A Care Management Information Blueprint for Dutch Health Insurers

A Care Management

Master Thesis A Care Management Information Blueprint for Dutch Health Insurers

July, 2010

Author Hillebrant H. Idsinga h.h.idsinga@student.rug.nl s1214985

MSc Business Administration: Business & ICT

University of Groningen University of Groningen

Faculty of Economics and Business Nettelbosje 2, 9747 AE Groningen The Netherlands

Prof. Dr. Henk G. Sol

Professor of Business and ICT First Supervisor

Drs. J. B. van Meurs Second Supervisor

Accenture Accenture Nederland Gustav Mahlerplein 90 1082 MA Amsterdam

Ruurd Reitsma Manager

Accenture IT Strategy & Transformation (ITST) External Supervisor

Paul N. van der Waay Senior Executive

A

A

C

C

K

K

N

N

O

O

W

W

L

L

E

E

D

D

G

G

M

M

E

E

N

N

T

T

S

S

This Master thesis is the final deliverable of my MSc BA Business & ICT study at the University of Groningen.

I would like to thank several people that contributed to the achievement of this thesis. First of all, my supervisor from the University of Groningen: Prof. Dr. Henk Sol challenged me to focus on the right subject. He opened doors for me that might not have been opened

otherwise by referring me to the right people and by being an advocate for my academic research in the discussions with ‘the business’.

I am very grateful to Ruurd Reitsma and Marcel van Oers who initiated the internship project that led to this master thesis. In the first two months of my internship Marcel has helped me to start this project while ‘keeping the end in mind’. Over the next few months Ruurd has helped me countless times with valuable feedback and by pointing me to the right sources. Without his continuous support I would not have been able to deliver the two ‘deliverables’ of my research: the IT Strategy Point-of-View on health insurers and this Master thesis. In the absence of Marcel and Ruurd, Maarten Beekman helped me to stay on track.

I am also very grateful to my primary sponsor within Accenture IT Strategy and Transformation, Paul van der Waay. He contributed with knowledge and advice. His involvement upgraded a regular internship to a special one, where I had the opportunity to meet the right people with the right information. Marijntje Wetzels of the Health & Life Sciences practice contributed to a great extent. She helped to identify and to prioritize the cases for this research. She introduced me to a number of interviewees, including Daniel Schlegel, who in turn contributed by sharing his expertise on global health insurer issues. Other Accenture colleagues that contributed are Harald Timmer, Geert van den Goor, Hans Kuipers, Arnaud Hartog, Wouter Pomp, Stanja Mau-Sjoe, Erwin Vorwerk, Eric de Groot, Arthur van den Bovenkamp and everyone who provided me with valuable feedback at the bi-weekly IT Strategy Community of Practice meetings.

Of course this research would not have been possible without the help of all the interviewees who devoted about two hours of their valuable time.

The last few months would not have been the same without my fellow interns. The Friday drinks in the winter of 2009 and the office party of fiscal year 2010 will be printed in my memory forever. In the first period of my internship, I had much fun with Rebecca, Marlies, Ali, Sven, Hans-Willem; and later with Hans, Wouter and Martijn. Hans-Willem Giesen also contributed in the shaping of my thesis. We helped each other reach our goals within

Accenture in weekly substantive meetings.

I would like to thank my (college) friends and members of Minax. They have given me laughter, fun and precious memories for my time in college.

My aunt and ‘landlord’, Alie Meester, provided me with an inspiring place to stay in the city centre of Amsterdam during my internship. A few years ago I would never have guessed that I would be writing my thesis with a view over the Amsterdam canals.

Finally I would like to thank my family. First of all, my girlfriend, Barbara, whom I met during my stay in Amsterdam. She supported me throughout the process, with her love, friendship, patience and expertise: within four weeks after we met, she already helped me shaping my research proposal.

I am very much obliged to my mother, father, Willem, my brothers, grandmother and other family. They advised me throughout the years and offered financial and emotional support in good and bad times. With her expertise in health care, my mother provided me with valuable feedback. She also collected piles of health related newspaper clippings on my desk, every time I was able to visit them in the North. Without doubt they are the most loving, caring and supportive people I know.

A

A

B

B

S

S

T

T

R

R

A

A

C

C

T

T

Health care is in crisis: costs are rising unsustainably and there is a general lack of quality for patients. A systematic transformation is needed, with a focus on improving quality of care that will result in lower overall costs.

In the Netherlands this systematic transformation has partly taken place, with health insurers in a pivotal role. They reveal themselves more and more as the directors of health care.

A pre-study to this research and a literature review suggest that health insurers need more information in this new role. Health insurers seem to have sufficient information to manage care in general. But, in order to be able to reduce claims costs and to improve quality of care they need to be able to respond flexibly to new initiatives that can assist in achieving that goal. They need to be able to manage health care delivery strategically, tactically and operationally at the micro level, i.e. the individual client or care provider.

The ‘summum bonum’ is where initiatives can reduce claims costs and at the same time improve quality of care. This qualitative design-oriented research identified relevant health insurer intervention cases and theorized the information needed to practically manage these cases. A blueprint containing these information needs is the main artifact of this research. The identified cases are:

A. Internet-delivered health insurer interventions: second opinion online B. Health coaching for co-morbid chronic diseases powered by call centers C. Disease management programs/clinics for specific (chronic) conditions D. Detect, evaluate, purchase and support new and innovative care initiatives E. Care performance management: Support the adoption of the most recent best

performing treatments

F. Provider quality monitoring and profiling in contracting

The information needs for Dutch health insurers to practically manage these health insurer intervention cases are mainly in care purchasing. The information needs focus on the characteristics, performance, compliance and medical outcomes of treatments, clinics and doctors.

In product distribution the information needs lie in identifying patients that can participate in care interventions, identifying other stakeholders that can participate, and planning and promoting interventions/treatments. In product definition, maintenance, underwriting and pricing the main information needs are directions, guidelines and criteria for the

interventions. In policy servicing no information needs were found. In claim handling, the main information needs are in identifying providers that use specific treatments or

medicines and determining financial impact of interventions. © 2009-2010 by Hillebrant Idsinga

C

C

O

O

N

N

T

T

E

E

N

N

T

T

S

S

Acknowledgments ... iii

Abstract ... vii

1 Introduction ... 1

1.1 Dysfunctional competition in health care ... 1

1.1.1 Higher quality results in lower costs ... 1

1.1.2 Innovation in health care faces major challenges: technology is not the solution itself ... 2

1.1.3 Systematic transformation ... 2

1.2 Health care reform in the Netherlands ... 3

1.2.1 New role of health insurers ... 4

1.3 A business point-of-view on Dutch health insurers ... 5

1.3.1 Key forces that impact Dutch health insurers ... 6

1.3.2 The changing role of Dutch health insures ... 6

1.3.3 Large Dutch health insurers struggle to make a profit and have less satisfied clients ... 7

1.3.4 Business Agenda ... 7

1.4 Research focus: Information needs for Dutch health insurers ... 8

2 Research Approach ... 10

2.1 Research objective ... 10

2.2 Problem formulation and research questions ... 10

2.2.1 Research question ... 10

2.2.2 Research definitions ... 11

2.3 Research Methodology ... 12

2.3.1 Experts and interviewees ... 12

2.3.2 Research design ... 12

2.3.3 Research contribution ... 14

2.3.4 Research procedure ... 15

2.3.5 Thesis structure, data collection and analysis ... 16

3 Health Insurer Intervention Cases ... 18

3.1 Health insurer intervention cases ... 18

3.2 Case relevancy ... 18

3.3.1 Relevancy from literature ... 19

3.3.2 The interviewees’ opinion ... 20

3.3.3 Mapping on systematic transformation characteristics ... 20

3.3.4 Overall Case Relevancy ... 21

3.4 Health coaching for co-morbid chronic diseases powered by call centers (B) ... 21

3.4.1 Relevancy from literature ... 21

3.4.2 The interviewees’ opinion ... 22

3.4.3 Mapping on systematic transformation characteristics ... 22

3.4.4 Overall Case Relevancy ... 23

3.5 Disease management programs/clinics for specific (chronic) conditions (C) ... 23

3.5.1 Relevancy from literature ... 24

3.5.2 The interviewees’ opinion ... 25

3.5.3 Mapping on systematic transformation characteristics ... 25

3.5.4 Overall Case Relevancy ... 25

3.6 Detect, evaluate, purchase and support new and innovative care initiatives (D) ... 26

3.6.1 Relevancy from literature ... 28

3.6.2 The interviewees’ opinion ... 28

3.6.3 Mapping on systematic transformation characteristics ... 28

3.6.4 Overall Case Relevancy ... 29

3.7 Care performance mgt: support adoption most recent best performing treatments (E) ... 29

3.7.1 Relevancy from literature ... 30

3.7.2 The interviewees’ opinion ... 30

3.7.3 Mapping on systematic transformation characteristics ... 30

3.7.4 Overall Case Relevancy ... 31

3.8 Provider quality monitoring/profiling in contracting (F) ... 31

3.8.1 Relevancy from literature ... 31

3.8.2 The interviewees’ opinion ... 31

3.8.3 Mapping on systematic transformation characteristics ... 32

3.8.4 Overall Case Relevancy ... 32

3.9 Intermediate Conclusions ... 32

4.1 Accenture iModel ... 33

4.1.1 How the model is used ... 34

4.2 Impact of the health insurer intervention cases ... 34

4.2.1 Internet-delivered health insurer interventions: second opinion online ... 34

4.2.2 Health coaching for co-morbid chronic diseases powered by call centers ... 38

4.2.3 Disease management programs for specific (chronic) conditions ... 41

4.2.4 Detect, evaluate, purchase and support new and innovative care initiatives ... 43

4.2.5 Care performance mgt: Support adoption of most recent best performing treatments... 46

4.2.6 Provider quality monitoring and profiling in contracting ... 49

4.3 Intermediate conclusions ... 51

5 Testing information needs ... 52

5.1 Information needs for Dutch health insurers tested with interviewees ... 52

5.1.1 Internet-delivered health insurer interventions: second-opinion online ... 52

5.1.2 Health-coaching for co-morbid chronic diseases powered by call centers ... 53

5.1.3 Disease management programs/clinics for specific (chronic) conditions ... 53

5.1.4 Detect, evaluate, purchase and support new and innovative care initiatives ... 53

5.1.5 Care performance mgt: Support the adoption of most-recent best performing treatments ... 54

5.1.6 Provider quality monitoring and profiling in contracting ... 54

5.2 Additional outcomes of the interviews ... 55

6 Information blueprint for Dutch health insurers ... 56

6.1 Intermediate conclusions ... 59

7 Final conclusions ... 61

7.1 Research limitations ... 62

7.2 Recommendations for further research ... 62

References... 64

List of Figures and tables ... 69

Figures ... 69

Tables ... 69

Appendix ... 70

1

1

I

I

N

N

T

T

R

R

O

O

D

D

U

U

C

C

T

T

I

I

O

O

N

N

1.1 D

YSFUNCTIONAL COMPETITION IN HEALTH CARE

The discussion on health care is mostly about the unsustainable rising of medical spending and the lack of quality health care. Health care is in crisis: health care delivery is often expensive and deeply dissatisfying to customers (Christensen, Bohmer and Kenagy, 2000; Herzlinger, 2006; Porter and Teisberg, 2004; Porter and Teisberg, 2006). Costs are rising and cannot be explained by improvements in quality (Porter and Teisberg, 2004). For quality the opposite is true: services are restricted, patients receive care that lags accepted standards and there are high rates of preventable medical errors (Porter and Teisberg, 2004;

Herzlinger, 2006).

The theoretical foundation of this thesis is based on the work of Porter and Christensen (Christensen, Bohmer and Kenagy, 2000; Porter and Teisberg, 2004). Both authors have a similar explanation on why health care is failing. The first author argues (Porter and

Teisberg, 2004) that there is dysfunctional competition in health care. Health care players are not creating value for patients, but instead they are increasing revenues, shifting costs and restricting services. The second (Christensen, Bohmer and Kenagy, 2000) argues that health care is becoming increasingly expensive because the industry is not investing in simpler alternatives to expensive care. The industry players wrongfully think that it is not in their own interest to find low-cost alternatives: they consider that it threatens their livelihoods in the care system.

1.1.1 H

Both authors argue that the solution is in improving quality of care. Improved quality of care results in lower overall costs. Christensen (Christensen, Bohmer and Kenagy, 2000) argues that less-expensive professionals can be enabled to do progressively more

sophisticated things in less expensive settings. Over time the performance output of less expensive professionals and methods, like nurse practitioners and self-care, is rising more rapidly than the diagnostic- and treatment performance that most patients need or can use. In Porters view (Porter and Teisberg, 2004) positive-sum competition in health care

1.1.2 I

:

Innovations can make health care better and cheaper (Herzlinger, 2006): they can focus on changing the way consumers buy and use health care, on using technology to develop new products and treatments and on generating new business models.

But new business models in health care are facing four major challenges (Hwang and Christensen, 2008): health care is fragmented, it is lacking a retail market, there are regulatory barriers and the reimbursement policies do not improve health care delivery. Herzlinger (2006) identifies six similar forces that can hinder efforts at innovation

(Herzlinger, 2006):

 Industry players might attack the innovator

 Financial challenges: funding the development and long-term funding is crucial

 Government policies can hinder innovation

 Technology infrastructure needed to support the innovation may not be present

 Customers armed with information disregard treatments they don’t agree with

 Empowered consumers and cost-pressured health insurers demand accountability from innovators on cost-effectiveness and long-term safety, in addition to shorter-term efficacy and safety requirements

It seems that innovations or technology is not the solution itself. Also Hwang and

Christensen (2008) argue that most technological enablers in health care have failed to lower costs, improve quality of care and increase accessibility.

But if technology or innovation is not the solution itself, how is it useful? Porter (Porter, May 13, 2009; Porter and Teisberg, 2004) suggests that information is crucial for well-functioning competition and that information technology should be used to enable the restructuring of care delivery and to enable measuring results. The information should be patient-centered, complete, use common data definitions and interoperability standards, accessible for all stakeholders and should cover the full cycle of care. Christensen et al. (2000) emphasize that technologies need to focus on enabling less expensive professionals to do progressively more sophisticated things in less-expensive settings.

1.1.3 S

Both authors (Porter and Teisberg, 2004; Hwang and Christensen, 2008; Christensen, Bohmer and Kenagy, 2000) argue that health care needs to undergo a systematic

efficiency. They should help members to learn about and obtain the highest-value care, by identifying treatment alternatives and recommending providers that can deliver these excellent outcomes (II). Health insurers should have effective disease-management

programs for the chronically ill patients (III). The efficiency part of the strategy is to simplify billing and administrative processes (IV). Overall health insurers should increase consumer choice (V) and increase value for patients, rather than shifting costs (VI). To enable all this health insurers need information on providers’ experience, outcomes and prices (VII). The characteristics of Christensen’s (Christensen, Bohmer and Kenagy, 2000) solution start with the fact that the clinicians’ skill level should be matched to the difficulty of the medical problem (VIII). Health insurers should invest in technologies that simplify complex

problems, instead of only in high-end complex technologies (IX). New organizations need to be created that initiate disruptive innovations (X). Finally the inertia of regulation should be overcome (XI).

1.2 H

EALTH CARE REFORM IN THE

N

ETHERLANDS

The Dutch have come far in achieving this systematic transformation. Historically the Dutch health care system has always been characterized by private initiative in both funding and provision of care (Ven and Schut, 2008). Ven and Schut (2008) identify three major waves of health care reform in the Netherlands:

 The ‚universal coverage wave‛ (1940 – 1970) where the government focuses on public health with universal access and a minimum level of quality.

 The ‚cost containment wave‛ (1970 – 2000) where the government is trying to draw the uncontainable growth in health care spending to a stop.

 The ‚efficiency through managed-competition wave‛ (2000 – 2010) where ultimately the old care system was replaced with a system similar to Enthoven’s model of national health insurance based on managed competition in the private sector (Enthoven, 1978).

From 2006 every Dutch citizen is obliged to buy individual health insurance from private health insurers, with a benefit package pre-determined by government. Insurers are legally obliged to accept all. High-costs patients are compensated with a risk-equalization fund (Ven and Schut, 2008).

1.2.1 N

Because of the increased competition and the changes in the Dutch health care system, health insurers are placed in a new pivotal role in this system (van Eenennaam and Stouten, 2007) (See: Figure 1). On one side health insurers have to offer a competitive premium to their members and on the other side they have to be efficient in care purchasing. Members have to be able to make conscious choices, when faced with care alternatives, and care providers have to offer care with the right ratio of price to quality.

Patients / Insured

Health Insurers

Conscious choice behavior

Offer care with the right price/quality

Competition

Care Providers

Efficient care purchasing

Competition

Competitive premium

Figure 1 Pivotal role of health insurers in the new Dutch care system (van Eenennaam and Stouten, 2007)

Van Eenennaam and Stouten (2007) identify four key archetype roles that health insurers can have (See: Figure 2). The traditional role is the role of administrator (or: payer). The administrator focuses on standardization, cost control and efficiency. The second role is the role of purchaser who focuses on a sustainable competitive position by having an exceptional process of care purchasing. The third role is the role of advisor who has a customer-centric approach with a strong focus on quality of care providers. The fourth role is the role of

director. The director is different from the other three roles because it follows a chain-of-care

approach. The director integrates different care provider offerings and optimizes the care process for its customers. The director contracts care providers based information: on price, quality and volume. They have a long-term vision on care in general, care-renewal and its response to new regulations and changes in market conditions.

health care: ‚…we do that by acting as facilitating partner and leveraging our leading position to stimulate supplier excellence and easier access to quality care‛. The second largest Dutch health insurer, Univé-IZA-VGZ-Trias (Univé-VGZ-IZA-Trias, 2009) states it wants to respond to customer needs in health and care: ‚For our members we are an

advisor, guide or business minder [..] we inform our policyholders clearly about the quality of care and advise them in their choice‛. The third largest health insurer is CZ. Its mission is to be ‚the guide in health care‛ (CZ, 2009) by being groundbreaking in offering health care renewal: ‚…we are the guide, our customers are in control. In 2009 we actively supported our members in finding the best care, in staying healthy and in living healthy lives. CZ allowed insight in more information on care providers, so that our members knew what to choose‛. Finally, Menzis presents itself as an advocate for its care clients who points the way in health care (Menzis, 2008): ‚We show our members the way to quality, while maintaining their total freedom of choice. With [our product] TopZorg we let the free-market not only focus on price, but most of all on quality *of care+‛.

Director

Administrator

towards insurance market

to w a rd s c a re p u rc h a s e m a rk e t tow ards car e pr ovid ing mar ket

Advisor

Purchaser

Figure 2 Four archetype roles for health insurers (van Eenennaam and Stouten, 2007)

1.3 A

BUSINESS POINT

-

OF

-

VIEW ON

D

UTCH HEALTH INSURERS

The Amsterdam based IT Strategy and Transformation (ITST) office of Accenture initiated this study. Accenture is a global management consulting, technology services and

(Accenture, 2010b). For this purpose, Accenture Netherlands invited the writer of this thesis to develop an industry specific strategy point-of-view on health care. A typical

IT-strategy point-of-view outlines what happens in the industry, which relevant technologies emerge, what the business agenda of high-performing companies should be and how chief information officers (CIOs) or IT directors should respond. They are also the intended audience a point-of-view.

After a quick assessment with internal experts the focus of this point-of-view was laid on Dutch health insurers. Health insurers are relevant for Accenture and research in this direction was projected to be very valuable.

The full outcomes of this pre-study (Reitsma and Idsinga, 2010) are shown in the Appendix. The pre-study identified, among other things, the following issues:

 Key forces that impact Dutch Health insurers are at the level of customers, products, route-to-market and earnings

 Health insurers are slowly moving toward the director’s role in health care

 Large Health insurers struggle to make a profit and have less satisfied clients

1.3.1 K

D

Experts identify that Dutch health insurers are impacted by key forces at four different levels of their business model:

1. At the ‘customer’ level patients require more information. They are better informed and increasingly involved in decision-making. They require more and more

personalized services.

2. This affects the ‘products’ that health insurers offer. Technological trends, like internet computing and tele-health also change products and services.

3. At the ‘route-to-market’ level, there is a constant pressure of major regulatory

changes, while health insurers are already situated in a heavily regulated market. Insurers lack sufficient market power in the care purchasing process: care providers have the information advantage. They have more knowledge on the quality and volume of care.

4. Finally the health insurers are impacted on the ‘earnings’ level: there is a constant

pressure on lowering costs and at the same time improve quality of care.

1.3.2 T

D

1.3.3 L

D

While Dutch health insurers are moving towards the director’s role in health care they face both financial and quality-delivery challenges. Figure 3 shows insurer size (represented by the size of the bubbles), profits per insured (x-axis) and average customer satisfaction (y-axis) based on data from the Dutch national bank (De Nederlandsche Bank, 2008) and a quality index for health care in the Netherlands (Rijksinstituut voor Volksgezondheid en Milieu, 2009). As can be observed, the four largest Dutch health insurers are struggling to make a profit and have less satisfied clients1_.

Figure 3 Health insurers in the Netherlands: size, customer satisfaction and technical profits According to the experts there is a strong need to reduce costs and at the same time improve quality of care. But cutting costs in health care is not easy. Health insurers have low

operational costs, sc. only 4% of total costs2_{. The most effective source of cost reduction} seems to be claims costs, which accounts for 96% of total health insurer costs.

1.3.4 B

A

To be able to reduce claims costs and at the same time improve quality of care, the experts of Accenture suggest a business agenda (See: Figure 4) for Dutch health insurers. Health

insurers should show the following activities:

 a differentiated management of medical costs  focusing on prevention

 purchasing care with the best information available

1 _{Customer satisfaction statement based on mean service scores of all brand labels for the four largest} Dutch health insurers (Achmea, Univé-IZA-VGZ-Trias, CZ and Menzis) compared with the other health insurers, using data from the health portal of the Ministry of Health (Rijksinstituut voor Volksgezondheid en Milieu, 2009).

 offering personalized services to members  effectively operating internal processes

 responding with foresight to new rules and regulations

 having a corporate culture that rewards innovation and attracts and retains innovative employees

The experts emphasize that all these activities need to be fueled by information in order to be successfully executed.

Business Agenda

Improve quality of care and at the same time reduce costs of claims

Corporate culture that supports the director’s role in health care Sophisticated offering of personalized services Differentiated medical cost management and prevention IN F O R M A T IO N IN F O R M A T IO N

Figure 4 Accenture’s business agenda for Dutch health insurers

1.4 R

ESEARCH FOCUS

:

I

NFORMATION NEEDS FOR

D

UTCH HEALTH INSURERS

Literature suggests that health care is in crisis. A systematic transformation is needed, with a focus on improving quality of care, which will result in lower overall costs (See: chapter 1.1). In the Netherlands this systematic transformation has partly taken place, with health

insurers in a pivotal role: they reveal themselves more and more as the directors of health care (See: chapter 1.2).

According to literature, innovations or technology are not the solution itself. Instead information over the full cycle of care is crucial for well functioning competition in health care.

The results from the pre-study (See: chapter 1.3) suggest something similar. Dutch health insurers need to have a focused business agenda that helps them to reduce claims costs and improve quality of care. But in order to execute that business agenda, health insurers need a lot of information. For example, if a health insurer wants to offer specialized services it needs to know what services it should offer to what target group within their member population.

Health insurers seem to have sufficient information to manage care in general (at the macro level3_{). But, in order to be able to reduce claims costs and improve quality of care they need}

to be able to respond flexibly to new initiatives that can assist in achieving that goal. They need to be able to manage health care delivery strategically, tactically and operationally at the micro level4_{, i.e. the individual client or care provider. The ‘summum bonum’ is where}

initiatives can reduce claims costs and at the same time improve quality of care. With Accenture supervisors and sponsors of this project, in collaboration with the

University of Groningen it was decided to focus on these information needs for Dutch health insurers.

2

2

R

R

E

E

S

S

E

E

A

A

R

R

C

C

H

H

A

A

P

P

P

P

R

R

O

O

A

A

C

C

H

H

2.1 R

ESEARCH OBJECTIVE

The objective of this research is to identify the information needs that Dutch health insurers have in order to be able to manage care delivery at the micro level5 _{and to be able to respond} to new initiatives in health care that improve quality of care and reduce costs. The objective is that this research results in a practical solution for health insurers.

2.2 P

ROBLEM FORMULATION AND RESEARCH QUESTIONS

Using the results from the literature review (See: chapter 1.1 - 1.2) and the results from the pre-study (See: chapter 1.3) a problem statement can be formulated.

Following the Pyramid Principle (Minto, 2009) of situation, complication, question and answer, the research problem will be worked out.

The current situation for Dutch health insurers is the following:

 Dutch Health insurers are slowly moving towards a director’s role in health care

 Large Dutch health insurers struggle to make a profit and have less satisfied clients

 Claims costs count for 96% of all costs, operational costs are minimal (4%)

 Health insurers have sufficient information at the macro level6 _{to manage care} delivery

 People have access to more information and are more assertive The complications for Dutch health insurers are:

 Health insurers are unable to effectively reduce claims costs

 Health insurers are increasingly stimulated to act as the director of health care

 Health insurers need to be able to respond flexibly to new initiatives that improve quality of care

 The information of health insurers lacks granularity to be able to manage health care delivery strategically, tactically and operationally at the micro level7

These situations and complications call for a research question that needs to be answered. This will be the research question for this research.

2.2.1 R

The following research question is defined to be able to fulfill the research objective:

“What does an information management blueprint for Dutch health insurers look like, with which they can manage care delivery and respond to new initiatives at the micro level8_?”

To be able to answer the research question, three sub questions were defined:

 Which health insurer interventions9_{, relevant for Dutch health insurers, emerge?}

 How do these health insurer interventions impact the Dutch health insurers’ business processes, system and data?

 Which information is needed for health insurers to practically manage these interventions?

By answering these sub questions the research question will be answered. The final results will be summarized into an information blueprint10_{. This information blueprint is the} practical solution for the information problem that Dutch health insurers have.

2.2.2 R

To prevent ambiguity within this document frequently used terms in this research are defined in this section.

2.2.2.1 H

Health insurer interventions are actions that health insurers can take to intervene in health care. These actions can be active (e.g. initiating a care management project) or passive (e.g. funding a project).

2.2.2.2 I

An information blueprint is a visual representation of where information needs within an organization exist.

2.2.2.3 L

Health insurers can have information on clients and providers at the following levels:

 Macro: Information at the whole population of clients and providers level needed to

manage care in general.

 Meso: Information at the level of care where different groups and populations of

clients and care providers can be determined.

 Micro: Information at the individual client and provider level of care needed to

manage specific client needs or specific care provider offerings

2.2.2.4 C

Health insurers basically have two types of costs: operational costs and claims costs. Operational costs are the recurring expenses related to the operation of the health insurers

business. The sum of all health insurance claims, filed by policy holders, is called claims costs.

2.2.2.5 D

(

)

Health insurers can have one of four archetype roles in health care (van Eenennaam and Stouten, 2007). One of these roles is the director. A health insurer in this role follows a chain-of-care approach; it integrates different care provider offerings and optimizes the care process for its members. The director contracts care based on price-, quality- and volume information. They have a long-term vision on care in general, care-renewal and its response to new regulations and changes in market conditions. (See: chapter 1.2.1).

2.3 R

ESEARCH

M

ETHODOLOGY

2.3.1 E

For this research two types of experts were interviewed. For reasons of clarity the first group is consequently called ‘experts’ and the second group ‘interviewees’.

2.3.1.1 E

Internal experts that helped with the identification of the health insurer cases and with determining relevancy and impact, included: three senior executives (partners) leading three different practices within Accenture Netherlands; one high-level foreign senior executive with deep experience in global health care; four senior managers; two managers and two consultants.

2.3.1.2 I

For this research also five interviewees with a background in health insurance were interviewed. Two interviewees from one of the four largest Dutch health insurers: one specialized in health insurer corporate strategy and an information management expert. The third interviewee was an information manager from a large national health insurer (i.e. an insurer with no strong regional background). The fourth interviewee has worked for a large health insurer for many years; he was responsible for setting up and managing the care office11 _{for one of the Dutch provinces. The fifth interviewee was an internal expert from} Accenture with experience in health care.

2.3.2 R

This is a qualitative research. A qualitative research aims to achieve an in-depth

understanding and interpretation of situations (Cooper and Schindler, 2006) in order to build theory. It uses non-quantitative data collection to increase the understanding of a topic (Cooper and Schindler, 2006).

The nature of this qualitative research is threefold:

I. Exploratory: The pre-study of this research started as an exploratory research, in a

sense that it aimed to provide insights into and comprehension (Kotler and Armstrong, 2010) of the issues that Dutch health insurers face. This corresponds with the explanation that Cooper and Schindler (2006) give about exploration: it is useful when researchers lack a clear idea of problems they will meet during the study (Cooper and Schindler, 2006).

The outcomes of this exploratory pre-study was consolidated into a point-of-view and it induced further research, focusing on the information needs for Dutch health insurers.

II. Descriptive: A typical descriptive research reveals the ‘who’, ‘what’, ‘when’ and

‘where’ of a subject: it describes the subject and groups the problems found (Cooper and Schindler, 2006). This research is a descriptive research in a sense that it aims to clearly address the problems and situations (Kotler and

Armstrong, 2010) that health insurers face when they want to intervene in the care process.

III. Design-oriented: Next to descriptive-driven research programs as elaborated

above, in business studies like these, also prescriptive-driven research is needed in order to develop research products that can be used in designing solutions for management problems (Van Aken, 2004; Van Aken, 1994; Van Aken, 1994). This so called ‘design science’ develops knowledge for the professional in the field. Seen from the player’s perspective, this prescription-driven research is solution-focused rather than problem-solution-focused like with descriptive research (Van Aken, 2004). Van Aken (2004) argues that an effective partnership between description-driven research and prescriptive-description-driven research creates real knowledge for professionals.

In addition to Van Aken’s arguments, Hevner et al. (2004) have a similar vision. They consider a combination between both behavioral science and design science as a way of acquiring two types of knowledge. The first type of knowledge is knowledge that aids the productive application of information technology to human organizations and their management. The second type is knowledge concerning both the management of information technology and the use of information technology for managerial purpose.

design science creates and evaluates artifacts intended to solve identified organizational problems (Hevner et al., 2004).

IT artifacts can be constructs, models and methods applied in the development and use of information systems (Hevner et al., 2004). Artifacts are not full-grown information systems, but they are innovations that define the ideas, practices, technical capabilities and products through which the analysis, design,

implementation and use of information systems can be accomplished (Hevner et al., 2004).

This research creates knowledge for professionals (the players) as elaborated by van Aken (2004), therefore it aims to be a combination between prescriptive and descriptive research. It can also be characterized as design-oriented, as

formulated by Hevner et al. (2004), because it aims to:

a. identify what relevant information is needed to solve a business problem b. create an artifact that meets that business problem (sc. the information

blueprint)

The artifact that this research aims for is not an information system, but it is a map with information needs for health insurers, that they can use to design and implement the future information systems that will allow them to obtain and process the information they need.

2.3.3 R

Hevner et al. (2004) provide an IS research framework for design-oriented research (See: Figure 5). In this research process (See: Figure 5, middle column), behavioral science

addresses research through the development and justification of theories that can explain or predict phenomena related to the identified business needs (Hevner et al., 2004). At the same time design science addresses research trough the building and evaluation of artifacts

designed to meet those business needs (Hevner et al., 2004).

Environment

People

Assess

Information Systems

Research Knowledge Base

Organizations Technology Develop/Build Theories and artifacts Justify/Evaluate e.g. analytical, case studies Additions to the knowledge base

Foundations

e.g. theories, frameworks

Methodologies

e.g. data analysis technologies, measures Business Needs Applicable Knowledge Relevance Rigor Application in the appropriate environment Refine

Figure 5 Simplified version of the IS Research Framework (Hevner et al., 2004)

2.3.4 R

In September 2009 the exploratory pre-study for this master thesis was initiated at Accenture Amsterdam.

First secondary data was analyzed: academic literature, external data sources and internal documents. Next, internal experts were interviewed. Using the outcomes of this research, the point-of-view for health insurers was created and presented on several occasions to the senior executive of Accenture ITST. During these presentations the point-of-view was iteratively reviewed by both the senior executive and the external supervisor of this thesis. Based on the outcomes of the point-of-view, the next steps for this thesis research were determined. From this moment the research became design-oriented, with a players’ perspective as elaborated above.

First, a list of possible health insurer intervention cases was composed. These case studies were found during: (a) the initial interviews with experts; (b) during the literature study; and (c) during the exploration of other sources (e.g. Internet search; internal documents). Next, during a meeting with five key experts the final health insurer interventions were determined. With joint experiences in health care, the experts reached an agreement on (a) the main point of the cases and (b) one example from practice for every case.

These cases were described and were tested on relevancy by (a) using the transformation characteristics derived from literature; and (b) by questioning interviewees on case

Next, for every case the process, information needs, systems and data requirements were determined using the Accenture iModel. All this information was summarized in one-page overviews.

These one-page overviews were used in the next step: the in-depth interviews with health insurers. During the interviews all intervention cases were explained to the interviewees. Firstly, interviewees were asked if they found the cases to be relevant. Next, every case was discussed in detail. The interviews were semi-structured: case by case it started with specific questions and then it followed the individual’s tangents of thought with interviewer probes (Cooper and Schindler, 2006). Questions were asked on the information needs for every intervention case, e.g.:

 What do you think of this intervention case?

 Are the examples well-chosen, or do you have alternatives?

 Do you already perform these activities?

 How can health insurers practically manage these cases?

 Which information do health insurers need to perform them?

 Which information is most important?

 Are the information needs present in these one-page process overviews? Which information is missing?

 How can health insurers get the information they need?

 Can health insurers perform these interventions with information present in the organization?

In the final step the information needs, derived from the iModel combined with the opinions of the interviewees, were consolidated in the information blueprint.

2.3.5 T

,

The research model (See Figure 6) shows how data has been collected and how it has been analyzed and elaborated in order to answer the research questions. It is divided in two parts. The left side of the model represents the content and structure of this thesis. The right side represents how data has been collected and analyzed.

The theoretical perspectives are discussed in chapter 1. The first part of this chapter is based on academic literature. In this chapter also the results of the pre-study are outlined, this part is both based on literature and on the experts’ opinions.

The research approach is discussed in chapter 2.

In chapter 3 the health insurer intervention cases are discussed. Their relevancy is based on secondary data (i.e. academic literature) and the opinions of the interviewees.

data are described. A possible framework to determine case impact on health insurers is the Accenture iModel (Accenture Technology Consulting, 2008). This model was used to

determine the ‘business critical information’ for each health insurer intervention. It evaluates impact on processes, systems, data, organizational capability and governance. This model (See Figure 9, page 34) will be further explained in chapter 4.1.

In the chapter 5 the information needs for Dutch health insurers, that the interviewees identified, are outlined. The information needs that surfaced in chapter 4 were tested with interviewees during in-depth interviews. In chapter 6 the consolidated information needs from both chapters 4 and 5 are shown in an information blueprint.

Finally chapter 7 outlines the final conclusions of this research.

Data collection and analysis

Theoretical Perspectives BACKGROUND CHAPTER 1 Secondary Data Analysis Accenture iModel

Health Insurer Intervention Cases

Experience Surveys

Impact on Dutch Health Insurers

CASES CHAPTER 3 IMPACT CHAPTER 4 _Impact Impact Relevancy

Information Needs of Dutch

Health Insurers Test Depth Interviews

Information Blueprint for Dutch Health Insurers

TEST

CHAPTER 5

Content

Secondary Data Analysis

Theory FINAL CONCLUSIONS CHAPTER 7 RESEARCH APPROACH CHAPTER 2 ARTIFACT CHAPTER 6

3

3

H

H

E

E

A

A

L

L

T

T

H

H

I

I

N

N

S

S

U

U

R

R

E

E

R

R

I

I

N

N

T

T

E

E

R

R

V

V

E

E

N

N

T

T

I

I

O

O

N

N

C

C

A

A

S

S

E

E

S

S

In this chapter the health insurer intervention cases will be elaborated. For every case firstly academic views are outlined. Next the views of the interviewees are summarized. Why do they think these cases are relevant? And finally the cases are mapped on the systematic transformation characteristics as defined in chapter 3.2.

3.1 H

EALTH INSURER INTERVENTION CASES

The following six health insurer intervention cases were chosen with the help of experts: A. Internet-delivered health insurer interventions: second opinion online

B. Health coaching for co-morbid chronic diseases powered by call centers C. Disease management programs/clinics for specific (chronic) conditions D. Detect, evaluate, purchase and support new and innovative care initiatives E. Care performance management: Support the adoption of the most recent best

performing treatments

F. Provider quality monitoring and profiling in contracting

3.2 C

ASE RELEVANCY

Relevancy of the cases is determined based on the characteristics of the systematic

transformation in health care (See: chapter 1) as argued by Porter (Porter and Teisberg, 2006) and Christensen (Christensen, Grossman and Hwang, 2009).

For this research health insurer intervention cases are relevant when they meet one or more of the following eleven characteristics (I-XI):

I. Help organize care around at the level of specific diseases and conditions

II. Identify treatment alternatives and recommend providers with excellent outcomes III. Offer effective disease management for chronically ill patients

IV. Simplify billing and administrative processes V. Increase consumer choice

VI. Increase value for patients

VII. Enhance information on providers’ experience, outcome and prices VIII. Match clinicians’ skill level to the difficulty of the medical problem

IX. Use technology that simplifies complex problems X. Innovate disruptively through new organizations XI. Overcome the inertia of regulation

3.3 O

NLINE SERVICES

:

SECOND OPINION ONLINE

(A)

technology: many patients can be reached at once and large amounts of information can be easily stored and updated while providing personalized feedback. Other reasons are cost reduction for patients, increased convenience for patients, health service cost reduction, patient isolation reduction, the need for timely information, reduction of stigma, increased user and supplier control of the intervention.

This case is about health insurers offering second opinion services online. Patients can get second opinion consultations from a team of medical specialists, specially chosen for the specific question that they have. In the United States there are several care providers that offer these services. One well-known example is the Cleveland Clinic with its MyConsult online medical second opinion service (The Cleveland Clinic, 2010): ‚*this service+…connects you to the specialty physician expertise you need when you are faced with a serious

diagnosis. Following a thorough review of your medical records and diagnostic tests,

Cleveland Clinic experts render a medical second opinion that includes treatment options or alternatives, as well as recommendations regarding your future therapeutic considerations.‛ The clinic started this service in 2001. Nowadays second opinions can be offered for 600 life-threatening or life-altering diagnoses. About 17% of all internal diagnoses reviewed are modified. Nationwide in the United States, the rate of diagnostic errors has been estimated as twice that high (Porter and Teisberg, 2009).

In the Netherlands only health insurer CZ offers second opinion services online, partnering with Best Doctors® (CZ, 2010).

3.3.1 R

Much is written on why people seek a second opinion. Most-mentioned reasons for seeking a second opinion (Sutherland and Verhoef, 1994) are confirmation of the diagnosis or treatment, dissatisfaction with the first doctor and/or the patient’s desire for confirmation of the problem.

But do second opinions also lower claims costs and improve quality of care? Literature suggests it does. First the implementation of second opinion centers helps to improve the implementation of guideline recommendations (Shrader et al., 2009). Improved

implementation of guidelines gives more patients access to the best care available, this prevents regional differences in access to medical care, the so-called ‘postal code lottery health care’ (Kerr and Scott, 2009) (See: Paragraph 3.7)

Next second opinions are needed to discover new and improved treatments. The need for second opinions will continue because of new treatments, like telemedicine, that

3.3.2 T

’

The interviewees that were interviewed consider that second opinions online are relevant for the following reasons:

 The information collected with second opinion services can steer the care purchasing process.

 Seconds opinions online can improve the insight in the performance of doctors and doctor-collectives.

 Health insurers can offer care alternatives through second opinions.

 It can improve the care process: if a health insurer purchases high-quality care, a second opinion is an important sign that something goes wrong in the process.

 Second opinions online can improve the quality of the benchmarking information12 that health insurers offer to general practitioners.

Interviewees mentioned that second opinions online are just one example of many possible online services that health insurer could offer their members. Most important with these kinds of interventions is that a behavioral change must take place and that this can be measured.

3.3.3 M

This case complies with most of the characteristics of systematic transformation as described in chapter 3.1. By offering second opinions online health insurers have more information to be able to identify treatment alternatives and need to be able to recommend providers with excellent outcomes (II). They need to know more on providers’ experience, outcome and prices (VII). By offering second opinions as an online service they simplify the

administrative process for second opinions in general (IV). Consumer choice will increase because the second opinion offers treatment alternatives/facilities to choose from (V). As the patient will get the best treatment possible, patient value increases (VI).

Second opinions online are also a good example of matching the clinicians skill level to the difficulty of the medical problem (VIII). Questions can be easily forwarded to the physician that has the best experience with a particular case. It is also a good example of putting technology in charge of simplifying complex problems (IX).

The remaining characteristics (I, III, X and XI) are less clear. Although the second opinions online can be organized around specific diseases and conditions (I) it seems that this is not a distinctive feature of this intervention. Also this intervention is not specifically aimed at the chronically ill patient (III) .The question is whether new organizations innovate through second opinions online (X), it is more likely that existing organizations do. Finally the intervention is not specifically aimed at overcoming the inertia of regulation (XI).

3.3.4 O

C

R

Summarizing, we can conclude that second opinions online are relevant:

 Literature suggest that second opinions online can improve quality of care and reduce costs.

 Interviewees think that second opinions online are relevant, mainly because of the improved insight through more information.

 At the scale of transformation characteristics this intervention scores seven out of eleven.

3.4 H

EALTH COACHING FOR CO

-

MORBID CHRONIC DISEASES POWERED BY CALL

CENTERS

(B)

In the 1900s people died of infectious diseases which over the course of the century could ultimately be treated with the four basic health interventions: contained sanitation,

quarantine, antibiotics and vaccines. Nowadays the most common causes of death are heart diseases, strokes and cancer: the outcomes of hypertension, diabetes, cigarette use and obesity (Eddy and Robinson, 2009). These diseases cannot be treated with the traditional four health interventions of the 20th _{century. We need new ways to deal with these chronic} diseases. One possibility is to look at health coaching. Health coaching is an intervention where a coach helps to educate the coachee on specific health-related topics. It is about education and promotion of health within a coaching context. Subsequently the coach helps the coachee with achieving their health-related goals (Palmer, Tubbs and Whybrow, 2003). This case is about health coaching by call centers, with the goal to improve medical and financial outcomes for co-morbid/chronic diseases, by coaching patients that can be

influenced to change their behavior and/or lifestyle. An example case is the Accenture health coaching program in Germany (Wetzels and van der Weijden, 2008). In 2007 a large health insurance fund implemented a care management solution that included health coaching by call centers. Members seemed willing to participate: roughly 30% of potential candidates agreed in writing (as required by German privacy laws) to actually participate in the program. From Accenture experience both clinical (e.g. programs that resulted in 28% weight reduction) and financial outcomes (e.g. up to 39% average claim cost reduction) improved.

3.4.1 R

Effective programs of health coaching interventions correctly identify individuals at risk, maximize recruitment effort, use valid coaching techniques and delivery mechanisms to ensure participant engagement and evaluate and demonstrate the casual association

 Systematically identify and stratify members at risk of lifestyle-related disease using tools, like health risk assessments that can predict future acute health services utilization and costs, to facilitate proactive enrolment of high risk members.

 Once high-risk members have been identified, the program should incorporate a recruitment strategy that includes outreach to the highest risk members to enroll them into the health coaching service.

 Health coaching is often compared with motivational interviewing: During a typical health coaching session, the proficient practitioner or coach emphasizes the three underlying assumptions of motivational interviewing – collaboration, evocation, and autonomy – in order to establish rapport, reduce resistance, and elicit ‘change talk’ (one own reasons and arguments for change).

In early studies telephone contact has been proposed as a means of increasing health care behavior related to adherence (Kaplan and Simon, 1990). Butterworth et al. (2007) argue that in-person or telephonic methods are favored because they are more compatible with the motivational interviewing approach mentioned above. But, positive health outcomes for chronic illness require both effective treatments and adherence to those treatments (Haynes et al., 2008). When looking at adherence the Haynes et al (2008) conclude that simple interventions alone, like phone-calls, help for short-term drug treatments. For long-term treatments only some complex ones led to improvement in medical outcomes. Mostly, multiple forms of supervision, including telephonic, were used.

3.4.2 T

’

The interviewees acknowledge that health coaching is relevant for the following reasons:

 Care costs for chronic diseases account the largest share of total care costs

 Low-complexity care will move to self-care in the future

 Self-management is the solution to postpone the demand for care from expensive care professionals

3.4.3 M

The other characteristics (IV, V, VII, X and XI) do not apply. Health coaching by call centers does not simplify billing in any way (IV) and consumer choice does not increase (V). Health insurers will not get more information on provider experience, outcome or prices (VII). There is no disruptive innovation through new organizations (X), health insurers do the coaching themselves. The inertia of regulations (XI) is not overcome when health insurers offer these services.

3.4.4 O

C

R

Summarizing we can conclude that health coaching by call centers is a relevant intervention for health insurers:

 Literature suggests that well-organized health coaching programs can be effective.

 Interviewees believe that health coaching is relevant, mainly because it uses cheap technologies instead of expensive health professionals.

 At the scale of transformation characteristics this intervention scores six out of eleven.

3.5 D

ISEASE MANAGEMENT PROGRAMS

/

CLINICS FOR SPECIFIC

(

CHRONIC

)

CONDITIONS

(C)

As elaborated in chapter 3.4 new ways are needed to deal with chronic diseases. Chronic diseases are a major cost driver of the Dutch health care system. Almost 30% of the total Dutch population has at least one chronic disease. For the elderly (65+) this percentage grows to about 50% (Hoeymans, Schellevis and Wolters, 2008).

This health insurer intervention case is about disease management programs or clinics for specific chronic diseases. The example given here is the DiabetisZorgBeter13 _program initiated by the largest Dutch health insurer. The project ran from 2006 to 2007, with the main goal to improve the quality of diabetic-oriented primary care in the North-Eastern part of the Netherlands (Kenniscentrum voor Ketenzorg, 2009). In close collaboration with general practitioners, internist and diabetes nurses the chain of care for diabetics was optimized. The flowchart below (See: Figure 7) shows that patients are identified first. Next they are being diagnosed and finally the treatment begins with a number of checkups after treatment. Every treatment phase is supported by working documents, protocols and forms needed for the daily operation of the diabetic care program (Kenniscentrum voor Ketenzorg, 2009). The data in each process is collected and standardized. It was used for benchmarking the participating general practitioners. Every year the data is sent to the general practitioners in a benchmarking report. This report compares the performance of their practice (based on the population it serves) with the whole population (Kenniscentrum voor Ketenzorg, 2009).

Locating participants

Diagnostic phase

Medical anamnesis Nursing anamnesis

Draw up integrated care plan

Initial treatment phase

Dietary phase

Medication phase Self-discipline phase

Insulin phase Check ups First quarter Second quarter Third quarter Yearly disorder disorder

Figure 7 Simplified flowchart of the treatment phases of DiabetisZorgBeter (Kenniscentrum voor Ketenzorg, 2009)

The project seems to have been successful: results show that the relative risk of complications is 20-80% lower than the control group. Participation in the project has improved the treatment by using standardized protocols and checkups. The project report concludes: ‚the care we offer is not unique, but our collaboration is‛ (Kenniscentrum voor Ketenzorg, 2009).

3.5.1 R

The Disease Management Association of America (Disease Management Association of America, 2010) defines disease management as ‚…a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant‛. Disease management programs require the following elements (Goetzel et al., 2005; Disease Management Association of America, 2010):

 Identified population with specific health and disease conditions

 Evidence-based practice guidelines to treat that population

 Collaboration among physicians and other providers

 Risk stratification so interventions are matched with patient needs

 Measurement, evaluation and management of process and outcomes

 Reporting and feedback loops with all stakeholders (patient, physician, health plan and other providers)

 Appropriate use of information technology

There is evidence that disease management improves quality of care by improving health outcomes, this evidence includes disease management for diabetes (Goetzel et al., 2005; Norris et al., 2002).

Goetzel et al. (2005) argue that there is evidence from a financial perspective that disease management directed at diabetes has a positive return on investment (ROI), but that additional studies are needed. For other diseases there is sometimes more evidence.

3.5.2 T

’

The interviewees acknowledge that disease management programs for chronically ill patients are relevant because:

 Care cost for chronic diseases account the largest share of total care costs (70%)

 Health management programs improve the quality of care by streamlining the process

 With health management insurers can influence the demand side of healthcare and postpone the need for more expensive care professionals

3.5.3 M

This case complies with six characteristics of systematic transformation as described in chapter 3.1. Disease management programs for clinic diseases help organize care around the level of specific diseases and conditions (I). This case is the ultimate representation of

effective disease management programs for chronically ill patients (III). This case also has the possibility to simplify administrative processes for the chronically ill (IV). By offering better and integrated services the value for the patient increases (VI). All participants of the disease management program have access to more information, including experience, customer satisfaction and clinical outcomes (VII). It is also a good example of matching the skill level of the clinicians to the difficulty of the medical problem (VIII).

The other characteristics (II, V, IX-XI) do not apply or are less clear. Although these disease management programs optimize the care process for patients, they do not offer treatment alternatives or other providers with excellent outcomes (II), also consumer choice is therefore not increased (V).

3.5.4 O

C

R