In the last two decades, several Western countries introduced some form of managed competition in their health care system [1, 2]. Common goal of these reforms is creating a demand driven system that provides more patient centered care . To achieve this goal the quality of health care providers needs to be assessed and publicly reported [4, 5]. Patients and health plans may then use quality information to make informed choices between health care providers.
The public reporting of provider quality can stimulate quality improvement through informed patient choice, quality contracting of providers by health plans and/or by intrinsic motivation of health care providers . Previous studies have shown that public reporting of quality information does stimulate hospitals to initiate quality improvement projects. It remains unclear if--and to what extent--the introduction of managed competition combined with public quality reporting may affect quality [7–9].
We set out to answer this question in the context of the Dutch 2006 Health Insurance Act (HIA) reform. It was enacted to stimulate managed competition in the hospital market. Before the reforms all hospitals were financed through 'input' reimbursement. Hence hospital budget did not directly depend on production, but rather on historic agreements with the insurer regarding their budget. The after reform characteristics of the Dutch health can be summarized as followed: [2, 10]
There is a mandatory basic health insurance for everyone, purchased through private insurers (both profit and not-for-profit are possible);
There is annual consumer choice of insurer and insurer products and choice between in kind and restitution policy;
Insurers are obliged to have a system of open enrollment and are compensated via a risk-equalization system;
There is a mandatory deductible of € 150 and avoluntary deductible up to € 650 per person per year;
Insurers are expected to contract selectively with competing health care providers;
The government requires health care providers to release quality information.
To enable provider competition, products were defined in terms of Diagnosis Treatment Combinations (DTCs), which are to some extent comparable to diagnosis related groups . A number of initiatives were aimed at making provider quality transparent. These include widespread measurement of medical quality indicators that aim to indicate outcome utility and the measurement of the Consumer Quality Index (CQI) that aims to measure process utility. It is partly based on the Consumer Assessment of Healthcare Providers and Systems . The CQI therefore is a partial measure of healthcare quality based on more objective consumer experiences rather than a more subjective satisfaction .
From 2006 onwards health plans were increasingly stimulated to negotiate with hospitals on price, quantity and quality of care. While in 2006 negotiations were restricted to products accounting for 7% of the total hospital budget, this was increased to 34% in 2009, and is expected to further increase to 70% in the near future. Consequently, hospitals are increasingly exposed to competition . However, the bargaining power of health plans remains limited due to a limited use of selective hospital contracting by health plans. In addition health plans are currently reluctant with proactive member channeling toward preferred hospitals . While this may have reduced competition during 2006-2009, the threat of significant competition in the future may have sparked hospital policy changes.
We examined whether the patient experiences of hospital care improved in the period 2006-2009. In addition we investigated whether forced public reporting of hospitals and higher levels of competition--in line with previous studies and policy objectives--were associated with better patient experiences [7, 9, 16, 17].