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Who is responsible for metropolitan health systems: the limitations of managed competition?
Plochg, T., Delnoij, D.M.J., Klazinga, N.S. Who is responsible for metropolitan health systems: the limitations of managed competition? European Journal of Public Health: 2003, 13(4 sup) 45. Abstract. 11th Annual Eupha Meeting 'Globalisation and Health in Europe: Harmonising Public Health Practices'. Rome, Italy, 20-22 November 2003.
Background: In a number of European countries managed competition has been introduced to increase efficiency and the delivery of patient centred care. In social insurance countries, this has also led to the creation of insurance with free choice sickness funds for publicly insured. The sickness funds should act as strategic purchasers who contract care that fits the needs of the populations they serve. The ageing populations of European health systems need an integrated package of prevention, cure, care and social services. For metropolitan areas this is especially relevant, as numerous problems concentrate in districts where the health status of citizens is significantly below average. However, it is unclear who can and is willing to act as the conductor of such a system. By default, in systems with an insurance market multiple sickness funds operate within the same regional or local setting and they are responsible for contracting cure and care only. Prevention and social services are the domain of other public agencies (municipalities, in the Netherlands). Aim: Taking the city of Amsterdam as a case study, this paper explores how the sickness fund with the largest market share in Amsterdam (>70%) and the municipality of Amsterdam perceive their roles and responsibilities in orchestrating the local health system. Methods: Results of this case study are largely based on qualitative data, gathered in 15 semi-structured interviews with key-players in the sickness fund and in four consecutive meetings with representatives of the city of Amsterdam. Additional data have been collected through a questionnaire and document analysis. Results: The sickness fund is not willing to take up a conductor role. There is no business case for doing so. First, the sickness fund represents only a proportion of the Amsterdam population and thus cannot protect public interests. Second, the current context of health care fosters price competition and risk selection instead of strategic purchasing. Third, the national health policy leaves insufficient room to take up a conductor role. Last, a public health orientation is not in the interest of the sickness fund as profits are uncertain and not clear. With the sickness fund unwilling to take up the conductor role, the municipality of Amsterdam feels forced to formulate health care policies as public interests are challenged. A policy document, including plans towards the organisation of health care, will be released in the course of 2003. The municipality takes up problems in the field of general practice (shortages), primary care and mother and childcare in inner city areas. However, the municipality has too limited means, responsibilities and power to organise the local health system. Conclusions: This leads to the paradox that the sickness fund is most capable of taking the lead, but unwilling, whereas the municipality is willing but is restricted in its possibilities to do so. This demonstrates the limitations of managed competition when it comes to ensuring community health. (aut.ref.)
Background: In a number of European countries managed competition has been introduced to increase efficiency and the delivery of patient centred care. In social insurance countries, this has also led to the creation of insurance with free choice sickness funds for publicly insured. The sickness funds should act as strategic purchasers who contract care that fits the needs of the populations they serve. The ageing populations of European health systems need an integrated package of prevention, cure, care and social services. For metropolitan areas this is especially relevant, as numerous problems concentrate in districts where the health status of citizens is significantly below average. However, it is unclear who can and is willing to act as the conductor of such a system. By default, in systems with an insurance market multiple sickness funds operate within the same regional or local setting and they are responsible for contracting cure and care only. Prevention and social services are the domain of other public agencies (municipalities, in the Netherlands). Aim: Taking the city of Amsterdam as a case study, this paper explores how the sickness fund with the largest market share in Amsterdam (>70%) and the municipality of Amsterdam perceive their roles and responsibilities in orchestrating the local health system. Methods: Results of this case study are largely based on qualitative data, gathered in 15 semi-structured interviews with key-players in the sickness fund and in four consecutive meetings with representatives of the city of Amsterdam. Additional data have been collected through a questionnaire and document analysis. Results: The sickness fund is not willing to take up a conductor role. There is no business case for doing so. First, the sickness fund represents only a proportion of the Amsterdam population and thus cannot protect public interests. Second, the current context of health care fosters price competition and risk selection instead of strategic purchasing. Third, the national health policy leaves insufficient room to take up a conductor role. Last, a public health orientation is not in the interest of the sickness fund as profits are uncertain and not clear. With the sickness fund unwilling to take up the conductor role, the municipality of Amsterdam feels forced to formulate health care policies as public interests are challenged. A policy document, including plans towards the organisation of health care, will be released in the course of 2003. The municipality takes up problems in the field of general practice (shortages), primary care and mother and childcare in inner city areas. However, the municipality has too limited means, responsibilities and power to organise the local health system. Conclusions: This leads to the paradox that the sickness fund is most capable of taking the lead, but unwilling, whereas the municipality is willing but is restricted in its possibilities to do so. This demonstrates the limitations of managed competition when it comes to ensuring community health. (aut.ref.)