ABSTRACT
Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.
Subject(s)
General Practice/economics , Health Services Needs and Demand/economics , Health Services/economics , Practice Patterns, Physicians'/economics , Reimbursement Mechanisms/ethics , Adolescent , Adult , Age Distribution , Aged , Cost Sharing/economics , Cost Sharing/ethics , Cost Sharing/trends , General Practice/ethics , General Practice/trends , Health Services/ethics , Health Services/statistics & numerical data , Health Services/trends , Health Services Needs and Demand/ethics , Humans , Managed Competition/ethics , Managed Competition/trends , Middle Aged , Models, Econometric , Netherlands , Poisson Distribution , Practice Patterns, Physicians'/ethics , Practice Patterns, Physicians'/trends , Reimbursement Mechanisms/trends , Social Security/economics , Social Security/ethics , Young AdultSubject(s)
Ethics, Clinical , Managed Competition/organization & administration , Principle-Based Ethics , Quality of Health Care , Resource Allocation/ethics , Capitalism , Efficiency, Organizational , Health Care Costs/trends , Health Care Sector , Humans , Managed Competition/ethics , Models, Organizational , Physician-Patient Relations/ethics , Resource Allocation/economics , Resource Allocation/organization & administration , Social Responsibility , United StatesABSTRACT
Market-oriented strategies, embodied in managed competition, have become the primary focus of contemporary U.S. health policy. This dominance reflects the emergence of a bipartisan coalition of support among political elites. This study traces the historical evolution of elite support for the market and suggests that the consensus favoring managed competition is deceptively fragile, with support riven by cleavages in the values used to judge fairness in the allocation of medical care. A unique data set of matched questions asked of both policy elites and the general public is used to document these differences in ethical norms. The implications of these cleavages help to explain three puzzling aspects of contemporary U.S. health policy: (1) the persisting inability to translate the principles of managed competition into politically feasible reforms, (2) the repeated failures to implement demonstration projects intended to test competitive pricing within the Medicare program, and (3) the inability of state regulations to assuage the public's concerns about managed care. Some prescriptions for a more revealing and effective treatment of market reforms in health policy conclude this study.
