1. 1 Managed competition in health care in the Netherlands The displacement of public responsibility Romke van der Veen

2. 2 Changes in health care Universal and comprehensive health insurance Introduction of market-principles in health- insurance and health provision Goals of managed care: –cost control –maintenance of quality –less central steering

3. 3 Transformation of the Welfare State From public to private provision From protection to promoting participation From universality to selectivity From citizenship to membership

4. 4 …. in Health Care System still collective and solidaristic: –Insurance obligation –Allowance –Risk equalisation Market limited: –Basic package (90%) –Acceptance obligation –Care obligation (in kind/reimbursement)

5. 5 From public bureaucracy to public management From hierarchy to freedom for managers From state to market From rules to incentives From normconformity to output/results

6. 6 …. in Health Care Private insurance companies Insurance –nominal premium –no-claim –supplementary insurance Heath care provision –competition (between care providers) –contracts (providers-insurers)

7. 7 3 domains, 3 logics Economic domain – logic of the market Public domain – logic of the state: rules and solidarity Professional domain – professional logic: knowledge and cooperation

8. 8 Conditions of managed care

9. 9 Field/actor:Systemrationality:Conditional: Insurance-market and Care provision market (1) Homogeneity Transparency Atomistic Competion Information (=Transparency) Care provision market (2)CooperationProfesionalism Insurance company and Care provider (1) Economic actorCompetition Management Transparency Care provider (2)Cooperation Care Professionalism ProfessionalCareProfessionalism Citizen (1) Citizen (2) Economic actor Patient Competition Transparency (Professional) trust

10. 10 Systemlogic requires Competition Transparency Professionalism Management

11. 11 Competition Market –scarcity; local dominance; market contraction Insurer-provider: no managed care In kind/reimbursement: –no in kind --- no managed care Professionals: –make no distinction in treatment –functioning in chain hinders competition

12. 12 Transparency Costly and complex Not all actors interested in transparency –conflicts with competition –conflicts with professional autonomy Gathering information can produce unwanted and unintended consequences

13. 13 Professionalism Contradictory forces working on professionals? Dominance of one of the three: –overconsumption –low quality –low cooperation Dominance of professional? Risk of decoupling

14. 14 Management Taylorisation No machine bureaucracy, difficult to standardize Manager highly dependent Management = managing conflicting interests

15. Displacement of public responsibility Privatization –of risks: decollectivization –of administration Decentralization –of regulatory and administrative respoinsibility Europeanization –upward displacement 15