Judith de Jong

The Dutch health insurance reform: switching between insurers, a comparison between the general population and the chronically ill and disabled

BackgroundOn 1 January 2006 a number of far-reaching changes in the Dutch health insurance system came into effect. In the new system of managed competition consumer mobility plays an important role. Consumers are free to change their insurer and insurance plan every year. The idea is that consumers who are not satisfied with the premium or quality of care provided will opt for a different insurer. This would force insurers to strive for good prices and quality of care. Internationally, the Dutch changes are under the attention of both policy makers and researchers. Questions answered in this article relate to switching behaviour, reasons for switching, and differences between population categories.MethodsPostal questionnaires were sent to 1516 members of the Dutch Health Care Consumer Panel and to 3757 members of the National Panel of the Chronically ill and Disabled (NPCD) in April 2006. The questionnaire was returned by 1198 members of the Consumer Panel (response 79%) and by 3211 members of the NPCD (response 86%). Among other things, questions were asked about choices for a health insurer and insurance plan and the reasons for this choice.ResultsYoung and healthy people switch insurer more often than elderly or people in bad health. The chronically ill and disabled do not switch less often than the general population when both populations are comparable on age, sex and education.For the general population, premium is more important than content, while the chronically ill and disabled value content of the insurance package as well. However, quality of care is not important for either group as a reason for switching.ConclusionThere is increased mobility in the new system for both the general population and the chronically ill and disabled. This however is not based on quality of care. If reasons for switching are unrelated to the quality of care, it is hard to believe that switching influences the quality of care. As yet there are no signs of barriers to switch insurer for the chronically ill and disabled. This however could change in the future and it is therefore important to monitor changes.

Patient Activation and Health Literacy as Predictors of Health Information Use in a General Sample of Dutch Health Care Consumers

In demand-led health care systems, consumers are expected to play an informed, active role in health care decisions by making use of health information. The ability to seek and use this information depends on specific knowledge, skills, and self-confidence. In this study, the authors validated a translated instrument to measure patient activation (Dutch PAM-13) in a general sample of Dutch health care consumers. Furthermore, the authors examined the relative contribution of patient activation and functional health literacy to the seeking and use of health information in The Netherlands. The mean patient activation score in the Dutch sample was higher for younger health care consumers and for those with a higher education, higher income, and better self-reported general and mental health status. More activated consumers were more likely to seek and use health information. Patient activation proved to be a stronger predictor for seeking and using health information than functional health literacy.

The relative effect of health literacy and patient activation on provider choice in the Netherlands

Active provider choice by patients has become an important policy theme in western, countries over the last decades. However, not many patients and consumers exercise their right to, choose. Both health literacy and patient activation are likely to have an impact on the choice process. In, this article the relative effect of health literacy and patient activation on provider choice in the, Netherlands is studied. A questionnaire was sent to a representative sample of 2000 Dutch citizens. The questionnaire, included a measure of functional health literacy, the Dutch version of the Patient Activation Measure, and questions assessing active provider choice, reasons not to engage in it and other ways of provider, selection. The majority of respondents (59.6%) would not search for information on the basis of which they, could select the best provider or hospital. Most people rely on their general practitioners advice. Both, low literacy and lower patient activation levels were negatively associated with active provider choice. In a regression analysis gender, education and patient activation proved the most important, predictors. The policy focus on active provider choice might result in inequity, with men, less educated, and less activated people being at a disadvantage.

The intention to switch health insurer and actual switching behaviour: are there differences between groups of people?

Background  Several western countries have introduced managed competition in their health care system. In the Netherlands, a new health insurance law was introduced in January 2006 making it easier to switch health insurer each year.

Do guidelines create uniformity in medical practice

This article aimed to test the general hypothesis that guidelines create uniformity, or reduce variation, in medical practice. Medical practice variation has policy interest and is one of the reasons for developing guidelines. The development and implementation of guidelines was considered in the broader context of processes of rationalization. We focused on the influence of voluntary guidelines developed by the professional organization for family physicians in the Netherlands on variation in drug prescription. Data were used from the First and Second Dutch National Survey of General Practice (DNSGP1 and DNSGP2), collected in 1987 and 2001 respectively. DNSGP1 consisted of 103 practices and 161 GPs serving 335.000 patients. DNSGP2 consisted of 104 practices and 195 GPs serving 390.000 patients. Two groups of diagnoses were created, one containing all diagnoses for which guidelines were introduced and one containing all other diagnoses. For both groups a measure of concentration, Herfindahl-Hirschman Index (HHI), was used to represent variation. This measure of concentration was compared between both groups using multilevel analysis. Results showed that although there was an overall increase in variation (a significantly lower HHI) in prescription, the increase was less in the cases of diagnoses for which guidelines were introduced. Guidelines, primarily, had an effect on variations in single-handed practices. The overall conclusion is that the introduction of guidelines, although it probably tempered the increase in variation, did not reduce variation.

Understanding and using comparative healthcare information; the effect of the amount of information and consumer characteristics and skills

BackgroundConsumers are increasingly exposed to comparative healthcare information (information about the quality of different healthcare providers). Partly because of its complexity, the use of this information has been limited. The objective of this study was to examine how the amount of presented information influences the comprehension and use of comparative healthcare information when important consumer characteristics and skills are taken into account.MethodsIn this randomized controlled experiment, comparative information on total hip or knee surgery was used as a test case. An online survey was distributed among 800 members of the NIVEL Insurants Panel and 76 hip- or knee surgery patients. Participants were assigned to one of four subgroups, who were shown 3, 7, 11 or 15 quality aspects of three hospitals. We conducted Kruskall-Wallis tests, Chi-square tests and hierarchical multiple linear regression analyses to examine relationships between the amount of information and consumer characteristics and skills (literacy, numeracy, active choice behaviour) on one hand, and outcome measures related to effectively using information (comprehension, perceived usefulness of information, hospital choice, ease of making a choice) on the other hand.Results414 people (47%) participated. Regression analysis showed that the amount of information slightly influenced the comprehension and the perceived usefulness of comparative healthcare information. It did not affect consumers’ hospital choice and ease of making this choice. Consumer characteristics (especially age) and skills (especially literacy) were the most important factors affecting the comprehension of information and the ease of making a hospital choice. For the perceived usefulness of comparative information, active choice behaviour was the most influencing factor.ConclusionThe effects of the amount of information were not unambiguous. It remains unclear what the ideal amount of quality information to be presented would be. Reducing the amount of information will probably not automatically result in more effective use of comparative healthcare information by consumers. More important, consumer characteristics and skills appeared to be more influential factors contributing to information comprehension and use. Consequently, we would suggest that more emphasis on improving consumers’ skills is needed to enhance the use of comparative healthcare information.

Part-time and full-time medical specialists, are there differences in allocation of time?

BackgroundAn increasing number of medical specialists prefer to work part-time. This development can be found worldwide. Problems to be faced in the realization of part-time work in medicine include the division of night and weekend shifts, as well as communication between physicians and continuity of care. People tend to think that physicians working part-time are less devoted to their work, implying that full-time physicians complete a greater number of tasks. The central question in this article is whether part-time medical specialists allocate their time differently to their tasks than full-time medical specialists.MethodsA questionnaire was sent by mail to all internists (N = 817), surgeons (N = 693) and radiologists (N = 621) working in general hospitals in the Netherlands. Questions were asked about the actual situation, such as hours worked and night and weekend shifts. The response was 53% (n = 411) for internists, 52% (n = 359) for surgeons, and 36% (n = 213) for radiologists. Due to non-response on specific questions there were 367 internists, 316 surgeons, and 71 radiologists included in the analyses. Multilevel analyses were used to analyze the data.ResultsPart-time medical specialists do not spend proportionally more time on direct patient care. With respect to night and weekend shifts, part-time medical specialists account for proportionally more or an equal share of these shifts. The number of hours worked per FTE is higher for part-time than for full-time medical specialists, although this difference is only significant for surgeons.ConclusionIn general, part-time medical specialists do their share of the job. However, we focussed on input only. Besides input, output like the numbers of services provided deserves attention as well. The trend in medicine towards more part-time work has an important consequence: more medical specialists are needed to get the work done. Therefore, a greater number of medical specialists have to be trained. Part-time work is not only a female concern; there are also (international) trends for male medical specialists that show a decline in the number of hours worked. This indicates an overall change in attitudes towards the number of hours medical specialists should work.

Use and Uptake of eHealth in General Practice: A Cross-Sectional Survey and Focus Group Study Among Health Care Users and General Practitioners

Background Policy makers promote the use of eHealth to widen access to health care services and to improve the quality and safety of care. Nevertheless, the enthusiasm among policy makers for eHealth does not match its uptake and use. eHealth is defined in this study as “health services delivered or enhanced through the Internet and related information and communication technologies.” Objective The objective of this study was to investigate (1) the current use of eHealth in the Netherlands by general practitioners (GPs) and health care users, (2) the future plans of GPs to provide eHealth and the willingness of health care users to use eHealth services, and (3) the perceived positive effects and barriers from the perspective of GPs and health care users. Methods A cross-sectional survey of a sample of Dutch GPs and members of the Dutch Health Care Consumer Panel was conducted in April 2014. A pre-structured questionnaire was completed by 171 GPs (12% response) and by 754 health care users (50% response). In addition, two focus groups were conducted in June 2014: one group with GPs (8 participants) and one with health care users (10 participants). Results Three-quarters of Dutch GPs that responded to the questionnaire (67.3%, 115/171) offered patients the possibility of requesting a prescription via the Internet, and half of them offered patients the possibility of asking a question via the Internet (49.1%, 84/171). In general, they did intend to provide future eHealth services. Nonetheless, many of the GPs perceived barriers, especially concerning its innovation (eg, insufficient reliable, secure systems) and the sociopolitical context (eg, lack of financial compensation for the time spent on implementation). By contrast, health care users were generally not aware of existing eHealth services offered by their GPs. Nevertheless, half of them were willing to use eHealth services when offered by their GP. In general, health care users have positive attitudes regarding eHealth. One in five (20.6%, 148/718) health care users perceived barriers to the use of eHealth. These included concerns about the safety of health information obtained via the Internet (66.7%, 96/144) and privacy aspects (55.6%, 80/144). Conclusions GPs and health care users have generally positive attitudes towards eHealth, which is a prerequisite for the uptake of eHealth. But, general practitioners in particular perceive barriers to using eHealth and consider the implementation of eHealth to be complex. This study shows that there is room for improving awareness of eHealth services in primary care. It will take some time before these issues are resolved and eHealth can be fully adopted.

Regulated competition in health care: Switching and barriers to switching in the Dutch health insurance system

BackgroundIn 2006, a number of changes in the Dutch health insurance system came into effect. In this new system mobility of insured is important. The idea is that insured switch insurers because they are not satisfied with quality of care and the premium of their insurance. As a result, insurers will in theory strive for a better balance between price and quality. The Dutch changes have caught the attention, internationally, of both policy makers and researchers. In our study we examined switching behaviour over three years (2007-2009). We tested if there are differences in the numbers of switchers between groups defined by socio-demographic and health characteristics and between the general population and people with chronic illness or disability. We also looked at reasons for (not-)switching and at perceived barriers to switching.MethodsSwitching behaviour and reasons for (not-)switching were measured over three years (2007-2009) by sending postal questionnaires to members of the Dutch Health Care Consumer Panel and of the National Panel of people with Chronic illness or Disability. Data were available for each year and for each panel for at least 1896 respondents - a response of between 71% and 88%.ResultsThe percentages of switchers are low; 6% in 2007, 4% in 2008 and 3% in 2009. Younger and higher educated people switch more often than older and lower educated people and women switch more often than men. There is no difference in the percentage of switchers between the general population and people with chronic illness or disability. People with a bad self-perceived health, and chronically ill and disabled, perceive more barriers to switching than others.ConclusionThe percentages of switchers are comparable to the old system. Switching is not based on quality of care and thus it can be questioned whether it will lead to a better balance between price and quality. Although there is no difference in the frequency of switching among the chronically ill and disabled and people with a bad self-perceived health compared to others, they do perceive more barriers to switching. This suggests there are inequalities in the new system.

Does managed care make a difference? Physicians' length of stay decisions under managed and non-managed care

BackgroundIn this study we examined the influence of type of insurance and the influence of managed care in particular, on the length of stay decisions physicians make and on variation in medical practice.MethodsWe studied lengths of stay for comparable patients who are insured under managed or non-managed care plans. Seven Diagnosis Related Groups were chosen, two medical (COPD and CHF), one surgical (hip replacement) and four obstetrical (hysterectomy with and without complications and Cesarean section with and without complications). The 1999, 2000 and 2001 – data from hospitals in New York State were used and analyzed with multilevel analysis.ResultsAverage length of stay does not differ between managed and non-managed care patients. Less variation was found for managed care patients. In both groups, the variation was smaller for DRGs that are easy to standardize than for other DRGs.ConclusionType of insurance does not affect length of stay. An explanation might be that hospitals have a general policy concerning length of stay, independent of the type of insurance of the patient.