Overview

In January 2006, the Dutch embarked upon a reform of their health care system based upon the principles of regulated competition with more freedom of choice and risk-bearing health insurers with opportunities for free purchasing and liberalization of investments by institutions. Goals of this health reform were better accessibility, lower costs, more quality and maximum solidarity. This unique path of the Netherlands attracted a lot of interest worldwide.

Have these goals been met after fifteen years? Dutch authors, professor Patrick Jeurissen, Radboudumc in Nijmegen, and professor Hans Maarse, Maastricht University, present their analysis in the book ‘The market reform in Dutch health care: Results, lessons and prospects' that will be published on 8 December 2021. In general they note that in certain areas the gap between theory and practice is large. Institutions compete less heavily than politically-inspired images suggest and under the flag of contract prices and ceiling agreements this led de facto to a new budget system in parts of healthcare. Mutual market shares between healthcare providers are shifting but by little.

Since 2012, health care spending has slowed down, relative to the period started and also relative to the US and surrounding countries. Since that year, insurers also have become more risk-bearing and compete with each other for a low health care premium, aided by covenants in which parties are mutually bound to realize less money for care.

Health care procurement focuses primarily on controlling financial frameworks. A decrease in growth in volume of care has been realized and now and then we see waiting lists. Despite the fact that there is room to diminish inappropriate care, the volume of care will have to increase over time with an aging Dutch population.

Since 2012, the annual budget overruns have turned into underspending, especially in home care, pharmaceuticals, mental, and primary health care. In this light, it is remarkable that precisely these sectors are the ones that should give shape to the mantra of 'right-care-in-the-right-place' that many professed.

Market forces also stimulated new health care provisions like independent treatment centers, outpatient clinics and room for new care models, such as networks. However, scaling up good examples is often difficult. There is no evidence that 'market forces' have worsened the quality of care, although quality was not improved as intended. Mandatory out-of-pocket payments are among the lowest in Europe.

As a result of 15 years of 'market forces' differences, however, they have become bigger. There are more ‘rich’ and more ‘poor’ institutions; the difference between expensive and cheap policies is increasing; and more and more policyholders are opting for a voluntary deductible and a cheaper budget policy. The practice variation in care provision remains persistently high and hospitals continue to offer the entire spectrum of care.

The administrative organization of the system is complex and not always clear. The administrative and regulatory burdens are high, indeed higher than in many other countries. Professionals are increasingly confronted with this.

A new large-scale reform however is not desirable. For that, the unique experiment of regulated ‘market forces’ over the past fifteen years has belied pessimistic forecasts too many times. On the other hand, COVID has now made it crystal clear that parts of health care do not seem well prepared for such a crisis. The government had to put large parts of regulated market forces out of action, for example, we cannot expect an expansion of IC capacity from the market. The government must regulate this.

Another major and topical issue is whether, and if so, how, the historically low budgetary growth of the past decade can be continued? This requires a care-related transformation. Such a transformation should broadly focus on effective care for people with multiple disorders, choices in expensive facilities for top specialist care and fewer administrative burdens for healthcare professionals.