will only enhance cost-containment, efficiency, quality, and... more Competitive health insurance markets will only enhance cost-containment, efficiency, quality, and consumer responsiveness if all consumers feel free to easily switch insurer. Consumers will switch insurer if their perceived switching benefits outweigh their perceived switching costs. We developed a conceptual framework with potential switching benefits and costs in competitive health insurance markets. Moreover, we used a questionnaire among Dutch consumers (1091 respondents) to empirically examine the relevance of the different switching benefits and costs in consumers' decision to (not) switch insurer. Price, insurers' service quality, insurers' contracted provider network, the benefits of supplementary insurance, and welcome gifts are potential switching benefits. Transaction costs, learning costs, 'benefit loss' costs, uncertainty costs, the costs of (not) switching provider, and sunk costs are potential switching costs. In 2013 most Dutch consumers switched ...

Health care management science, 2000

Under inadequate capitation formulae competing health insurers have an incentive for cream skimmi... more Under inadequate capitation formulae competing health insurers have an incentive for cream skimming, i.e., the selection of enrollees whom the insurer expects to be profitable. When evaluating different capitation formulae, previous studies used various indicators of incentives for cream skimming. These conventional indicators are based on all actual profits and losses or on all predictable profits and losses. For the latter type of indicators, this paper proposes, as a new approach, to ignore the small predictable profits and losses. We assume that this new approach provides a better indication of the size of the cream skimming problem than the conventional one, because an insurer has to take into account its costs of cream skimming and the (statistical) uncertainties about the net benefits of cream skimming. Both approaches are applied in theoretical and empirical analyses. The results show that, if our assumption is right, the problem of cream skimming is overestimated by the con...

Social science & medicine (1982), 1992

In many countries the concept of capitating health care insurers is receiving increasing attentio... more 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 1/5 of ...

Health Policy, 2015

OECD Health Data are a well-known source for detailed information about health expenditure. These... more OECD Health Data are a well-known source for detailed information about health expenditure. These data enable us to analyze health policy issues over time and in comparison with other countries. However, current official Belgian estimates of private expenditure (as published in the OECD Health Data) have proven not to be reliable. We distinguish four potential major sources of problems with estimating private health spending: interpretation of definitions, formulation of assumptions, missing or incomplete data and incorrect data. Using alternative sources of billing information, we have reached more accurate estimates of private and out-of-pocket expenditure. For Belgium we found differences of more than 100% between our estimates and the official Belgian estimates of private health expenditure (as published in the OECD Health Data). For instance, according to OECD Health Data private expenditure on hospitals in Belgium amounts to €3.1 billion, while according to our alternative calculations these expenses represent only €1.1 billion. Total private expenditure differs only 1%, but this is a mere coincidence. This exercise may be of interest to other OECD countries looking to improve their estimates of private expenditure on health.

SSRN Electronic Journal, 2000

The main objective ofrisk adjustment in systems ofregulated competition on healthinsurance market... more The main objective ofrisk adjustment in systems ofregulated competition on healthinsurance markets is the removal ofincentives f or undesirable risk selection.W e introduce a simple conceptual f ramework to clarif y how the definition of"acceptable costs"and the distinction between legitimate and illegitimate risk adjusters imply di cult ethical trade-o s between equity, avoidance ofundesirable risk selection and cost-e ectiveness. Focusing on the situation in Belgium, Germany, I srael, the Netherlands and Switzerland, we show how di erences in the importance attached to solidarity and in the belief s about market e ciency, have led to di erent decisions with respect to the definition ofthe basic benefits package, the choice ofrisk-adjusters, the possibilities ofmanaged care, the degree of consumer choice and the relative importance ofincome-related financing sources in the overall system.

This article considers the potential for insurer competition to improve health system performance... more This article considers the potential for insurer competition to improve health system performance by strengthening purchasing. Economic theory suggests that insurer competition will enhance efficiency if: (1) people have free choice of insurer, (2) competition is based on price and quality rather than risk selection and (3) insurers have tools to influence health care costs and quality. The article assesses the extent to which these assumptions hold in Belgium, Germany, the Netherlands and Switzerland. It finds that health insurance market reforms in these countries have had mixed results in fulfilling these assumptions. In spite of significant investment in risk equalisation, incentives for risk selection remain. Consumer mobility is lower among older and chronically ill people, possibly due to close interaction between statutory and voluntary coverage. Although insurers in some countries increasingly have tools to enhance value, they may not always use them. The analysis suggests that the instrumental value of insurer competition rests on multiple assumptions that can only be upheld through frequently complex interventions often requiring elusive data. Making it work therefore requires action on several fronts, particularly to ensure incentives are aligned across the health system, and awareness of the political nature of some barriers to success.

Social Science & Medicine, 1994

In 1988 the Dutch government launched a proposal for a national health insurance based on regulat... more 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.

Social Science & Medicine, 1994

Social Science & Medicine, 1998

AbstractÐRisk-adjusted capitation payments (RACPs) to competing health insurers are an essential ... more AbstractÐRisk-adjusted capitation payments (RACPs) to competing health insurers are an essential element of market-oriented health care reforms in many countries. RACPs based on demographic variables only are insucient, because they leave ample room for cream skimming. However, the implementation of improved RACPs does not appear to be straightforward. A solution might be to supplement imperfect RACPs with a form of mandatory pooling that reduces the incentives for cream skimming. In a previous paper it was concluded that high-risk pooling (HRP), is a promising supplement to RACPs. The purpose of this paper is to compare HRP with two other main variants of mandatory pooling. These variants are called excess-of-loss (EOL) and proportional pooling (PP). Each variant includes ex post compensations to insurers for some members which depend to various degrees on actually incurred costs. Therefore, these pooling variants reduce the incentives for cream skimming which are inherent in imperfect RACPs, but they also reduce the incentives for eciency and cost containment. As a rough measure of the latter incentives we use the percentage of total costs for which an insurer is at risk. This paper analyzes which of the three main pooling variants yields the greatest reduction of incentives for cream skimming given such a percentage. The results show that HRP is the most eective of the three pooling variants. #

Journal of Health Services Research & Policy, 2011

Health Affairs the Policy Journal of the Health Sphere, May 1, 2004

Health Affairs, 1994

Prologue: "Americans know too little about the implementation of market-reform strategies in othe... more Prologue: "Americans know too little about the implementation of market-reform strategies in other countries," says Alain Enthoven, whose work on managed competition has formed the underpinnings of the most recent health system reforms in the Netherlands. In fact, he continues, "the Dutch are further down the road to managed competition than we [Americans] are." In this paper four leading Dutch researchers bring the American policy audience up to date on how managed competition is being implemented in their country. What is critical to the sucess of reforms, both in the Netherlands and in the United States, are risk adjustment mechanisms to prevent cream skimming-that is, to prevent plans from selecting the best health risks and avoiding those predicted to cost more. In a health system bused on up-front capitation, health plans see it in their interest to attract persons whose costs will not exceed the amount paid to the plan for their care. Wynund van de

Health Policy, 2016

Germany, the Netherlands, and Switzerland have taken steps toward regulated competition on the he... more Germany, the Netherlands, and Switzerland have taken steps toward regulated competition on the health insurance market to enhance efficiency and consumer responsiveness. The rationale of giving the consumer a periodic choice of health insurer is that individual risk-bearing insurers are stimulated to effectively purchase and manage the care on behalf of their enrollees. For Europe this is largely a terra incognita, while the United States have at least fifty years of relevant experience. Twenty years ago the United States were confronted with a substantial backlash against managed care. Based on the US experience we come to the following lessons for Europe. First, the greatest backlash against managed care can be expected from the healthcare providers. Second, consumers are willing to give up to some extent their free choice of healthcare provider in return for a lower premium. Third, insurers should (be allowed to) offer consumers a choice between an insurance product with free choice of provider and lower-priced products with restricted reimbursement for non-contracted providers. Fourth, insurers should use input from consumers, provide them in a timely manner with relevant information about the (non-) contracted providers, and reassure consumers that in-network providers offer good quality care. Fifth, the development of national guidelines and quality indicators, with input from the medical profession, can increase the acceptance of managed care.

Health Econometrics and Data Group Working Papers, 2006

Many cou ntries are consid ering the option of red u cing the share of m and atory health insu ra... more Many cou ntries are consid ering the option of red u cing the share of m and atory health insu rance (MH I) and to increasingly rely on volu ntary (su pplementary) health insu rance (VH I) schem es to cover health care expend itu res. It is w ell-know n that com petitive m arkets for VH I tend to risk-rated prem iu m s. After d iscu ssing the d eterm inants of riskrating in com petitive VH I m arkets, w e provid e em pirical evid ence of the potential reduction of (risk-) solidarity caused by the transfer of benefits from MHI to VHI coverage.

Expert Review of Pharmacoeconomics Outcomes Research, Jun 1, 2013

The Netherlands relies on risk equalization to compensate competing health insurers for predictab... more The Netherlands relies on risk equalization to compensate competing health insurers for predictable variation in individual medical expenses. Without accurate risk equalization insurers are confronted with incentives for risk selection. The goal of this study is to evaluate the improvement in predictive accuracy of the Dutch risk equalization model since its introduction in 1993. Based on individual-level claims data (n = 15.6 million), we estimate the risk equalization models that have been successively applied in The Netherlands since 1993. Using individual-level survey data (n = 8735), we examine the average under-/ overcompensation by these models for several relevant subgroups in the population. We find that in the course of years, the risk equalization model has been substantially improved. Even the current model (2012), however, does not eliminate incentives for risk selection completely. To achieve the public objectives, further improvement of the Dutch risk equalization model is crucial.

Economisch Statistische Berichten, 2012

Health Economics, Policy and Law, 2015

All consumer groups with specific preferences must feel free to easily switch insurer in order to... more All consumer groups with specific preferences must feel free to easily switch insurer in order to discipline insurers to be responsive to consumers' heterogeneous preferences. This paper provides insight into the switching behaviour of low-risks (i.e. young or healthy consumers) and high-risks (i.e. elderly or unhealthy consumers) in the Netherlands in the period 2009-2012. We analysed: (1) administrative data with objective health status information (i.e. medically diagnosed diseases and pharmaceutical use) and information on health care expenses of nearly the entire Dutch population (n=15.3 million individuals) and (2) three-year sample data (n=1152 individuals). Our findings indicate that switching rates strongly decrease with age. For example, in 2009, consumers aged 25-44 switched 10 times more than consumers aged 75 or older. Another finding is that switching rates decrease as the predicted health care expenses increase. Although healthy consumers switch twice as much as unhealthy consumers, this difference becomes much smaller after adjusting for age. We conclude that our findings can be explained by higher perceived switching costs by elderly consumers than by young consumers. Consequently, insurers have low incentives to act as quality-conscious purchasers of care for the elderly consumers. Therefore, strategies should be developed to increase the choice of insurer of elderly consumers.

TSG, 2008

ABSTRACT Risicoverevening is een noodzakelijke voorwaarde voor het goed functioneren van het zorg... more ABSTRACT Risicoverevening is een noodzakelijke voorwaarde voor het goed functioneren van het zorgstelsel. Uit eerder onderzoek is gebleken dat de risicoverevening in Nederland nog niet alle prikkels voor risicoselectie wegneemt. Het doel van voorliggend onderzoek is het evalueren van de risicovereveningsformule-2006 in Nederland. Voor dit onderzoek beschikken wij over een gegevensbestand waarin de resultaten van een gezondheidsenquête op individueel niveau zijn gekoppeld aan de schadegegevens uit de administratie van hun zorgverzekeraar. De conclusie is dat voor specifieke groepen verzekerden met een substantiële omvang (veelal meer dan 10% van de bevolking), ondanks het vereveningsysteem, forse voorspelbare verliezen (gemiddeld honderden euro’s per persoon per jaar) worden geleden. Deze subgroepen kunnen op eenvoudige wijze door de zorgverzekeraars worden onderscheiden. Zonder een wezenlijke verbetering van de risicoverevening kan het niet worden uitgesloten dat de beoogde effecten van de stelselwijziging, te weten verbetering van kwaliteit en doelmatigheid van de zorgverlening, niet zullen worden gerealiseerd. Dit rechtvaardigt een herbezinning op het overheidsstandpunt om de huidige ex-post compensaties in de risicoverevening snel af te bouwen.

Health policy (Amsterdam, Netherlands), Jan 29, 2014

Competitive health insurance markets will only enhance cost-containment, efficiency, quality, and... more Competitive health insurance markets will only enhance cost-containment, efficiency, quality, and consumer responsiveness if all consumers feel free to easily switch insurer. Consumers will switch insurer if their perceived switching benefits outweigh their perceived switching costs. We developed a conceptual framework with potential switching benefits and costs in competitive health insurance markets. Moreover, we used a questionnaire among Dutch consumers (1091 respondents) to empirically examine the relevance of the different switching benefits and costs in consumers' decision to (not) switch insurer. Price, insurers' service quality, insurers' contracted provider network, the benefits of supplementary insurance, and welcome gifts are potential switching benefits. Transaction costs, learning costs, 'benefit loss' costs, uncertainty costs, the costs of (not) switching provider, and sunk costs are potential switching costs. In 2013 most Dutch consumers switched ...

Health care management science, 2000

Under inadequate capitation formulae competing health insurers have an incentive for cream skimmi... more Under inadequate capitation formulae competing health insurers have an incentive for cream skimming, i.e., the selection of enrollees whom the insurer expects to be profitable. When evaluating different capitation formulae, previous studies used various indicators of incentives for cream skimming. These conventional indicators are based on all actual profits and losses or on all predictable profits and losses. For the latter type of indicators, this paper proposes, as a new approach, to ignore the small predictable profits and losses. We assume that this new approach provides a better indication of the size of the cream skimming problem than the conventional one, because an insurer has to take into account its costs of cream skimming and the (statistical) uncertainties about the net benefits of cream skimming. Both approaches are applied in theoretical and empirical analyses. The results show that, if our assumption is right, the problem of cream skimming is overestimated by the con...

Social science & medicine (1982), 1992

In many countries the concept of capitating health care insurers is receiving increasing attentio... more 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 1/5 of ...

Health Policy, 2015

OECD Health Data are a well-known source for detailed information about health expenditure. These... more OECD Health Data are a well-known source for detailed information about health expenditure. These data enable us to analyze health policy issues over time and in comparison with other countries. However, current official Belgian estimates of private expenditure (as published in the OECD Health Data) have proven not to be reliable. We distinguish four potential major sources of problems with estimating private health spending: interpretation of definitions, formulation of assumptions, missing or incomplete data and incorrect data. Using alternative sources of billing information, we have reached more accurate estimates of private and out-of-pocket expenditure. For Belgium we found differences of more than 100% between our estimates and the official Belgian estimates of private health expenditure (as published in the OECD Health Data). For instance, according to OECD Health Data private expenditure on hospitals in Belgium amounts to €3.1 billion, while according to our alternative calculations these expenses represent only €1.1 billion. Total private expenditure differs only 1%, but this is a mere coincidence. This exercise may be of interest to other OECD countries looking to improve their estimates of private expenditure on health.

SSRN Electronic Journal, 2000

The main objective ofrisk adjustment in systems ofregulated competition on healthinsurance market... more The main objective ofrisk adjustment in systems ofregulated competition on healthinsurance markets is the removal ofincentives f or undesirable risk selection.W e introduce a simple conceptual f ramework to clarif y how the definition of"acceptable costs"and the distinction between legitimate and illegitimate risk adjusters imply di cult ethical trade-o s between equity, avoidance ofundesirable risk selection and cost-e ectiveness. Focusing on the situation in Belgium, Germany, I srael, the Netherlands and Switzerland, we show how di erences in the importance attached to solidarity and in the belief s about market e ciency, have led to di erent decisions with respect to the definition ofthe basic benefits package, the choice ofrisk-adjusters, the possibilities ofmanaged care, the degree of consumer choice and the relative importance ofincome-related financing sources in the overall system.

This article considers the potential for insurer competition to improve health system performance... more This article considers the potential for insurer competition to improve health system performance by strengthening purchasing. Economic theory suggests that insurer competition will enhance efficiency if: (1) people have free choice of insurer, (2) competition is based on price and quality rather than risk selection and (3) insurers have tools to influence health care costs and quality. The article assesses the extent to which these assumptions hold in Belgium, Germany, the Netherlands and Switzerland. It finds that health insurance market reforms in these countries have had mixed results in fulfilling these assumptions. In spite of significant investment in risk equalisation, incentives for risk selection remain. Consumer mobility is lower among older and chronically ill people, possibly due to close interaction between statutory and voluntary coverage. Although insurers in some countries increasingly have tools to enhance value, they may not always use them. The analysis suggests that the instrumental value of insurer competition rests on multiple assumptions that can only be upheld through frequently complex interventions often requiring elusive data. Making it work therefore requires action on several fronts, particularly to ensure incentives are aligned across the health system, and awareness of the political nature of some barriers to success.

Social Science & Medicine, 1994

In 1988 the Dutch government launched a proposal for a national health insurance based on regulat... more 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.

Social Science & Medicine, 1994

Social Science & Medicine, 1998

AbstractÐRisk-adjusted capitation payments (RACPs) to competing health insurers are an essential ... more AbstractÐRisk-adjusted capitation payments (RACPs) to competing health insurers are an essential element of market-oriented health care reforms in many countries. RACPs based on demographic variables only are insucient, because they leave ample room for cream skimming. However, the implementation of improved RACPs does not appear to be straightforward. A solution might be to supplement imperfect RACPs with a form of mandatory pooling that reduces the incentives for cream skimming. In a previous paper it was concluded that high-risk pooling (HRP), is a promising supplement to RACPs. The purpose of this paper is to compare HRP with two other main variants of mandatory pooling. These variants are called excess-of-loss (EOL) and proportional pooling (PP). Each variant includes ex post compensations to insurers for some members which depend to various degrees on actually incurred costs. Therefore, these pooling variants reduce the incentives for cream skimming which are inherent in imperfect RACPs, but they also reduce the incentives for eciency and cost containment. As a rough measure of the latter incentives we use the percentage of total costs for which an insurer is at risk. This paper analyzes which of the three main pooling variants yields the greatest reduction of incentives for cream skimming given such a percentage. The results show that HRP is the most eective of the three pooling variants. #

Journal of Health Services Research & Policy, 2011