Patient choice of healthcare providers is an important theme, not only in the Netherlands but in the UK and Scandinavia as well [1–7]. To be able to evaluate whether promoting patient choice of healthcare providers has its desired effects, it must be clear exactly which effects are desired. For that reason, we modelled the assumptions underlying the promotion of patient choice of healthcare providers by analysing policy documents and interviewing key figures. We focused our analysis on the Netherlands. However, because much the same assumptions are made by policy makers in the other northern European countries as well [14, 15, 26], our analysis is also interesting for policy makers and researchers in those countries.
In the current paper, we answered four research questions. The first research question concerned the reasons for promoting patient choice. Patient choice of healthcare providers is one important element in a much broader system in which regulated competition between providers and insurers is key to controlling the development of costs and improving and safeguarding the quality, efficiency and accessibility of healthcare [31, 32]. Within the context of regulated competition, patients are expected to behave as rational actors. This line of reasoning originates from the classical economic theory [20, 68]. In addition, patient choice was deemed a ‘value’ or a goal in itself. However, in practice, the Dutch government did not really concern itself with this latter goal [37, 88]. Because it was assumed that patients value choice, no instruments were implemented to encourage patients to choose. Even so, literature indicates that a number of patient groups are in reality less inclined or able to choose actively, which may affect the equity of outcomes from patient choice policies [8, 12].
The second research question concerned the determinants that were assumed to influence patient choice. It was assumed that satisfying several conditions leads patients to choose a provider rationally. Those conditions are that patients are willing to choose and willing and able to travel and switch provider, that patients are informed, that there are sufficient healthcare providers to choose from and that patients are free to choose their healthcare provider. Regarding the third research question, i.e. how policy makers were to promote patient choice, the Dutch government and other parties implemented a variety of instruments to satisfy the conditions, thus creating a level playing field in which market forces could come into play. This resulted in a health insurance system that relies heavily on laws to regulate the market . In our analysis, we did not include the supervisors of the healthcare market such as the Dutch Health Care Authority (NZa), because we wanted to focus on instruments directed at the patient. These supervisory bodies were, however, considered essential for markets to develop.
Concerning the fourth research question about the side-effects of the policy, several possible side-effects are documented in the policy documents. If these side-effects exist, diminished competitive pressure and a healthcare provision market that is not really working without governmental intervention may result. It is however striking that no discussion was documented about the role of equality, neither as a possible negative side-effect of patient choice nor as part of the argument for patient choice. In the UK, for instance, fairness/equality was part of the case made for patient choice. In several other countries, such as the Nordic countries, there was some concern about the likelihood that introducing choice would result in adjustment of the healthcare system in favour of certain patient groups (e.g. healthy, more highly educated, young people). Other types of patients would be ignored by the providers . The fact that Dutch policy makers had no concerns about equity is especially interesting because they did expect differences in choice behaviour between different patient groups .
Because policy making is not a straightforward process, some aspects of the policy are ambiguous . These ambiguities can have a variety of causes. Secondly, policy on the health insurance system change was not strictly defined; instead, some choices were left open . One example is that the minister of VWS was unwilling to make a choice between insurance policy types and was ready to let ‘all the players on the market’ decide on the matter . Thirdly, in policy documents, assumptions are made and words are used for concepts that cannot be grasped merely by reading written material about the subject . For example, patient choice is a concept that refers to the indirect influence patients (the demand side) have on healthcare providers, but it is never explicitly defined as such. Fourthly, there might not be one single way to understand the policy; instead, words and assumptions that are used in it might have different meanings for different people. For some policy makers, patient choice refers to individual patients actively choosing a healthcare provider, while for others the concept refers to the threat of competitors that patients might choose. Finally, the development of the policy on health insurance system change has been a political process during which compromises had to be negotiated, for example regarding which goal of patient choice is the main focus. There are also other countries, in which patient choice has multiple goals, such as Scandinavia and the UK [2, 8, 10, 11]. However, the Netherlands is unique, since patient choice as a goal in its own right conflicts with letting insurers contract providers in selectively. Whereas the latter is essential for the functioning of the new health insurance system and regulated competition , the former was also included in the policy as a goal in its own right .
Healthcare provision and the insurance market
Although the current study focuses on the choice of providers, the healthcare insurance and provision markets are interrelated. However, the policy makers involved in the development of the current health insurance system tried to make sure that patients will always have a free choice of provider, independently of their insurance products (there may be some financial consequences). This makes it valid to analyse the healthcare provision market separately from the healthcare insurance market in the Dutch situation.
Limitations, strengths and follow-up research
One limitation of this study is that we confined our analysis mainly to policy documents about the Wmg and the Zvw. This meant that we did not incorporate the history of the health insurance system changes. We partially solved this issue by consulting additional literature in order to put our reconstruction into context. Furthermore, we did not have the opportunity to interview the person who was the Minister of Health during the years that the health insurance system acquired its final form. A strong point of this research is, however, that we held interviews both with key figures involved in the health insurance system change and with people who followed this development closely.
Another strength of this paper is that, as far as we know, few scientific papers have been written either in the Netherlands or abroad that aimed to model the policy assumptions underlying the promotion of patient choice by combining policy document analysis with interviews with key figures. The current paper therefore expands the body of literature about public policy evaluation, adds to the existing knowledge about regulated competition in healthcare, and will enable future research on the validity of this policy, e.g. whether patients are indeed willing to choose their provider.