Negotiations between health insurers and hospitals: A case study in the
Netherlands
Anthe Nolles S2561115 MSc BA O&MC
Theme: The role of controllers and auditors in Dutch health care Supervisor: dr. K. Linke
University of Groningen Faculty of Economics and Business E-mail address: anthe93@gmail.com
2 Abstract
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Table of contents
1. Introduction………5
2. Literature………7
2.1.1Quality of hospital care………...7
2.1.2 Costs and costs reduction incentives………...8
2.1.3 Efficiency……….………..9 2.1.4 Conclusion……….……….………...…....…9 2.2 Market forces……….……….………..…….10 2.2.1 Negotiation process……….……….………...…..11 2.2.2 Assessment of care……….……….………...…...11 2.2.3 Patients……….……….………...….11
2.3 The interests of the health insurer……….………...……..12
3. Methodology……….……….……….…….14 3.1 Research method……….……….……….…….14 3.1.1 Controllability……….………...…..14 3.1.2 Reliability……….………...…….14 3.1.3 Validity……….………...….15 3.2 Data……….……….………...….15 3.2.1 Sample……….……….………...….15 3.2.2 Data interpretation……….………..….17 4. Results………..18 4.1 Introduction……….……….……….….18
4.2 Factors that are important to the health insurer……….…….18
4.2.1 Quality……….………....…….18
4.2.2 Hospital prices……….……….…...…….19
4.2.3 Contracting all hospitals……….………..………...…….20
4.2.4 Geographic factors……….………...…….21
4.2.5 Expediency……….………..…...….22
4.2.6 Care provided at the right place………..……….23
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4.3 The assessment of the negotiated care……….…………...…..…….24
4.4 Patients………...25 4.5 Time pressure……….……….………..…….25 5. Conclusion……….……….………....….27 5.1 Practical Implications………27 5.2 Theoretical Implications………28 5.3 Limitations……….28 6. References……….……….………...…...30
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1.0 Introduction
The Dutch health care system has undergone a dramatic change in 2006. In the hope to achieve better quality for patients at lower prices, the health insurance market has been transformed into a competitive market by introducing the Zorgverzekeringswet (ZvW). Insurance companies can decide which care providers they want to close contracts with. This means that insurance companies can buy more or less care (within certain limits by the insurance law) and/or better quality (Halbersma, van Manen and Sauter, 2012). This selective purchasing by health insurance companies is aimed at rewarding care suppliers for supplying more efficient and better-quality care. The care provider and health insurer negotiate on price and volume, which is put to paper in an official contract. The prices for similar care products can therefore vary per hospital. Insurers are not obligated to sign contracts with all hospitals. The choice on whether or not to sign contracts with care suppliers can be of high importance for the insurance companies, as customers value ‘free choice’ greatly (Ho and Lee, 2013a). This means that customers want to be able to choose their own care provider, and they find it important that for example hospital care can be provided by every hospital of their own choice. This puts pressure on the insurance companies to sign contracts with as many Dutch hospitals as possible, which gives hospitals leverage on the insurance companies (Ho and Lee, 2013b). On the other hand, hospitals want to be in contract with as many insurance companies as possible, which gives the insurance company some leverage on hospitals for lower prices and higher quality (Halbersma, van Manen and Sauter, 2012).
The process of negotiating on the conditions of the contracts can take a long time, and can still be in process when the new year of the insurance term has already started. The prices that insurers and hospitals negotiate on are for the complete ‘care packages’, which are called DTC’s; Diagnosis Treatment Combinations. It entails all care provided for a certain treatment, and the prices for these DTC’s are negotiable and can thus differ between hospitals.
To increase the transparency in the Dutch healthcare system a new declaration system was introduced in 2012. The new DBC’s called DOT’s (DBC’s op weg naar transparantie) should make room for increasing market forces between hospitals and insurers (NZa, 2011a). This new system replaced over 30.000 DBC’s by only 4.400 DBC’s, which means hospitals and insurers have fewer DBC’s to negotiate on. NZa argues that this helps health insurers as these fewer DBC’s make it easier for them to perform inspections (NZa, 2011b). The NZa does however recognize that for the year 2012 the negotiation expenses rose, because the composition of the DBC-care products differed. The introduction of the DOT’s did indeed cause new problems (Skipr, 2013). The systems were not yet ready for these new DBC’s which led to problems in the declaration of treatments.
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and Shestalova, 2013; Bray et al., 2013; Rafferty et al., 2007), hospital costs and cost reduction incentives (Noether, 1998; Krabbe-Alkemade, Groot and Lindeboom, 2016) and studies investigating hospital’s efficiency (Porter and Teisbert, 2004; Choi et al., 2017). As more countries transform their healthcare systems into a competitive market, literature has become available on the effect of market forces on these healthcare indicators (Croes, Krabbe-Alkemade and Mikkers, 2017; Bijlsma, Boone and Zwart, 2009; Trish and Herring, 2015; Ho and Lee, 2013a). These researchers have mixed findings on how market forces influence the hospital’s quality and prices. What is missing from the literature, is research about the perspective of the health insurers in the negotiation process. Only a handful of papers study the health insurers aims in the negotiations. Fichera et al. (2015) looked at the quality targets of health insurers, but do not draw conclusions on other factors that might be relevant to the health insurer. The perspective of the health insurer requires further attention, and this study contributes to this by investigating the factors health insurers take into account when contracting hospital care. The current literature lacks information on the interests of the health insurers in the negotiation process, which harms the proper assessment of the effectiveness of the introduction of competitive market forces.
This leads to the following research question:
Which factors are important to health insurers in the negotiations with the hospitals?
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2.0 Literature review
The literature review will discuss what is established in the current literature. It starts with discussing what has been studied regarding hospital’s quality, costs and efficiency. This will be followed by a conclusion. Then, the literature on market forces will be discussed, followed by the interests of the health insurer. Argued is that the interests of the health insurer need further attention.
2.1.1 Quality of hospital care
The Institute of Medicine (1990) defines quality as ‘the degree to which health care services for
individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge'. Scott et al. (2011) stress the importance of the inclusion of patient
experience when defining hospital quality. Therefore, a more suited definition of quality would be the degree to which changes in the hospital provided care improves the well-being of patients. This includes measures for the health-related quality of life, but also measures for patient experience. Measures for quality are divided into measures that capture the quality of the process of care and measures that capture the outcomes of care. Process measures reflect the process of delivering health care and describe the specific actions that are associated with health care. It describes the health care that patients receive and assess to what extent the hospitals perform health care in order to achieve desired aims (Ali, Salehnejad and Mansur, 2017). Monitoring quality of hospital processes is likely to include waiting times, the availability of certain facilities and minimum safety standards such as infection rates. Monitoring hospital quality based on outcomes is likely to include readmission rates1
and mortality.
There is an extensive body of literature on hospital quality and how it is influenced by competition, management practices and organizational factors, human capital and information technology. Propper (2012) studied the effect of competition on health care quality in England. She measured hospital quality by using outcome measures, including death rates. Her research shows that NHS hospitals provide higher quality of health care when located in a more competitive region. Bijlsma, Koning and Shestalova (2013) also found a positive effect of competition on hospital quality in The Netherlands. They studied the impact of competition on quality from 2004 to 2008 and found that hospitals in more competitive regions show higher improvement in several process measures of quality, such as the prevalence of decubitus2, the number of cancelled operations at short notice and the frequency of
HbA1c-tests3 on diabetic patients. However, in contrast to Propper’s (2012) findings, they found that
1 Percentage of patients that need to be rehospitalized within a specified time interval.
2 The share of patients with decubitus (skin damage caused by pressure) at a particular moment in time, shows
the quality of nursing in the hospital (Bijlsma, Koning and Shestalova, 2013).
3 HbA1c-test is a control procedure for diabetic patients. Allows doctors to reveal problems and timely
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the impact of competition on the outcome measures, including mortality during and within 30 days after treatment and readmission rates for heart failure, is to be negligible.
Research is available on the impact of management practices and organizational factors on quality. Bloom et al. (2014) analyzed data on management practices for operations, targets and human resources in 2000 hospitals in different continents. They measure management scores by using the Bloom and Van Reenen methodology4, which consists of a list of 20 dimensions, including
standardization and protocols, clarity and comparability of targets and the managing of talent. Better management practices have a positive influence on the hospital’s outcomes, such as heart attack survival rates, and financial outcomes like profits. In line with these findings are the results of Ali, Salehnejad and Mansur (2017), who did research on the impact of the organizational process of stroke care on hospital performance and the quality of clinical care. Analysis of the organizational process included measures on the availability of stroke units, neurovascular facilities, whether the hospital provides education and engages in clinical research, whether the hospital had produced reports within the last year and whether it considered patients’ views. They found that the organizational design of the hospital is fundamental in driving hospital quality. Bray et al. (2013) have found, by using six individual measures of the stroke process such as whether the patient was seen by a stroke consultant or associate specialist within 24 hours of admission and whether a brain scan takes place within 24 hours of admission, that hospitals with higher organizational scores are more likely to achieve higher hospital quality, which was measured by mortality outcomes.
The literature comprises many studies that relate factors to heterogeneity in quality among hospitals. Rafferty et al. (2007) studied the role of human capital in providing high quality care. Examining the level of nurse staffing in NHS and US hospitals they find a positive relationship between nurse staffing and outcome measures. Athey and Stern (1998) find a positive relationship between health information technology and outcome measures. Menachemi et al. (2008) find similar results in their research on the relationship between IT adoption and quality of care using data from 98 acute-care hospitals. They found that hospitals who have adopted a greater number of IT applications are significantly more likely to have higher quality outcomes.
2.1.2 Costs and cost reduction incentives
Many countries are facing rising healthcare costs. In the Netherlands, the total health care expenditures increased from €6.5 billion to €90 billion in 40 years (CBS, 2013), and this dramatic growth in health care costs is also found in other countries (Krabbe-Alkemade, Groot and Lindeboom, 2016). In an
4 This is an interview-based tool that scores a set of 20 basic management practices on a grid from one (“worst
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attempt to reduce costs, many countries have reformed their healthcare system into a competitive system.
There are contradictory findings in the effect of competitive market reforms on the costs. Noether (1988) finds that in the US both price and quality competition amongst hospitals has an insignificant net effect on hospital prices. A research by Krabbe-Alkemade, Groot and Lindeboom (2016) shows that the implementation of market-based competition in the Netherlands has led to a decrease in total costs, production volume and overall number of activities. They also find that there is no relationship between price and quality scores in a newly reformed healthcare system. They find that hospitals with high quality indicators are not being compensated by higher prices.
2.1.3 Efficiency
Numerous studies examine the impact of volume on the efficiency of a hospital. Porter and Teisberg (2004) indicate that hospitals with larger volumes have better financial performances as hospitals with lower volumes, and state that this is mainly due to the learning effect. The authors argue that more experienced physicians can create better outcomes while lowering costs. Ali, Salehnejad and Mansur (2017) discuss how larger hospitals benefit from economies of scale, and how specialization can enhance the quality of care. ‘Practice makes perfect’ is a frequent used argument on why some hospitals are able to improve their efficiency. This would indicate that uncommon, rarely needed treatments may be unbeneficial for a hospital’s efficiency. Choi et al. (2017) find that patient volume has a U-shaped relationship with the efficiency of the hospital. When a hospital serves too few patients the efficiency decreases, however when the hospital reaches a certain number of patients there is an increase in the hospital’s efficiency. This may justify a hospitals effort to increase patient volume, by for example engaging in mergers and acquisitions. The authors do however recognize that serving too many patients may lead to a negative effect on the quality of the provided care.
2.1.4 Conclusion
10 2.2 Market forces
The Dutch health care system was reformed to a non-regulated price competitive system in 2006. The main objectives of these reforms were to increase the quality of care, to reduce the costs of health care and to reward efficiency in hospitals (Croes, Krabbe-Alkemade and Mikkers, 2017). These objectives are to be achieved through market forces. Hospitals and health insurers negotiate in a competitive market. The established literature on these three factors has mainly been focused on hospitals. There is a small number of literature available on hospitals and health insurers in a competitive market.
Krabbe-Alkemade, Groot and Lindeboom (2016) studied the effect of market competition on hospital’s costs, production volume and number of activities overall by analyzing DBC’s in 72 general hospitals. They found that market competition has led to higher average DBC costs. They relate this to the occurrence of more expensive activities, which can be explained by hospitals focusing on improving efficiency by using easily analyzable technologies. They also found that the effect of competition differs among specialties. This is because the competitive forces have made orthopedics substitute daycare care with outpatient5 and inpatient care6, which leads to higher average inpatient
costs. A reverse substitution is detected in cardiology, which leads to a lower share of inpatients and thus to lower average costs. What is also noticeable in their research is that hospital concentration does not have an impact on hospital costs. They explain this by stating that insurers do not use their power to selectively contract hospitals. However, this research did not take hospital quality into account, and was also limited to general hospitals. McKelllar et al. (2013) and Moriya, Vogt and Gaynor (2010) both find that higher levels of hospital concentration, which means lower competition amongst hospitals, are not significantly associated with higher hospital prices, but that higher levels of insurance concentration, lower competition amongst health insurers, are associated with lower hospital prices. Bijlsma, Boone and Zwart (2009) find that the increasing competitiveness in the healthcare market increases the insurers negotiation power. Propper (1996) looked at the effect of competition on the negotiated prices of provided care. He argues that when the health insurance company has higher negotiation power, the set prices will be lower.
Trish and Herring (2015) looked at the effect of negotiations on the customer premiums charged by health insurers. They found that in markets with higher levels of hospital concentration, the premiums are higher for the insured customer. In markets with increased insurer concentration the premiums are also higher, which is in the disadvantage to the customers. Ho and Lee (2013a) found similar results. They found that increased insurer competition leads to lower premiums, and lower prices paid to the hospital. They do find that the best hospitals have some leverage on the increased competition to negotiate higher care prices.
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The literature shows mixed evidence on how competitions works in the health care sector, and how market forces influence the quality and prices.
2.2.1 negotiation process
Hospitals and insurers negotiate on both price and level of activity. There is only a small pool of literature available on this negotiation process. The RVZ (2008) looked at the negotiation process and noted that, even though the negotiations start with quality, the conversation quickly shifts to price and budgets. To what extent these subjects are discussed is not elaborated on.
Siciliani and Stanciol (2012) studied the negotiation process between the purchaser of health care and the provider of care. They found that if in the negotiation process the power of the health insurer is high, the negotiations lead to higher activity and insurer’s utility, and lower prices and provider’s utility. What influences the power of the health insurer and the content of the negotiation process is not sufficiently addressed.
2.2.2 Assessment of care
In the competitive market the health insurer negotiates with hospitals about health care. The question remains however, whether insurers have the medical knowledge to assess the product quality on which they are negotiating on. The RVZ (2008) claims that insurers are disadvantaged in the negotiations because they have less knowledge on medical specialism. According to the hospitals, they lack the skills and knowledge. Less than a third of the hospitals believes in the competence of the insurer. There is no literature available on how health insurers assess the quality of care that they purchase. The hospital has a much larger body of knowledge on medical care. There is no evidence on how insurers deal with this difference in knowledge, and how they analyze the care. In order to pursue their interest, the insurer would need to know how to properly measure and evaluate these interests. The instruments health insurers use to evaluate hospital care require further attention.
2.2.3 Patients
This far, hospitals and insurers are discussed. But there are more stakeholders in the process of negotiation. An important stakeholder is the patient; the consumer of the product. They are in fact, represented by the health insurer in the negotiations. But are they included in the negotiations?
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discussed during the negotiations, health insurers however state that they are slightly discussed. In the literature, patients as stakeholders in the negotiations is hardly discussed. As they are indeed a stakeholder in the process, their role in the negotiations deserves further attention.
2.3 The interests of the health insurer
Next is a review of the interests of health insurers when contracting hospitals. Only a handful of studies are available on this matter.
Fichera et al. (2015) did research on negotiations in health care with the factor of quality included. They found by investigating negotiation outcomes, that in the selection of hospitals the insurer does not care much about the quality of the hospital. This would indicate that insurers are not much concerned with the quality of the purchased health care. This research is however limited to hospitals in England.
However, health insurers often provide information about hospitals concerning the quality on their website, on which the client can be directed to certain hospitals. They often offer a comparison of hospitals based on customer experiences (Legalee, 2016). This would indicate that the health insurer does take the factor of quality into account.
Another interest of the insurer may be to sign contracts with all hospitals. According to the insurers it is their third main goal7 in the negotiation process (RVZ, 2008). Legalee (2016) argues however, that
health insurers should not sign contracts with all hospitals in order to improve quality. The quality of care differs greatly among hospitals, and insurers should use that information to make purchasing decisions. When a hospital does not deliver care of a sufficient quality, the hospital should not be signed a contract with. This would increase the overall quality of delivered care in hospitals. Krabbe-Alkemade, Groot and Lindeboom (2016) state that in the Netherlands, insurers hardly ever use selective contracting. Most health insurers have contracted almost every hospital. However, the authors acknowledge that this can be explained by the limited share of market competitive segment in the period of their research. The RVZ (2008) explains the importance of selective contracting. By not contracting on quality, the power of the hospitals is increased. However, they acknowledge that there is not sufficient information available on the hospitals quality. Since quality information is not standardized, insurers can hardly contract selectively on quality.
The council for public health and care (RVZ) did research on how the insurers prioritize their own interests concerning the care purchasing process. They found that according to insurers 23 percent of their goals is aimed at the quality of care. What is remarkable about this, is that according to hospitals the insurers only aim 7 percent of their goals at quality. Hospitals think that insurers are mainly driven by cost control, while insurers state that quality is the main goal of care purchasing. Hospitals state
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that 74 percent of the goals of insurers is to decrease costs. Insurers themselves assess that only 36 percent of their goals is aimed at decreasing costs.
The literature lacks sufficient information on what the interests of the health insurer are and no conclusions can be drawn on which hospital factors are taken into consideration in the negotiations. Therefore, this research will consist of interviews with a strong focus on the factors that health insurers find important in the negotiations.
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3.0 Methodology
This chapter will discuss the choice of research method and the data. 3.1 Research method
The area of research has shown to be insufficiently investigated. Since research is yet scarce in this area, exploratory research is needed to develop knowledge. That is why the data for this research was collected by executing in-depth interviews with employees of health insurers. The goal of this qualitative research method is to see the research topic from the perspective of the health insurer, and to understand their development to this perspective. Conducting interviews with a low degree of structure imposed by the interviewer and mainly consisting of open questions is therefore the appropriate research method (Cassell and Symon, 2004). Respondents are working for health insurance companies, and will be directly involved in the negotiation process with the hospitals. They are expected to provide first-person perspective on the matter.
The literature review starts with personal questions for the interviewee to gain personal information. After this, the structure of the interview guide is similar to structure of the literature review. The literature review discussed the established literature and revealed the gaps and problems in the literature. The interview guide was designed to cover this information of which the literature seems to be lacking. All factors found in the literature that seem relevant to the health insurer are elaborately discussed in the interview in the same order as the literature review. In addition to this, questions are designed with the intention to provoke the interviewee to reveal other factors and give a complete image of their interests in the negotiation process.
The criteria aimed to be met in this research are controllability, reliability and validity. These three criteria are important because they are the basis for inter-subjective agreement on the research results (Aken, Berend and Bij, 2012).
3.1.1 Controllability
In order to make the research controllable, transcripts of the interviews are kept. Furthermore, the research was precisely described, to such extent that it is replicable for other researchers. This ensures the controllability of the research (Aken, Berend and Bij, 2012). Results are presented precisely, in a way where room for different interpretations is reduced to a minimum.
3.1.2 Reliability
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influenced by specific situations, the interviews were held during different times during the day. Half of the interviews are done in the morning and half of the interviews are done in the afternoon (after 2pm). The places where the interviews were held was also of a different category. The locations differ from a formal location, the work place of the respondent, to a more informal location. The latter is in the form of a Skype call.
3.1.3 Validity
To increase validity of the research results multiple interviews were held. The interviews will be guided to such extent that the concept is completely covered. In addition, for improving validity the interview protocol is controlled for the ‘fit’ with the meaning of the concept. (Aken, Berend and Bij, 2012). This means that the questions in the interview will be adequate for the subject of the research.
3.2 Data
The goal of this research was to expose the factors that health insurers find important in the negotiations with the hospitals. These factors were investigated by interviewing employees of health insurance companies who are involved in the negotiations with hospitals. The sample and data interpretation are discussed below.
3.2.1 Sample
The Dutch healthcare market has over forty providers of health insurances. These insurers are subsidiaries of nine firms. The nine parent companies negotiate medical care for all subsidiaries. The aim was to talk to employees of six different insurers. The selection criteria were based on the size of market share of the insurer. Six different insurers of which each has over 2.5 percent of market share in the Netherlands were contacted. The six largest health insurers were contacted, as these are expected to have a bigger influence on the healthcare market in the Netherlands. From these six firms, two were willing to participate in the research. Both companies have over ten percent of market share in the Netherlands (Zorgwijzer.nl, 2015a).
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Three insurance companies were contacted through the contact form on their website. This did not have a positive result for any of the three contacted insurers. A different health insurer was approached by a known contact. This person was able to deliver contact details of suited employees who might be interested in participating. Eight of these employees were contacted through email, of which four resulted in participating in the research. One of these participants recommended a participant employed by a different health insurer, which made it possible to directly contact an employee at the second investigated insurance company. This person also delivered contact details of a colleague who participated in the research. Another insurance company was approached by receiving contact details through university, but this person was not a suited participant, nor was he able to provide contact details of a suited participant in his firm.
A total of six employees were interviewed. Each participant has been directly involved with the negotiation process for one or more years. Each of them is speaking directly with the hospital’s representatives, and closes contracts on behalf of their organization. All participants are male. Five interviews were held in person at the building of the insurance company, and one was held through a Skype call. The table below shows more information on each interview and the participants.
Table 1
Details of participants and interviews
The insurance companies are to remain anonymous, which is why their names are fictional. Purchaser medial specialism entails preparing for the negotiations with hospitals, negotiating with the hospitals
Sex Title Insurer
(Fictional name) Amount of years working in current position Location interview Interview time (minutes) Background in medical care Education
1 Male Senior purchaser
medical specialism
WithLife 5 Office 30 No Business
Administration
2 Male Purchaser medical
specialism
WithLife 1 Skype 44 Yes Medicine
3 Male Senior purchaser
medical specialism
WithLife 5 Office 45 No Human movement
science
4 Male Senior purchaser
medical specialism
WithLife 7 Office 60 Yes Nursing
5 Male Senior purchaser
medical specialism
Nationwell 8 Office 36 Yes Nursing & Medical
sociology
6 Male Purchaser medical
specialism
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and carrying the responsibility of signing contracts to purchase sufficient hospital care for their customers. The respondents are present at the negotiation table and are experts in assessing and drawing contracts. They can explain all that is relevant to the negotiations with hospitals and how these negotiations work into detail.
3.2.2 Data interpretation
After completion of the interviews, the interviews were transcribed into a Microsoft Word document. This includes a field note on information of the interview, such as body language and ways of speaking. In the transcription process spoken language was adjusted, but not completely removed. The transcripts were then send to the participants. This gave the participants the opportunity to edit or remove anything they had said. The transcripts were adjusted accordingly. Once the transcripts were finalized the coding process began. Each interview was analyzed and common keywords and phrases were encoded. A framework was constructed in Microsoft Excel consisting of the codes with suitable category labels. Each interview was labeled depending on whether it was mentioned in that interviews. Page numbers were added for easy retrieval.
Following was a search for cross-case patterns, but attention was also paid to noticeable differences. When remarkable codes were found, all interviews were again analyzed to see if other participants gave similar or different views on that factor. The found insights were compared to the existing literature. Attention was paid to findings that differ strongly from existing findings. Based on the information in the excel sheet the structure emerged for reporting the results. After the issuing of the results, the interviews were again analyzed. Remarkable findings that were not yet included in the report of the results were added. All interviews in total are thoroughly read between five and ten times.
18 4.0 Results
This chapter will present the findings of the research.
4.1 Introduction
There is a certain hierarchy in the factors that health insurers find important in the negotiations. The results will be discussed in the order of this hierarchy; the most important factors will be discussed first, followed by less important factors. The results start with the factor of quality, which is seen as highly important by the participants. Also considered as highly important is the price of hospital care, which is discussed next. Followed are the mixed findings on whether insurers give importance to contracting all hospitals. Next addressed is how geographic factors influence contracting decisions. Although it is not found important by the health insurer and seen as a given, it may be part of the reason to contract a certain hospital. Then, participants indicated that they find it important that hospitals provide the necessary treatment, but not more than that. This is discussed under expediency. Another factor that came up in the interviews was the importance health insurers give to care being provided in the right place, and as close to the patient as possible. A technological development makes it possible to shift more care from the hospital to a location closer to the patient, which is of interest to the insurer. After this, some other factors are addressed that are not found highly important to the insurer, but are used in the analyzations for the preparations for the negotiations. When all the relevant factors are addressed, there is a discussion on how health insurers assess the care that they buy from the hospital and how the interests of the patient are included in the negotiations. Lastly, the remarkable aspect of time pressure in the negotiations is brought to light.
4.2 Factors that are important to health insurers
The factors are discussed in the order of importance insurers give to them. It starts with the most important factors quality and costs.
4.2.1 Quality
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to make the differences in quality between hospital more transparent. Patients should be able to receive more information on which hospitals show better quality, in for example hospitals with a lower chance on the need for a repeat treatment.
‘They cannot demonstrate this well because quality is not always transparent, and it is very
demanding for a hospital to gain insight in the quality and to compare it with other hospitals’ ‘so, we do have those conversations, but far too little to really relate them to our purchasing goals’ (Participant 5, Nationwell)
‘So, quality is definitely topic of conversation, but it is still difficult to make it objective and
comparable.’ (Participant 1, WithLife)
For other participants, quality was experienced as a given. Quality is assumed to be of a sufficient level, and the Dutch hospitals are assumed to deliver high quality care. Only when the quality appears to be inadequate they will take action.
‘You can expect that when you pay good money for a treatment, that you receive good quality.
So, we will not pay more for good quality. When that quality is below average, we will talk about it.’ (Participant 5, Nationwell)
Another participant indicated however that high quality is worth noticing and that the hospital can also be rewarded for showing a higher level of quality.
‘If they can prove that they deliver better quality that the rest, we should look at that, of
course.’ ‘That is the reason why we say to some hospitals; in this area of care you are allowed to make volume free agreements.’ (Participant 6, Nationwell)
These differences in responses are noticeable, as both participants are employees of the Nationwell organization. An explanation may be the difference in function. Participant 5 may have a different explanation as a senior purchaser medical specialism, but why this difference exists among job functions is yet to be explained.
4.2.2 Hospital prices
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‘I think that we as health insurers, have an important duty to maintain the healthcare system
that we have in the Netherlands.’ ’15 percent of the gross domestic product, so 15 percent of the income of a family is spend on healthcare. That number should not become much higher. So, I think that that is a big concern, to at least not let the premiums rise a lot the coming years. So, affordability is, I think, the number 1 concern’. (Participant 1, Withlife)
‘But what we do want all together for the Netherlands is it [the care] to be at a fair level.
Cause let’s be real, if we always honor all hospitals’ affairs, we would be bankrupt by now’
(Participant 6, Nationwell)
The prices of the DOT’s can be different per hospital, and each insurer can pay a different price for the same treatment at the same hospital. The reason that prices differ between hospitals are dependent on many aspects. Quality, costs of the building, infrastructure, population and cost structure are some of the reasons that came forward from the interviews. It was mentioned that the insurer is, however, trying to get the prices of different hospitals closer together. Especially the prices below the deductible. The patient is responsible for payment of this amount, and is therefore more attentive to differences in these prices. Participant 2 said that at this moment they are not able to explain the major differences in these prices to customers, which is why they are trying to bring these prices closer together. Major differences can only be explained when it is quality related, but differences in quality are difficult to demonstrate;
‘Especially for the prices that are below that [the deductible], we are very keen on getting
closer together. Because you cannot explain to the patient that the treatment will costs a lot more at a neighbor hospital, unless the quality is a lot better but we can often not demonstrate this’ (Participant 2, WithLife)
4.2.3 Contracting all hospitals
On whether to sign contracts with all hospitals, participants gave diverse statements. All four participants of health insurer Withlife were very clear that this was not a goal itself. They indicated that buying enough care for all their insured persons was the main goal, and that this does not necessarily mean that they must contract all hospitals.
‘It is not a goal in itself to contract all hospitals. What we do want is to purchase enough care
for all our insured persons.’ (Participant 1, Withlife)
‘I think most importantly is that we, because we have a duty of care according to the law, that
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to satisfy the duty of care. The question is whether you want to contract them because you believe the quality is good and that you pay a good price and that people can go there and that they are treated well. That is the important thing.’ (Participant 2, Withlife)
According to Legalee (2016), this way of purchasing care increases the hospital quality. Hospitals should use information like quality in their purchasing decisions, and should not per se sign contracts with all hospitals.
Contrary statements were given by the participants of Nationwell. They indicated that signing contract with all Dutch hospitals is necessary, and that it is in the interest of the patient. One of the reasons for this is that patients should be able to go to the hospital of their own choosing, and the specialist where he or she has been going in the past.
‘That is the interest of your insured person, the interest of that patient. Of course you want to
make sure that all those patients can go to the hospital of their own choosing. When you say, tomorrow I will not contract hospital X, and someone has been going to that pulmonologist or cardiologist for years, and now suddenly they cannot go there anymore, I would not like to be that patient. I would like to go to the hospital where I am familiar. So, in that sense, you do try to contract all hospitals to meet the patients’ wishes’ (Participant 5, Nationwell)
Another reason for contracting all hospitals because it is said to be needed in order to guarantee sufficient care. All hospitals are needed to purchase enough health care.
‘We have our duty of care. So, we should be able to guarantee the care everywhere in the
Netherlands. And that is the reason why we say that we have to contract every hospital’ (Participant 6, Nationwell)
On the question if this would put more pressure on them for arranging the contracts, participant 5 answered:
‘We tell those hospitals; in any way, we are going to sign a contract with each other. Period.’
As is shown above, the state of mind on the issue of contracting all hospitals differs between different health insurers. One insurer states that it is not a goal, the other states that it is necessary to guarantee enough care. This difference between health insurers is yet to be explained, and needs further research.
4.2.4 Geographic factors
22
that the insurer has in that hospital area. The insurer has a greater importance in a hospital with high market share, and therefore more time is needed for negotiating with the hospital.
‘You can see that mainly the hospitals where we have a large market share, so where we
represent many insured customers, we have more conversations with them.’ (participant 1,
Withlife)
‘There where the importance for the health insurer is larger, he will do more and those
conversations will be more complex.’ (Participant 3, Withlife)
The market share of an insurer in a certain area also puts more pressure on signing contracts with hospitals in that area, as they should purchase more care. When there is one hospital in a stretched-out area, insurers are obligated to sign a contract with that hospital. This is because guidelines exist on how long the maximum distance can be for insured people to get to the hospital. These are guidelines insurers must keep in mind, and insurers are therefore not always free to decide to deny contracts with a certain hospital.
‘For example the region around ABC, sixty percent of the people there are insured at Withlife.
To buy care for all those people, you must close a contract with the hospital in that region, because otherwise you cannot let those people get treatments close by’ (Participant 2,
WithLife)
This means that insurers are sometimes obligated to contract a hospital, even when they do not agree on other factors. For example, the insurer may not be pleased with the quality the hospital provides, but has to settle on this to be able to buy care in that region.
4.2.5 Expediency
What came up in the interviews was the importance some of the participants gave to the factor expediency; to deliver sufficient care and not more than that. Doctors should not provide care that is unnecessary because this negatively influences the costs. The insurers are very attentive to doctors not providing treatment for the purpose of their own income.
‘Expediency is in particular very important to us, at least that we do not see that too many
operations are taking place. Or at least no more than what we would expect based on a certain patient population’ (Participant 1, Withlife)
‘It is about giving the patient what he or she needs and no more than that, no extra scans,
23
he does what is necessary, and has no incentive to do more than is needed to make extra money.’ (Participant 2, Withlife)
4.2.6 Care provided at the right place
What was emphasized in most of the interviews was the importance of the care to be provided in the right place. What the participants indicated was that care should be provided as close to the patient as possible. If hospital care can just as good be provided by the general practitioner, then this care should be moved to the GP. They emphasize the importance that patients should not receive care in the hospital when this is unnecessary.
‘What we also find important is that care takes place at the right place. What we see the
coming years, is that we expect much of the hospital care to shift, either to the GP, or to the patient’s home. That is a technological development. So, care at the right place is also something that we find important, for care to be organized as close by the patient as possible.’
Participant 1, health insurer X’ 4.2.7 Other factors
In the preparations prior to the negotiations, the financial budgets are determined. The financial space that is given to the negotiators is based on many factors. One is the premium that they want to ask their customers for the coming year. This relates to the hospital budgets. Another factor is financial developments in the Netherlands, as well as physical developments. One participant named the aging of the population, and the growing number of people with chronical illnesses. This allows for the costs of health care to rise. These developments are analyzed and all related to the budgets, and influence the details of the contracts with the hospitals.
In the preparations for the negotiations with the hospital, the health insurer already takes many factors of the hospitals into consideration; the quality of the hospital, the efficiency, the asking prices and the volumes. Another participant mentions more factors to be considered in the preparations; Patient experiences, waiting times. The hospitals way of charging is also looked at, for example when they charge many expensive products in comparison to other hospitals. The agreement of the previous years was also mentioned by one of the participants.
‘You try to compare hospitals based on prices. But you also try to compare what happened in
24
image from that hospital. And that is how you enter the conversations’ (Participant 5,
Nationwell)
This shows that even before entering the negotiations many factors are analyzed by the health insurer. The making of the financial budgets is not a simple costs issue, and the insurer has a much bigger focus than this. Many factors are considered when establishing the budgets. The insurer indicates that it is far from their intention to deprive the hospital of sufficient resources. They feel that they together are responsible for providing the right care.
‘What do we want to spend at that hospital, what do we think is real without the hospital going
down. Because we need them. ‘(Participant 6, Nationwell)
4.3 The assessment of the negotiated care
The employees of the health insurers have to negotiate on medical care, but they are not medical experts themselves. It was investigated how they can assess the medical care they are negotiating on. All participants indicated that the insurance company has medical advisers employed. In the negotiations, they can request upon a medical advisor to join them for the conversation. The medical advisor can help them give a good idea of the quality of the treatment, or the importance of the treatment. They provide a contribution to the table when for example, conversations arise about new treatments, about treatments that the insurer finds that the hospital should provide less of, or not at all.
Lack of medical knowledge was not considered a problem by the participants. It was mentioned that in order to negotiate on hospital care, it is not per se needed to have detailed knowledge on the negotiated product in order to come to financial agreements.
‘It [knowledge of medical specialism] is not per se necessary in order to make a good
financial agreement.’ (Participant 3, Nationwell)
‘We want to pay a fair price, and we want a fair volume. You do not need to be a doctor to be
able to determine that.’ (Participant 1, WithLife)
It was also emphasized that it is a positive thing that the expertise is at the hospitals, and not at the insurer. And that it is also found the other way around, medical specialists do not always have much knowledge on how the financial aspect of the hospital works.
‘Obviously, the knowledge on medical specialism is at the hospitals and not at the health
25
of care or that we don’t know what we’re talking about at the moment that we are purchasing care’ (Participant 5, Nationwell)
It was commonly shared that the knowledge gap on medical expertise is not a problem for the insurer. Participants even mentioned that they have a knowledge advantage, as they have the information of all hospitals in the Netherlands available of the previous years. They can use this information to benchmark hospitals on. Hospitals themselves do not have much information available of other hospitals, so health insurers have this advantage over hospitals.
4.4 Patients
On whether and to what extent patients are included in the negotiations the participants were all on the same page. They indicated that patients are not directly included at the negotiation table, but that they are included in the policy developments which influence their negotiation approach. They take the perspectives of patient associations into consideration in the policies, and try to connect this to their purchasing goals in order to meet the interests of the patient.
4.5 Time pressure
What came forward in the interviews is the influence of time pressure on negotiations. In November prior to the new year, health insurers have the obligation to provide the information on which hospitals are contracted to their ensured people. When this date comes closer, the insurer experiences more pressure. The hospital does not feel this level of pressure to finalize the contracts in time, as they do not have this information obligation.
‘We want to communicate to our insured persons in time which care is contracted. And what
you see is that the hospital is not very triggered to speed up the negotiation process. So, that can be a field of tension.’ (participant 1, WithLife)
The time pressure can lead to more tension in the conversations.
‘And then you find yourself in time shortage at the end, and that is a difficult process to still
remain the conversation in a good way.’ (Participant 2, WithLife)
Some participants indicated that this time pressure is sometimes misused by hospitals as hospitals are aware of the deadline that the insurer has.
‘And sometimes the providers misuse it [the time pressure], then they will wait till the
26
‘They will be after me, internally, when I don’t have the deal closed up by that time. So, there
is a certain pressure put on me. And that leads to some sleepless nights in that period, sometimes. Yes, the deal has got to be closed, and I am the one who is responsible, and I must take care of it.’ (Participant 5, Nationwell)
The negotiations with the hospitals were described as ‘informal’ and ‘professional’, but become more tense when time is urgent and when the differences are still great. Some said the negotiations were sometimes seen as a game, where different techniques are used from both sides.
‘[When the parties cannot figure it out] Than those conversations are not getting any happier,
27 5.0 Conclusion
This research shows that health insurers deal with many different factors that determine their approach in the negotiations with hospitals, and creates an image of the many aspects associated with the negotiation process. Discussed below are practical and theoretical implications followed by the study’s limitations. This chapter includes recommendations for future research.
5.1 Practical implications
This research shows the difficulties that insurers encounter when assessing a hospital’s quality. The lack of guidelines on quality assessment makes it difficult to compare hospitals to each other. To improve the negotiation process, it would be helpful to establish clear guidelines on hospital quality. Valorization of scientific studies may be helpful to the insurers in order to define quality criteria. The literature shows for example the relation between human capital and quality, and IT and quality. These could be indicators for defining quality criteria. More factors found in the literature that are related to hospital outcomes can be used to create the guidelines of quality on which an insurer can make a more proper assessment of the quality that the hospital delivers. Insurers should use their negotiation power to request the information of hospitals on which the quality criteria are based on.
What also came up in the results was the lack of a joint vision on quality in the negotiations. Even within the insurance company different views and approaches regarding quality came up. In order to improve the effectiveness of the strive for quality a shared vision is helpful. It is recommended for the organization to create a vision on how to deal with quality in the negotiations, and to spread this vision throughout the entire organization. It can be helpful in the negotiations when employees are on the same page when it comes to including quality in the negotiation process.
Several studies demonstrate the relation between competition and quality (Propper, 2012; Bijslma, Koning and Shestalova, 2013). Insurers however seem to be unaware of this relation, as they do not make use of this knowledge in the negotiation process. A clear vision on which basis the prices have to be negotiated seems to be lacking as well. Clarity on whether it is the combination of price and quality that plays a key role or if geographic location is included as well would be helpful.
28 5.2 Theoretical implications
The results demonstrate that the health insurer finds the quality of the hospital highly important in the negotiation process, in contrast to other findings in the literature. However, the results also explain why it can be difficult for the insurer to actually bring the subject of quality to the table. Time pressure and geographic factors are examples of the obstacles that make it difficult to pressure hospitals to provide higher quality. An interesting avenue for future research is to study how insurers can make better use of their power to negotiate higher quality.
The literature has established that prices and budgets are highly important to insurers. This research enhances the literature by giving a richer explanation of the reasoning of insurers on why they give this much importance to negotiating on prices. The results demonstrate that the reason for the importance of negotiating on prices is related to the responsibility they feel to maintain the health care system. This explanation has not been found before in the literature.
Krabbe-Alkemade, Groot and Lindeboom (2016) found in their research that insurers barely use their negotiating power to selectively contract hospitals. This research contributes to these findings by gaining insight into the reasons why insurers do not selectively contract hospitals, and the obstacles they face when they are trying to purchase care from selectively chosen hospitals. The results show several reasons why the insurance companies often contract all hospitals in their country and hardly refuse to contract a hospital.
The literature review shows that the literature analyzes certain elements of health care, but lacks a model that includes all relevant elements. This study revealed that more factors are important in the negotiation process, for example time pressure, geographic factors and other factors. The literature would be enhanced with the creation of a model covering this complexity. The creation of such a model would be an interesting step for future research.
5.3 Limitations
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30 6.0 References
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Halbersma, R., van Manen, J., and Sauter, W. (2012). De verzekeraars als motor van het zorgtoestel.
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Ho, K., and Lee, R.S. (2013a). Insurer competition in health care markets. National Bureau of
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Legalee. (2016, may 16). Zorgverzekeraars & zorginkoop. Retrieved from https://legalee.nl/zorgverzekeraars-zorginkoop/
McKellar, M., Naimer, S., Landrum, M., Gibson, T., Chandra, A., and Chernew, M. (2013). Insurer Market Structure and Variation in Commercial Health Care Spending. Health Services Research, 49(3): 878-892.
Menachemi, N., Chukmaitov, A., Saunders, C., and Brooks, R.G. (2008). Hospital quality of care: does information technology matter? The relationship between information technology adoption and quality of care. Health Care Management Review, 33(1): 51-59.
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32 RVZ. (2008). Onderhandelen met zorg. Retrieved from
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Appendix A: Interview guide
Voordat we beginnen zal ik u wat over het doel van het onderzoek vertellen. Het thema voor mijn masteronderzoek onderzoekt verschillende stakeholders binnen de gezondheidszorg, en mijn focus ligt bij de zorgverzekeraar. Mijn onderzoek gaat over het onderhandelingsproces tussen de ziekenhuizen en zorgverzekeraars. En ik zou dus erg graag uw perspectief op dit onderwerp willen horen. Het interview zal ongeveer 60 minuten duren. Alle informatie uit dit interview zal vertrouwelijk worden behandeld, en de data zullen geanonimiseerd worden.
Gaat u ermee akkoord dat het interview opgenomen wordt?
Ik kan u een verslag van het interview toesturen om misinterpretaties te voorkomen; u kunt dan eventuele correcties nog aan mij doorgeven; is dat akkoord wat u betreft?
Ik kan u de eindversie van het eindrapport toesturen. Heeft u hier belang bij? Heeft u tot zover vragen voor mij?
Ik zou graag willen beginnen met wat persoonlijke vragen.
Persoonlijke gegevens
Welke opleiding heeft u genoten?
Hoelang bent u al werkzaam voor ‘naam organisatie’? Hoelang ben u al werkzaam in uw huidige functie? Wat is de officiële titel van uw functie?
34 Structuur onderhandelingsproces
Ik wil u graag wat vragen stellen over de structuur van het onderhandelingsproces wat u uit naam van ‘naam organisatie’ heeft met de ziekenhuizen in Nederland omtrent de contracten.
Zou u in het kort kunnen vertellen hoe het onderhandelingsproces eruitziet?
De respondent zoveel mogelijk zijn eigen verhaal laten doen. Waar niet duidelijk, vragen om opheldering.
Hoelang duurt het gemiddelde onderhandelingsproces met een ziekenhuis?
Hoeveel gesprekken vinden er ongeveer plaats per ziekenhuis?
Hoeveel mensen van ‘naam organisatie’ zijn er betrokken bij het onderhandelingsproces?
Sfeer onderhandelingsproces
Hoe zou u de sfeer tijdens het onderhandelingsproces omschrijven? (Duidelijk maken, in
termen van professioneel, informeel, vriendelijk of vijandig)
Als respondent niet zelf over de mate van verschillen tussen ziekenhuizen begint, hiernaar vragen.
Als het onderhandelingsproces meer moeizaam verloopt, verandert de sfeer/relatie met het ziekenhuis dan ook?
Zijn er nog andere partijen bij het onderhandelingsproces betrokken? (Bijvoorbeeld
beroepsverenigingen, patiëntenverenigingen)
Factoren zorgverzekeraar
Hoe zien uw voorbereidingen op het onderhandeling proces er uit?
Doorvragen. Alleen globale budgetten of op DOT-niveau?
Als zorgverzekeraar, heeft u voorafgaande aan de onderhandelingen al minimale eisen gesteld die uit de onderhandelingen voort zouden moeten komen?
Doorvragen. Als het ziekenhuis niet akkoord gaat met deze minimale eisen, wat gebeurt er met het contract?
35
Houdt u er vooraf rekening mee dat het sluiten van de contracten bij bepaalde ziekenhuizen meer moeite gaat kosten dan bij anderen?
Wat zijn factoren waar u als zorgverzekeraar op doelt in het onderhandelingsproces? Is dit bijvoorbeeld de kwaliteit van een ziekenhuis, waardoor zij meer druk kunnen uitoefenen op de zorgverzekeraar?
De prijzen voor behandelingen kunnen verschillen per ziekenhuis. Wat is de reden dat het ene ziekenhuis een hogere prijs kan onderhandelen dan het andere?
Het wordt weleens in twijfel getrokken of het belang van de patiënt genoeg centraal staat in het onderhandelingsproces. In welke mate vindt u deze twijfels terecht?
Hoe belangrijk is het voor ‘naam organisatie’ om contracten te sluiten met alle ziekenhuizen?
Ik noem een aantal factoren voor u. Zou u kunnen aangeven hoe belangrijk deze factoren zijn voor de zorgverzekeraar in het onderhandelingsproces op een schaal van 1 tot 10? (Waarbij 1 helemaal niet belangrijk, en 10 erg belangrijk)
Kwaliteit van het ziekenhuis Prijzen van de behandelingen
Het aantal behandelingen dat een ziekenhuis uitvoert De locatie van het ziekenhuis
Patiënttevredenheid
Het afsluiten van een contract met alle ziekenhuizen Efficiëntie van het ziekenhuis
36 Kennis van zorgverzekeraar wat betreft zorg
Denkt u dat de onderhandelaars van het ziekenhuis een informatievoorsprong wat betreft medisch specialisme hebben op de zorgverzekeraar?
Een onderzoek van de RVZ (Raad voor de volksgezondheid en zorg) wijst uit dat veel ziekenhuizen niet geloven in de kunde en kennis van de zorgverzekeraar. Slechts een derde van de ziekenhuizen geeft aan te denken dat de onderhandelaar van de verzekeraar voldoende kunde heeft. Hoe denkt u hierover?
U onderhandelt over medisch specialistische zorg, maar bent geen medisch specialist. Hoe beoordelen jullie de zorg waarover behandeld worden? Hebben jullie kennis van de medische behandelingen? Of beoordelen jullie de behandelingen op historische data?
Is er een medische specialist bij jullie in dienst die de benodigde kennis heeft over de onderhandelde behandelingen?
Is er ook data-sharing met andere zorgverzekeraars? Bent u bijvoorbeeld op de hoogte of andere zorgverzekeraars andere (lagers) prijzen kunnen onderhandelen met de ziekenhuizen?
Zo ja, waarom denkt u dat die verschillen kunnen bestaan?
Hoe controleert u of de gedeclareerde behandelingen ook daadwerkelijk zijn gedaan?
Hoe gaat ‘naam organisatie’ om met het risico van upcoding?
Afsluiting
We komen bij het einde van het interview. Zijn er nog zaken die niet aan bod zijn gekomen die u wel graag met mij wilt delen?
Mocht u nog vragen of opmerkingen hebben, kunt u altijd weer contact met mij opnemen.
