The aim of the present study was to determine whether the introduction of managed competition in the Dutch healthcare system and the coinciding publication of comparative quality information on health plans was associated with performance improvement in health plans. Experiences of consumers with their health plan were measured in four consecutive years (2005 to 2008) starting the year before the introduction of a new health insurance law [14–17]. In all years, the resulting comparative quality information was published on a Dutch website along with a press release mentioning the quality aspects that in general needed improvement the most. We expected that the performance of all health plans would improve over the years, endorsing the expected effects of managed competition. Moreover, following Hibbard et al., we hypothesized that the improvements over the years would be more profound for quality aspects that needed improvement most and for health plans that performed inferior at the first measurement (year 2005) [7, 8, 18].
When we look at the changes in performance between 2005 and 2008, the expected overall improvement in performance was found for only four out of seven quality aspects, namely general rating of health plans, conduct of employees, health plan information and transparency on (co)payment requirements. For three other aspects (i.e., access to call centre, getting the needed help from the call centre and the reimbursement of claims), we found that the overall performance first declined from 2005 and 2006 and then increased from 2006 to 2008; the performance of health plans was, however, not significantly better in 2008 than in 2005.
The decline in overall performance from 2005 to 2006 on these three quality aspects can be explained as followed. In January 2006, the Dutch government enacted the new insurance law. The new law brought about several changes for Dutch citizens and created turmoil within the Dutch population. In the beginning of 2006, much more consumers than usual telephoned their health plan for extra information decreasing the access of the call centre and making it more difficult for health-plan employees to provide the needed help. The administrative burden associated with the introduction of the new health insurance law could explain the decreased performance concerning reimbursement of claims. However, after the first year of the new health insurance system, the health plans did not appear to be able to improve the performance of the call centre and the reimbursement of claims to a level higher than in 2005.
Above-mentioned results also indicate that the overall performance of health plans did not improve more often for quality aspects that were identified as important areas of improvement in 2005 (i.e., transparency of (co)payment requirement, access to call centre and health plan information) than for the other quality aspects. In short, the introduction of managed competition in the Dutch healthcare system along with the publication of comparative quality information only had the assumed positive effects on the overall performance of health plans for a subset of quality aspects.
Next, we examined whether health plans that performed below average in 2005 improved their performance more often than health plans that did not perform below average in that year. On most (six out of seven) aspects the performance of below-average scoring health plans increased more than the performance of average and/or above-average scoring health plans. In other words, the idea that health plans who scored relatively low in 2005 would try harder to improve their performance than health plans who scored relatively high was confirmed [7, 8]. It is, however, important to keep in mind that relatively bad-performing health plans had more possibilities for improving their service. For well-performing health plans it was probably difficult to improve their performance over the years given their high point of departure on several quality aspects. For instance, scores on reimbursement of claims can vary between 1 and 4. Above-average health plans had an average score of 3.8 in 2005, which is very close to 4, leaving little room for improvement.
An important question is what stimulates health plans to improve their performance. Three different mechanisms have been proposed to explain why public reporting of quality information would stimulate healthcare providers to initiate quality improvement projects [3, 8, 21]. First, identifying shortcomings may be sufficient to motivate professionals to improve their performance given their intrinsic motivation to provide service of high quality (professionalism). Second, comparable to the assumed effects of managed competition, the possible loss of market share can stimulate efforts to improve quality. Organizations then have an economical interest to excel in public reports (market forces). Last, it is held that healthcare providers value a good reputation and therefore do not want to be associated with bad-performing organizations in public reports (reputation protection). The present results can not answer this question conclusively, but the finding that the overall performance of health plans did not improve more often for general points of improvement (as mentioned in the press-release) negates the idea that identifying shortcomings is sufficient to motivate health plans to improve the service they provide. Relatively bad-performing health plans did show more improvement than relatively good-performing health plans suggesting that health plans do not want to perform inferior compared to other health plans. In other words, as in previous studies [3, 7, 8, 18], reputation protection appears to be an factor stimulating health plans to initiate improvement projects but fear for loosing market share is probably also an important issue.
In addition, it remains to be seen whether consumers or organisations interesting in a collective arrangement (for instance, employers or patient organisations) use the information on Internet to choose between health plans. One way to answer this question is to establish whether health plans that perform below average indeed loose market share. Unfortunately, these data were not available. In general, about 3-4% of the Dutch population switches health insurer each year. This percentage is comparable to the switching rates in other countries such as Germany (4-5%) and Switzerland (5%) [10, 22, 23]. Studies have also revealed that consumers use quality information when choosing a health plan and that they tend to choose better performing health plans [3, 9]. It is, however, unknown whether a switching rate of 3-4% is enough for managed competition in health care to succeed .
Some limitations of the present study have to be noted. For one, a response bias occurred in all the four questionnaire studies on consumer experiences. Elderly and women responded more often than younger people and men. Previous studies have revealed that older people report more positive experiences than younger people; no consistent differences have been reported for men and women [25, 26]. This means that the average performance of the health plans is probably overestimated in the questionnaire studies. Fortunately, the response bias was present in all the four years the consumer experiences were measured. This limitation thus probably did not affect our conclusions concerning the changes in performance over the years.
It is also important to note that the changes we found over the years are small. Although some differences are statistically significant, we have to ask our selves whether we can derive policy implications from these changes. In addition, the design of the present study did not allow us to determine whether the introduction of managed competition and the publication of comparative quality information were responsible for the observed changes in performance.
Future research should examine whether and for what reasons health plans initiate improvement projects. Ideally, experiments should be carried out in which health plans are randomly assigned to one of several conditions: only a confidential report, only a public report or a combination of a confidential and public report on their performance. At the same time, it has to be determined how long it takes for improvement efforts of health plans to be implemented and to translate into more positive experiences of consumers. In addition, studies that investigate whether consumers use the comparative quality information when choosing a health plan and whether relatively bad-performing health plans indeed loose market share are essential.