Hans Maarse

The Privatization of Health Care in Europe: An Eight-Country Analysis

This article presents an analysis of recent changes in the public-private mix in health care in eight European countries. The leading question is to what extent a process of privatization in health care can be observed. The framework for the analysis of privatization draws on the idea that there are multiple public/private boundaries in health care. The overall picture that emerges from our analysis is diverse, but there is evidence that health care in Europe has become somewhat more private. The growth of the public fraction in health care spending has come to an end since the 1980s, and in a few countries the private fraction even increased substantially. We also found some evidence for a shift from public to private in health care provision. Furthermore, there are signs of privatization in health care management and operations, as well as investments. Specific attention is spent on the identification of factors that push privatization forward and factors that work as a barrier to privatization.

Has Solidarity Survived? A Comparative Analysis of the Effect of Social Health Insurance Reform in Four European Countries

Social health insurance reform has evolved as an important public policy issue in several European countries. Some of the most important reform programs have been the introduction of managed competition, a shift from full retrospective reimbursement of health insurers to prospective reimbursement, an increase of private payments, and a change in the health benefits of social health insurance. The article investigates the widespread assumption that reform programs have adverse effects on solidarity in social health insurance by looking at the concrete experience of four European countries (Belgium, Germany, the Netherlands, and Switzerland) over the past decade. A distinction is made between risk solidarity and income solidarity, and the scope of solidarity is shown to have two dimensions: entitlements and membership. The analysis consists of three parts: description of the structure of health insurance of each of the four countries in the early 1990s; discussion of health insurance reform; determination of the impact on each dimension of solidarity. The findings are mixed. There are indeed some examples of solidarity having declined as the result of health insurance reform. But, more important, many examples also were found of an increase in solidarity due to health insurance reform. In some cases, reform was explicitly intended to improve solidarity. If a reform program had a negative impact on solidarity (e.g., an increase in private payments), accompanying measures often were taken to keep solidarity intact as much as possible. Thus the assumption of a negative impact as a result of health insurance reform is not confirmed.

Purchasing health services abroad: practices of cross-border contracting and patient mobility in six European countries.

OBJECTIVES Contracting health services outside the public, statutory health system entails purchasing capacity from domestic non-public providers or from providers abroad. Over the last decade, these practices have made their way into European health systems, brought about by performance-oriented reforms and EU principles of free movement. The aim of the article is to explain the development, functioning, purposes and possible implications of cross-border contracting. METHODS Primary and secondary sources on purchasing from providers abroad have been collected in a systematic way and analysed in a structured frame. RESULTS We found practices in six European countries. The findings suggest that purchasers from benefit-in-kind systems contract capacity abroad when this responds to unmet demand; pressures domestic providers; and/or offers financial advantages, especially where statutory purchasers compete. Providers which receive patients tend to be located in countries where treatment costs are lower and/or where providers compete. The modalities of purchasing and delivering care abroad vary considerably depending on contracts being centralised or direct, the involvement of middlemen, funding and pricing mechanisms, cross-border pathways and volumes of patient flows. CONCLUSIONS The arrangements and concepts which cross-border contracting relies on suggest that statutory health purchasers, under pressure to deliver value for money and striving for cost-efficiency, experiment with new ways of organising health services for their populations.

How do patient characteristics influence informal payments for inpatient and outpatient health care in Albania: Results of logit and OLS models using Albanian LSMS 2005

BackgroundInformal payments for health care are common in most former communist countries. This paper explores the demand side of these payments in Albania. By using data from the Living Standard Measurement Survey 2005 we control for individual determinants of informal payments in inpatient and outpatient health care. We use these results to explain the main factors contributing to the occurrence and extent of informal payments in Albania.MethodsUsing multivariate methods (logit and OLS) we test three models to explain informal payments: the cultural, economic and governance model. The results of logit models are presented here as odds ratios (OR) and results from OLS models as regression coefficients (RC).ResultsOur findings suggest differences in determinants of informal payments in inpatient and outpatient care. Generally our results show that informal payments are dependent on certain characteristics of patients, including age, area of residence, education, health status and health insurance. However, they are less dependent on income, suggesting homogeneity of payments across income categories.ConclusionsWe have found more evidence for the validity of governance and economic models than for the cultural model.

Consumer Choice in Dutch Health Insurance after Reform

This article investigates the scope and effects of enhanced consumer choice in health insurance that is presented as a cornerstone of the new health insurance legislation in the Netherlands that will come into effect in 2006. The choice for choice marks the current libertarian trend in Dutch health care policymaking. One of our conclusions is that the scope of enhanced choice should not be overstated due to many legal and non-legal restrictions to it. The consumer choice advocates have great expectations of the impact of enhanced choice. A critical analysis of its impact demonstrates that these expectations may not become true and that enhanced consumer choice should not be perceived as the ‘magic bullet’ for many problems in health care.

Policy Making on Data Exclusivity in the European Union: From Industrial Interests to Legal Realities

After lengthening the duration of patents to twenty years in 1984, the pharmaceutical industry has turned to data exclusivity as a major vehicle for extending market protection, even after patents expire. Such protections give companies the power to tax consumers for innovation by charging above-market prices. This article draws upon unique information to describe how key actors lengthened data exclusivity for patented drugs to postpone generic competition in the European Union (EU) just before ten new members joined it. We explore the political route and the interests of different actors to understand the process by which industrial interests are translated into legal realities in the worlds largest harmonized market. Several factors influenced the outcome, including the role of the pharmaceutical unit of the Directorate General for Enterprise of the European Commission in promoting the interests of the innovative branch of the industry, the time pressure to find a viable compromise before EU enlargement, and the heterogeneous preferences of the other actors. The case illustrates the inherent tension between the desire of both health care administrators and patients for high-quality, low-cost medicines and the objective of the innovator pharmaceutical industry to find and approve new drugs that are price protected and sell them in a way that maximizes revenues.

A public-private analysis of the new Dutch health insurance system.

The 1 January 2006 will go down in history as a date that marked a significant change in Dutch health insurance. After many years of political debate and several failed attempts to implement a major re form?lastly in the early 1990s?the government mo bilised a parliamentary majority for its plan to implement a fundamental reconstruction of health insurance [1]. The new legislation (Zorgverzekerings wet) puts an end to the traditional dividing line be tween the statutory sickness fund scheme (Ziekenfondswet) that covered about 63% of the pop ulation and private health insurance, covering the remaining 37%. A single mandatory scheme covering the entire population replaces the dual arrangement that has been a characteristic element of health care financing in the Netherlands since the Second World War [2]. A second cornerstone of the new health insurance

Results of the market-oriented reform in the Netherlands: a review

The market-oriented reform in the Dutch health care system is now in its 10th year. This article offers a concise overview of some of its effects thus far on health insurance, healthcare purchasing and healthcare provision. Furthermore, attention is given to its impact on healthcare expenditures, power and trust relationships as well as the relationship between the Minister of Health and the Dutch Healthcare Authority. The reform triggered various alterations in Dutch health care some occurring quickly (e.g. health insurance), others taking longer (e.g. purchasing). These developments suggest a process of gradual transformation. The reform has instigated controversy which is increasingly framed as a power conflict between insurers and providers. Weakened consumer trust in insurers threatens the legitimacy of the reform. The relationship between Minister and Healthcare Authority appears to be more intimate than the formal independent status of this regulatory agency would suggest.

The politics of health-care reform in the Netherlands since 2006

This article comments on Schut and van de Vens overview of the results of purchaser competition in Dutch health care, which concludes that the glass can be seen as half full or half empty. Although it is true that results have been achieved, we believe that the evidence is incomplete and in some respects flimsy. More importantly, however, Schut and van de Ven neglect the political context of the market reform introduced in 2006. The reform is far from finished and there has been a constant need for political compromise. Optimism about the markets potential also seems to be on the wane. Several insurer and provider initiatives have provoked political resistance. As a result, there are good reasons to argue that the reforms future is uncertain.

A Comparative Study of Dementia Care in England and the Netherlands Using Neo-Institutionalist Perspectives

In this article, the authors compare dementia care in England and the Netherlands. They used qualitative methods to explore recommended standards of service provision and perceived achievements in mainstream care. They found some similarities in recommended standards and in major shortcomings in mainstream services: notably, weaknesses of generic services in supporting patients and carers, and failure to achieve integrated care. Priorities regarding service provision differed. Whereas in England, a social model of care was used to encourage empowerment of both the person with dementia and the carer, Dutch care professionals focused more on “warm care concepts” and on support of the carer rather than the patient. The balance between community care and institutional care also differed. The authors used neo-institutionalist concepts to explore these similarities and differences as embedded in the (historically developed) structural and cultural contexts of the respective health and social care systems.