Week 1 Bohm framework
National Health Service system: State – state – state (UK, Nordic countries, Iberian countries)
- reflects social democratic values of universal coverage, equal access to services and beliefs in
the efficiency of public services
National Health Insurance systems: State – state – private (Four Anglo Saxon countries)
- the fundamental health reforms were implemented by centrist or conservative parties which
generally adhere to the idea that public services are prone to inefficiency.
Social Health Insurance systems: Societal- societal – private (Four German speaking countries)
- private for-profit providers
Private Health systems: Private – private - private (USA)
- system-specific deficiency to provide affordable access to healthcare for the elderly,
chronically ill, and the poor
Etatist Social Health Insurance: State – societal – private (Netherlands, Belgium, France)
Week 1 Health reform outcome
- Competition and Market Structure: Although competition was introduced, the healthcare
market remained heavily concentrated. By 2023, four large insurers controlled 84% of the
market. Despite the intention to foster competition, selective contracting between insurers and
providers often faced barriers like regional limitations and providers’ market power.
- Healthcare Expenditures and Financial Risks: Reforms managed to slow down healthcare cost
growth since 2013 by introducing a collective spending agreement between the government
and stakeholders. However, it is noted that insurers and providers continue to focus more on
cost control than improving quality.
- Provision of Care: The number of hospitals decreased by 27% since 2000, and Independent
Treatment Centers (ITCs) increased significantly, taking on more specialized, high-volume
interventions. However, hospitals still dominated, holding around 96% of the total spending
on specialist care.
- Administrative Costs: Administrative costs remained a challenge despite the integration of
different insurance schemes. This was attributed to the complex nature of the regulated
competition, heavy reliance on protocols, and the multitude of oversight and procurement
procedures.
- Institutional Trust: Public trust in insurers remained low, contrasting with the relatively high
trust in healthcare providers. This lack of trust posed a systemic risk and fueled ongoing
political debate about the role of competition in healthcare.
, Week 2 Purchasing tools
1. Clinical guidelines/protocols: These are evidence-based recommendations on how
care should be provided for specific conditions or procedures. They can help ensure
care is effective and consistent.
2. Disease management programmes: Structured interventions designed to manage
specific chronic diseases, improving outcomes and controlling costs.
3. Financial incentives for patients to use preferred providers: Patients might pay
less out-of-pocket when they use providers that the insurer has designated as
"preferred" due to cost, quality, or other factors.
4. Formularies for medicines: Lists of medications that are covered by the insurer.
They can be used to guide prescribing and promote the use of cost-effective drugs.
5. Incentives for rational prescribing/dispensing of medicines: These can include
discounts, rebates, or other incentives to encourage patients and providers to use
cost-effective medicines.
6. Performance-based payment of providers: Payments to providers are tied to their
performance on certain quality or efficiency metrics.
7. Price negotiation: Insurers negotiate prices with providers. This can be for specific
services, procedures, or overall care.
8. Public disclosure of performance indicators: Making performance data public can
incentivize providers to improve and help patients make informed choices.
9. Selective contracting: Insurers select certain providers to be in their network based
on quality, cost, and other factors. Patients typically pay less when they use these
providers.
10. Utilisation review: A process that evaluates the necessity, appropriateness, and
efficiency of healthcare services.
11. Vertical insurer-provider integration: This refers to the merging or close affiliation
of insurers and providers.
12. Waiting list management: Tools or strategies used to manage and prioritize patients
waiting for certain services or procedures.
Based on the article of Thomson et al., please explain why the uptake of the following three
purchasing tools ‘development of disease management programmes’, ‘purchaser-provider integration’
and ‘price negotiation’ is often still limited: Disease Management Programmes. Limited by patient
choice restrictions such as GP gatekeeping system. Purchaser-provider integration: legal restrictions to
encourage competition (anti-trust rules). Price negotiation. Lack of purchaser information on costs
(and quality)
Selective contracting. Example: buying all knee surgeries from one of two possible hospitals
- Useful because it triggers competition which drives higher quality.
- Not useful because there is scarce capacity so insurers actually do not have providers to select
Financial incentives. Example: Pay for performance contract
- Useful because it financially rewards better quality and cost-effective care delivery
- Not useful because providers can game around the incentive reward system
Clinical guidelines. Example: Agreeing on a new guideline on COPD care
- Useful because it supports and pushes care providers to deliver care according the most recent
evidence base, leading to best possible quality.
- Not useful because care for individual patients is hard to control in guidelines. Providers do
not appreciate top-down prescription of guidelines by purchasers
Waiting list management. Example: making sure a patient is helped earlier at Ommelander hospital,
which has a shorter WT than Martini
- Provides patients with timely care, reducing unnecessary waiting time which prevents
worsening of a disease, thereby improving outcomes.
- Not useful because purchasers do not have the right insights into and knowledge of which
provider is best for a patient in which situation
National Health Service system: State – state – state (UK, Nordic countries, Iberian countries)
- reflects social democratic values of universal coverage, equal access to services and beliefs in
the efficiency of public services
National Health Insurance systems: State – state – private (Four Anglo Saxon countries)
- the fundamental health reforms were implemented by centrist or conservative parties which
generally adhere to the idea that public services are prone to inefficiency.
Social Health Insurance systems: Societal- societal – private (Four German speaking countries)
- private for-profit providers
Private Health systems: Private – private - private (USA)
- system-specific deficiency to provide affordable access to healthcare for the elderly,
chronically ill, and the poor
Etatist Social Health Insurance: State – societal – private (Netherlands, Belgium, France)
Week 1 Health reform outcome
- Competition and Market Structure: Although competition was introduced, the healthcare
market remained heavily concentrated. By 2023, four large insurers controlled 84% of the
market. Despite the intention to foster competition, selective contracting between insurers and
providers often faced barriers like regional limitations and providers’ market power.
- Healthcare Expenditures and Financial Risks: Reforms managed to slow down healthcare cost
growth since 2013 by introducing a collective spending agreement between the government
and stakeholders. However, it is noted that insurers and providers continue to focus more on
cost control than improving quality.
- Provision of Care: The number of hospitals decreased by 27% since 2000, and Independent
Treatment Centers (ITCs) increased significantly, taking on more specialized, high-volume
interventions. However, hospitals still dominated, holding around 96% of the total spending
on specialist care.
- Administrative Costs: Administrative costs remained a challenge despite the integration of
different insurance schemes. This was attributed to the complex nature of the regulated
competition, heavy reliance on protocols, and the multitude of oversight and procurement
procedures.
- Institutional Trust: Public trust in insurers remained low, contrasting with the relatively high
trust in healthcare providers. This lack of trust posed a systemic risk and fueled ongoing
political debate about the role of competition in healthcare.
, Week 2 Purchasing tools
1. Clinical guidelines/protocols: These are evidence-based recommendations on how
care should be provided for specific conditions or procedures. They can help ensure
care is effective and consistent.
2. Disease management programmes: Structured interventions designed to manage
specific chronic diseases, improving outcomes and controlling costs.
3. Financial incentives for patients to use preferred providers: Patients might pay
less out-of-pocket when they use providers that the insurer has designated as
"preferred" due to cost, quality, or other factors.
4. Formularies for medicines: Lists of medications that are covered by the insurer.
They can be used to guide prescribing and promote the use of cost-effective drugs.
5. Incentives for rational prescribing/dispensing of medicines: These can include
discounts, rebates, or other incentives to encourage patients and providers to use
cost-effective medicines.
6. Performance-based payment of providers: Payments to providers are tied to their
performance on certain quality or efficiency metrics.
7. Price negotiation: Insurers negotiate prices with providers. This can be for specific
services, procedures, or overall care.
8. Public disclosure of performance indicators: Making performance data public can
incentivize providers to improve and help patients make informed choices.
9. Selective contracting: Insurers select certain providers to be in their network based
on quality, cost, and other factors. Patients typically pay less when they use these
providers.
10. Utilisation review: A process that evaluates the necessity, appropriateness, and
efficiency of healthcare services.
11. Vertical insurer-provider integration: This refers to the merging or close affiliation
of insurers and providers.
12. Waiting list management: Tools or strategies used to manage and prioritize patients
waiting for certain services or procedures.
Based on the article of Thomson et al., please explain why the uptake of the following three
purchasing tools ‘development of disease management programmes’, ‘purchaser-provider integration’
and ‘price negotiation’ is often still limited: Disease Management Programmes. Limited by patient
choice restrictions such as GP gatekeeping system. Purchaser-provider integration: legal restrictions to
encourage competition (anti-trust rules). Price negotiation. Lack of purchaser information on costs
(and quality)
Selective contracting. Example: buying all knee surgeries from one of two possible hospitals
- Useful because it triggers competition which drives higher quality.
- Not useful because there is scarce capacity so insurers actually do not have providers to select
Financial incentives. Example: Pay for performance contract
- Useful because it financially rewards better quality and cost-effective care delivery
- Not useful because providers can game around the incentive reward system
Clinical guidelines. Example: Agreeing on a new guideline on COPD care
- Useful because it supports and pushes care providers to deliver care according the most recent
evidence base, leading to best possible quality.
- Not useful because care for individual patients is hard to control in guidelines. Providers do
not appreciate top-down prescription of guidelines by purchasers
Waiting list management. Example: making sure a patient is helped earlier at Ommelander hospital,
which has a shorter WT than Martini
- Provides patients with timely care, reducing unnecessary waiting time which prevents
worsening of a disease, thereby improving outcomes.
- Not useful because purchasers do not have the right insights into and knowledge of which
provider is best for a patient in which situation
