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Table 3 The side-effects of the policy regarding the enhancement of patient choice of healthcare providers that are mentioned in the policy documents

From: Free choice of healthcare providers in the Netherlands is both a goal in itself and a precondition: modelling the policy assumptions underlying the promotion of patient choice through documentary analysis and interviews

Condition Risk Effect
Willingness/ability to travel/choose Some patients are not willing or able to travel or choose. There may not be enough competitive pressure [41, 51].
  There is an urgent situation. Patients do not have time to search providers [56].
Sufficient choice Healthcare providers and insurers enlarge (especially high quality-providers) or merge. Additionally, the plethora of rules implemented to regulate the market will lead to diminished entrepreneurial activity. Patients do not have sufficient choice options [41, 83] and costs will increase [84, 85]. Consequently, there may not be enough competitive pressure [41, 51].
  Patients have too many choice options. Patients may delay choice [84].
Transparency – quality The comparative information that is to be developed will be opaque, excessive, incomprehensible, not comparable, scattered and the various healthcare providers often are disparate. Patients are unable to assess the quality of the providers and consequently cannot be critical about quality, are unwilling to pay for quality and focus on price information instead [41, 65, 86]. Consequently, there will not be enough competitive pressure [38].
  Not every patient has Internet access or is able to search the Internet, assess the different options and make an informed decision. Inequalities exist in the accessibility of the comparative information and ability to choose. Consequently, many patients will not choose and the competitive pressure will be diminished [37, 65, 66].
  Healthcare providers have to deliver a large amount of data. Transparency is hindered [86].
  The bureaucracy of the system leads to possibilities for data to be manipulated. Providers show strategic behaviour and commit fraud [83].
  Patients choose based solely on information about quality. The relationship of mutual trust between patient and doctor is being undermined [83].
Transparency - costs Patients do not get to see their healthcare costs, only have to pay a small premium. Patients are often unaware of the costs that they incurred, which limits their cost awareness. This might diminish the influence of the financial incentives to avoid excessive care use [40, 83, 84].
Freedom of choice Insurers contract a limited number of providers. Patients will not have freedom of choice [36, 40, 41].
  Only the ‘rich’ are able to choose a policy which offers them free choice. Inequalities exist in the freedom of choice patients have [40, 85].
  Insurers do not buy high-cost care in order to fend off high-risk insured parties. Inequalities exist in the choices people have [37].