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Jos Boertjens, Johan van Manen, Misja Mikkers and Wolf Sauter

Because the risk of ill health is part of the human condition, there is a universal interest in providing access to high-quality healthcare while controlling the sacrifices that are necessary to obtain it – after all, the funds used for healthcare cannot be allocated to alternative uses. Affordability is therefore an important consideration that is closely linked to access. Quality determines the health value of the treatment provided. Arriving at a social consensus on how to achieve these goals is difficult, however, which in most countries leads to intense debate on healthcare, as the contributions to this book regarding the US, South Africa, Colombia and the Netherlands all illustrate. Unsurprisingly, there is no one particular healthcare system that meets all three of the needs identified above perfectly. Instead, there is a wide variety of such systems, each with different advantages, disadvantages and trade-offs. Hence it is important that data on the problems encountered are collected and analysed, and that learning occurs between different health systems. This is a practical as well as a scientific challenge, because hitherto most studies on healthcare regulation have not taken a comparative perspective based on comparable data. In fact, in many respects, no such data yet exists. This book charts hospital financing across the three dimensions of access, affordability and quality. It does so based on an international comparison spanning four different continents. For the purpose of our project, we have collected 11 country reports, compiled by national experts according to a standard structure. In addition, six thematic chapters are included that explore specific questions. The invited authors include academics and practitioners (primarily, but not exclusively, policymakers).

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William M. Sage

In this chapter the author explains the enormous waste in the US Healthcare System and the little progress that has been made to achieve efficiency and fairness. To large extent the ‘deep legal architecture’ – the accumulation laws, regulations, self regulatory practices and subsidies – prevents meaningful competition in medical markets. Three areas of improvement are described. First, there is a great urgency to restructuring payment methods for health care delivery, in order to improve efficiency. Second, barriers to market entry in health care markets should be broken down, collusion between health care providers to divide markets and exclusion of new competitors should be prevented to ensure meaningful competition. Third, investment in combatting poverty, lack of education and substandard housing may lead to less costly and more effective health care.

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Jarleth M. Burke

The Cross-Border Health Care Directive (CBHD) has the potential to herald a revolution in the ability of EU citizens to access healthcare across European boundaries. The author argues that the CBHD, while activating rights, does too little to operationalize them. The CBHD could function as a major corrective to government failure in the healthcare setting, but critically, its implementation means that information asymmetry and related problems are not tackled systematically. In addition, the calculation of reimbursement tariffs by the Member States is largely un-policed, leading to potential gaming. Nevertheless, very dysfunctional public delivery systems may begin to face material patient out-flows. Although the CBHD makes provision for the Member States to curb reimbursement rights in response, this requires developing a detailed framework for that purpose. The relative priority this framework gives to patient as opposed to provider interests is likely to determine its strictness.

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Jos Boertjens and Mary Guy

In this chapter the authors compare the health care systems of England and the Netherlands with respect to contracting, accountability frameworks and the duty to provide care and access to health care. The objectives of contracting are different in these two countries. While in the Netherlands contracting is envisaged to promote efficiency and quality, contracting in England appears to set a minimum requirement. Under the Dutch system, the insurer must fulfill its duty to provide care. In England it is difficult to hold any party accountable for ensuring that patients receive necessary care. Various types of co-payments and out-of-pocket charges occur in both England and the Netherlands. In both countries personal care budgets exist to put patients in charge of their own budgets.

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Ana Rodríguez-Álvarez and Maria J. Perez-Villadoniga

In health care systems such as Spain where patients do not pay the full price for health care services, waiting lists may be used as a rationing mechanism. The authors describe a theoretical model of the demand for and the supply of health care. They derive a waiting list function from the theoretical model that implies that waiting lists will increase as a result of increases in demand or reductions in supply. Then the authors estimate the obtained waiting list function. The results of the empirical estimation confirm the predictions of the theoretical model. Notably the recent recession has led to significant reductions in public expenditure of health care and caused longer waiting lists.

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Josine Janus

This chapter is a case study of a payment reform in New York State by Medicaid. The payment was organized as a Delivery System Reform Incentive Payment (DSRIP) programme with the ultimate goal of reducing avoidable hospital care by 25 per cent, while making sure that no more providers would require financial state-aid to survive. The programme aimed to incentivize providers to coordinate care, increase transparency of services and payments based on outcome. The programme runs from 2015 until 2020. The first results look promising, but it is too early to draw definite conclusions. Although the programme is still unfolding, some lessons can already be drawn: rewarding voluntary participation ensures motivated participants, the programme must be flexible and the programme should maintain pace.

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Peter Bogetoft, Misja Mikkers and Victoria Shestalova

In this chapter the authors describe an integrated contract (population based financing) between health care payers, such as governments and/or health insurers) and different health care providers. The chapter considers a simple and stylized theoretical model involving a health care payer and two different health care providers (e.g., general practitioners and hospitals) and compares different contracting options. Based on the theoretical model, the authors argue that population bases financing offers better incentives for the coordination in the provision of health care services. Contracts should be augmented with quality outcome measures to provide incentives to prevent undertreatment. The chapter gives examples of integrated contracting in the US, Germany and a proposed experiment in the Netherlands.

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Julia Bobek, Lena Lepuschütz and Florian Bachner

Austria has a long history of social protection through the social health insurance (SHI) system. Insurance coverage is mandatory and the assignment to a particular insurance fund is determined by law, depending on the place of occupation, type of occupation and occupational status (unemployed, retired person, and so on). This means that there is no regulated competition between SHI funds in Austria and the level of SHI coverage is very high. Around 99.9 per cent (8.8 million residents in 2017) of Austrians are covered by SHI. The Austrian healthcare system in general and the hospital sector in particular are characterized by a high degree of fragmentation. Competencies in the field of inpatient care lie with the nine federal states; financing is split between the federal level, the federal states and SHI.

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Filip Dewallens and Julie Vermeulen

The Belgian healthcare system has a system of compulsory insurance with almost universal coverage of the population (99 per cent), administered by healthcare sickness funds (mutualité’s). Citizens can choose a mutualité freely, and can switch between mutualités at any time. Mutualités do not negotiate directly with individual hospitals, negotiations take place at the national level. Hospitals need to meet a limited set of national criteria in order to obtain recognition and must fit within standards for national programming. Most physicians in Belgium work within the Belgian state health insurance scheme, while some combine this with private work or work entirely in the private sector. Future developments involve proposals for strengthening value based financing of healthcare and clustering of hospitals, the latter creating a network of neighbouring hospitals, a development aimed at sharing of the financial risks between hospital and insurance.

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Silvie Jerabkova

The Bismarck type health care system relies on mandatory health insurance. Contributions to health insurance are paid by the employer as well as the employee. Self-employed persons pay their fees directly. For the economically inactive population, contributions are covered by the state. Contributions are collected directly by the health insurance funds and are pooled and redistributed through a risk adjusted scheme based on age, sex, high costs during the reference period and pharmacy-based costs. All policyholders are covered under the same benefits package, which is defined by law. There are seven health insurance funds. There is no competition since premiums are identical and reimbursements are not dependent on the quality of care. The publicly managed General Health Insurance Fund holds approximately 60 per cent of the market and guarantees the functioning of the whole system. The other six health insurance funds are ‘occupational’ funds.