Romy Bes Selective contracting by health insurers: the perspective of enrolees

Date of PhD defense:  18 januari 2018 
Institute: Nivel/Maastricht University
Promotor: Prof. dr. J.D. de Jong (Maastricht University)
Prof. dr. P.P. Groenewegen (Universiteit Utrecht)
Prof. dr. E.C. Curfs (Open Universiteit)
In the Dutch health care system, health insurers play an important role. They are supposed to prudently purchase care on behalf of their enrolees, the patients. They are supposed to purchase care based on price and quality and need to channel their enrolees to contracted care providers in order to increase competition between care providers. This competition should lead to better value for money health care. Channelling enrolees is usually done with negative financial incentives, which means that enrolees need to pay (part of) the costs themselves if they consult with a provider that is not contracted by their health insurer. 

In my thesis, I researched the perspective of enrolees on this matter. I have found that selective contracting and health insurers channelling patients to contracted care providers is experienced very negatively by enrolees. Health insurers suffer from a trust issue, which means that enrolees generally do not trust them to purchase good quality care on their behalf. We found that this trust is very important in the acceptance of selective contracting. Furthermore, we found that information on why certain care providers are not contracted is also very important in this acceptance. However, even if enrolees have trust in their health insurer and if they are informed, the negative feeling towards selective contracting does not disappear entirely. Thus, we conducted an experiment to find out if enrolees can be channelled towards good quality care providers in a different, more positive way. One customer service team (14 employees) started to offer advice to enrolees who called them about any issue regarding physiotherapy. We found that 45% of the enrolees who accepted the advice and also went to a physiotherapist afterwards, followed the advice they received from the customer service employee. Furthermore, enrolees were happy with the offered advice and the team who offered the advice received higher reviews compared to other teams. Although we could not be sure the effect in the reviews was solely caused by the intervention, it is very positive that the ratings did not go down, as may be expected, since enrolees usually do not like it when their health insurer interferes with their care provider choice. 

One of the statements from my thesis was: Selective contracting where non-contracted care providers are only partially reimbursed, hardly contributes to achieving the goals of the health care system. 
I found that enrolees who have the highest chance of needing care in the near future, elderly and enrolees with lower self-reported health status, are least likely to choose a restrictive health plan. Therefore, care providers will not receive an incentive to compete with each other to be contracted by health insurer, since enrolees who use care will choose a free choice health plan and will still visit them. 

What I liked most about my research was the close collaboration with health insurer VGZ. For the experiment I did, I worked very closely together with employees of VGZ and I got to see how they work in practice and what goes in to running a well-functioning customer service. It was also very nice to see how my results could be implemented in practice. Of course, doing research in this setting also causes challenges, since as a researcher you are not able to control everything. However, the challenges made the project more interesting to work on, I really enjoyed that.

Key points: 
- Enrolees are very negative about selective contracting and channelling patients to contracted care providers.
- Trust in the health insurer and information from the health insurer about why certain care providers are not contracted increases enrolees’ acceptance of selective contracting, however, the negative feeling is not cancelled out. 
- Channelling enrolees in a more positive way, for instance by having customer service offering them advice when choosing a physiotherapist, has the potential to be very successful en is more readily accepted by enrolees.
Romy Bes