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Global Innovations

Universal Mandatory Health Insurance In The Netherlands: A Model For The United States?

Abstract

 
Policy analysts consider the Netherlands health system a possible model for the United States. Since 2006 all Dutch citizens have to buy standardized individual health insurance coverage from a private insurer. Consumers have an annual choice among insurers, and insurers can selectively contract or integrate with health care providers. Subsidies make health insurance affordable for everyone. A Risk Equalization Fund compensates insurers for enrollees with predictably high medical expenses. The reform is a work in progress. So far the emphasis has been on the health insurance market. The challenge is now to successfully reform the market for the provision of health care.

In this paper we focus on the Netherlands health care reforms. We discuss the three major waves of reform in the Netherlands during the past century, and we focus on the national Health Insurance Act that was implemented in 2006.

Three Waves Of Health Care Reform

Top Three Waves Of Health... National Health Insurance Based... Conclusions And Policy... NOTES

 
Historically, the Dutch health care system has been characterized by much private initiative in both funding and provision of care. Until 1941 there was no government regulation with respect to health insurance. Doctors were free to establish practices and to set prices. Around 1940 there were several hundred local community health insurance organizations. These local insurers paid general practitioners (GPs) by capitation and often had their own facilities, so they could be considered early health maintenance organizations (HMOs). Since the first unsuccessful attempt to enact universal health insurance in 1904, it took more than a century to implement mandatory comprehensive coverage for all. In this process, three major waves of health care reforms can be discerned.¹

First wave: toward universal coverage (about 1940–1970). Until the 1970s the primary focus of the Dutch government was to promote public health, guarantee a minimum level of quality (for example, by professional licensure), and ensure universal access to basic health services. After decades of political debate, a mandatory health insurance scheme for low- and middle-income groups was introduced in 1941. In 2005 this scheme covered 68 percent of the Dutch population. Coverage included physician services, prescription drugs, hospitalization (365 days), maternity care, dental care for children, some paramedical care, and some medical devices. People with incomes above a certain threshold were excluded. Most of them voluntarily bought insurance from a private insurer. In 2005 only about 1.5 percent of the population did not have any health insurance, except for "exceptional" medical expenses that were covered by the Exceptional Medical Expenses Act. This act was passed in 1968 and constituted a mandatory national health insurance scheme with an income-related premium, covering long-term care, care for the mentally and physically disabled, and hospitalization for longer than one year.

Second wave: cost containment by government (about 1970–2000). By the end of the 1960s the Dutch government became worried about the seemingly uncontrollable growth of health care spending. The reason for this was twofold. First, rising health care spending could jeopardize the goal of universal access to basic care. Second, the government feared that rising health care costs would result in higher labor costs, which would raise unemployment and harm the Dutch open economy, which relies heavily on exports. The growing pressure to contain medical spending led to increasing supply and price regulation beginning in the mid-1970s.

In 1983 the government decided to replace the open-ended hospital reimbursement system with a budgeting system, which in 1984 was expanded to all other in-patient care institutions. The Health Care Prices Act (1982) enabled government to control physicians’ fees and, in a later stage, also their total revenues. Traditionally, medical specialists received a fee for each item of service. Using the threat of substantial fee cuts, government forced them to give up their fee-for-service (FFS) payment system. By the mid-1990s the FFS system was largely replaced by a "lump-sum payment" per hospital for all specialists working in that hospital. Further steps have since been taken toward partnership and integration of hospitals and medical specialists.

Cost sharing has always been a controversial issue in the Netherlands. As a consequence, demand-side constraints have played a restricted role in containing costs, as compared to supply-side constraints.

Third wave: efficiency through managed competition (from about 2000). From the early 1980s top-down rationing policies were subjected to growing criticism, focused particularly on the lack of incentives for efficiency and innovation within the prevailing system of health care finance and delivery. This led to broad support for incentive-based reforms and a reconsideration of the role of competition. In 1987 the government-appointed Dekker Committee advised a market-oriented health care reform and a national health insurance system. The Health Insurance Act (2006) and the current regulatory regime are based on these proposals.

The act was the culmination of a series of market-oriented reforms that were gradually implemented beginning in the early 1990s. A number of complicated preconditions had to be fulfilled to combine competition with universal access and to create the appropriate incentives for consumers, providers, and insurers. First, an adequate system of risk equalization had to be developed (see below). Next, an adequate system of product classification and medical pricing had to be developed, to give providers appropriate incentives for efficiency and to prevent stinting on the delivery of services. Third, an adequate system of outcome and quality measurement was necessary to enable specified contracts between insurers and health care providers and to prevent competition focusing only on price. Fourth, an adequate system of consumer information about the price and quality of insurers and care providers had to be developed to enable effective consumer choice. Finally, an adequate governance structure, including an effective competition policy, had to be devised.

Since none of these preconditions was fulfilled in 1987, a "radical" reform clearly was not feasible. During the twenty years following the Dekker plan, health care politics can be described as an ongoing process of competing policy programs; however, successive governments have consistently worked on the realization of the preconditions for managed competition.² After decades of central price and capacity control by government, the Dutch health care system is now in transition from supply-side regulation toward managed competition. The center-left coalition government that in February 2007 replaced the previous center-right coalition continues in this policy direction.

National Health Insurance Based On Managed Competition In The Private Sector

Top Three Waves Of Health... National Health Insurance Based... Conclusions And Policy... NOTES

 
Since 1 January 2006, the Health Insurance Act has obliged each person who legally lives or works in the Netherlands to buy individual private health insurance, with a legally prescribed benefit package, from a private insurance company. Contrary to the previous private insurance scheme, insurers are legally obliged to accept each applicant for a basic insurance contract at a community-rated premium and without exclusion of coverage because of pre-existing conditions. In an international context, the Dutch health system reform is unique: this is the first country that is consistently implementing Alain Enthoven’s model of national health insurance based on managed competition in the private sector.³

Financing. All individuals have to pay an income-related contribution (7.2 percent of the first 31,200 of annual income in 2008) to the tax collector, who transfers these contributions to a Risk Equalization Fund (REF).⁴ Employers are legally obliged to compensate their employees for these income-related contributions. These compensations are the same regardless of the chosen insurer and are taxable income for employees. In addition, all adults have to pay a premium directly to the chosen insurer. Each insurer sets its own community-rated premium. For high-risk insured people, insurers receive a high risk-adjusted equalization payment from the REF. For low-risk insured people, insurers have to pay an equalization payment to the REF. According to the Health Insurance Act, the sum of the income-related contributions equals 50 percent of the total insurers’ revenues for the mandatory basic insurance. In 2008 the average premium equals about 1,100 (about US$1,600) per adult (age eighteen and older) per year.

About two-thirds of Dutch households receive an income-related subsidy ("care allowance") from the government, which is at most 1,464 (in 2008; about US$2,200) per household per year.⁵ Because the allowance is independent of the choice of insurers, consumers are fully price-sensitive at the margin. No premium is required for coverage of children (under age eighteen); government compensates the REF for their health care costs.

People are free to buy voluntary supplementary health insurance for benefits that are not included in the mandatory basic insurance, such as dental care for adults, physiotherapy, eyeglasses, alternative medicine, and cosmetic surgery. For such insurance, insurers may risk-rate premiums and refuse applicants. More than 90 percent of the population buys supplementary health insurance, almost always from the same insurer that provides their basic coverage.

Since 2006 health care is primarily financed through two mandatory universal schemes with different regulatory regimes: a scheme for curative health care services under a regime of managed competition (Health Insurance Act) and a scheme for long-term care services under a regime of price and supply regulation (Exceptional Medical Expenses Act). The rationale for this distinction is based on differences between the types of risks and the feasibility of risk equalization, and between types of care for which the managed competition model is considered to be (in)appropriate.⁶ In this paper we focus on the Health Insurance Act.

Entitlements. In the Health Insurance Act, the basic benefit package is described in terms of functions of care and not, as before, in terms of providers. For example, plans must provide "rehabilitation care" rather than "care delivered by rehabilitation institutions." This facilitates the entry of other providers.

Insurers must specify the precise entitlements (that is, the contractual rights) in the insurance contract—for example, a list of contracted providers, covered pharmaceuticals, or procedural conditions. Consumers can be entitled to receive "care in kind" or reimbursement of medical expenses. Insurers are free to selectively contract with providers and to use financial incentives to motivate consumers to use preferred providers. Alternatively, insurers may offer contracts with full reimbursement of all providers. In sum, although the standardized basic benefit package is prescribed in the Health Insurance Act, there can be substantial variation in the insured person’s entitlements.

Consumer choice of health insurance. For each type of insurance contract, an insurer is obliged to accept each applicant at any time ("guaranteed issue") for the same premium ("community rating per product") in each province. Insurers with fewer than 850,000 enrollees are allowed to restrict their activities to one or several of the twelve provinces. The contract period is at most one year. According to the act, consumers have at least one option per year (on 1 January) to switch to another insurer or basic insurance contract. Insurers are legally required to publish next year’s basic insurance contracts by November 15. There are about fourteen insurers, and some of them have several subsidiaries operating under different labels. The largest four insurers (including subsidiaries) have about 90 percent of the market. In anticipation of the new national health insurance scheme in 2006, price competition in the insurance market strongly increased. As the result of a "premium war," the health insurers incurred a total loss of 563 million (2 percent of revenues) in 2006.⁷ The introduction of the new health insurance scheme prompted many people to reconsider their choice of insurers, resulting in an all-time high switching rate of 18 percent of the total population. In 2007, price competition resulted in similar losses.⁸

The Health Insurance Act provides the option of "group discounts." Insurers are allowed to give a premium discount of up to 10 percent to insured people who belong to a "group," which can be any legal entity. In 2007, about 57 percent of the population obtained such a group discount, with an average discount of 7 percent.⁹ Two-thirds of them had a group discount via their employer. But there are many other types of groups, such as patient organizations, sport associations, labor unions, cooperative banks (for their clients/members), and independent entrepreneurs who organize groups (for example, via the Internet). In principle, the entitlements for the basic insurance, including the consumer’s choice of providers, are identical for those with a group discount and those without such a discount. The only difference is the premium. For supplementary insurance, however, the conditions may differ between group and individual contracts. In practice, many groups also negotiate about the conditions of the supplementary insurance, which are often interrelated with the conditions of the basic insurance.

According to the Health Insurance Act, every adult has a deductible of 150 per year (excluding GP services and maternity care). Consumers can obtain a discount if they voluntarily choose a higher deductible (up to 650 per year).

Enforcing the mandate to buy insurance. One of the issues that has not been settled yet is the enforcement of the individual mandate.¹⁰ Although all Dutch citizens are legally obliged to buy basic health insurance coverage, in 2006 about 1.5 percent failed to do so.¹¹ Uninsured people are liable to a penalty of 130 percent of the premium over the period of not being insured, with a maximum of five years. However, the problem is that (1) government does not (yet) know who is uninsured, and (2) most uninsured people probably have such a low income that they cannot pay the penalty. If uninsured people need medical care, they can enroll with any insurer, because insurers are legally obliged to accept them. Alternatively, providers of care can arrange the insurance enrollment of uninsured patients prior to treatment.

Government intends to actively enforce the mandate. As a first step, it is actively tracking down the identity of the uninsured by matching the files of all insurers with the files of civil registrations.¹² After identification, the uninsured will receive a warning notice. If they persist in being uninsured, a last-resort option is that some public authority will enroll them as insured with some insurer.

A related problem is the large number of insured people who do not pay the premium. About 1.5 percent of the insured have not paid any premium in the past six months.¹³ In default of payment, insurers are allowed to cancel the contract and to refuse enrollment during the next five years. However, all other insurers are legally obliged to accept the expelled person. If the person again does not pay the premium, the second insurer may also cancel the contract. And the person might go to a third insurer, and so on. So the insurers fear a "merry-go-round" of defaulters. Canceling the contracts of defaulters is therefore not in their collective interest.

To increase the enforcement of premium payments, the Dutch government intends to create the legal option in case of default to directly withhold a payment from the defaulters’ income or welfare payments, just as it does for payroll taxes. This withheld payment will be higher than the highest premium in the market.¹⁴ The government holds the view that each adult can afford the premium because in determining the level of the welfare payments and the legal minimum wage, the payment of the premium was taken into account. Therefore, according to government, nobody should withdraw from the responsibility to pay their premium.

An alternative way to reduce the potential risk of default or not taking up insurance would be to replace the current 50:50 ratio between income-related contributions and direct out-of-pocket-premium with, for example, an 85:15 ratio, as it was in 2005. The average annual out-of-pocket-premium would then be about 350 per person (the 2005 level) rather than 1,100 (the 2008 level), and the income-related contribution would increase. In addition, the administratively complex and costly system of income-related care allowances that was introduced in 2006 could be abolished without influencing access.

Risk Equalization Fund. To prevent insurers from seeking only young, healthy customers, government has implemented a risk-equalization system, similar to that in the former social health insurance market. Until 2002 the risk-equalization payments were primarily based on age, sex, and indicators of disability and socioeconomic status. Because the ex ante risk-adjusted equalization payments insufficiently compensated the insurers for the (extreme) high expenditures of high-risk insured people, insurers also received some ex post compensations based on their actual expenses. As a result, the insurer’s average financial risk on medical expenses was limited to 36 percent of gains and losses in 2000.

Since 2002 the following risk factors have been added: Pharmacy-based Cost Groups (PCGs) in 2002, and Diagnostic Cost Groups (DCGs) and being self-employed (yes/no) in 2004.¹⁵ PCGs and DCGs are indicators of health status, derived from prior prescription drugs and the diagnosis of prior hospitalization. Based on these risk adjusters, all individuals are classified into subgroups of insured people who are more or less homogeneous in future predicted health expenses. Together with these improvements in the equalization formula, the Dutch government increased insurers’ financial risk from 36 percent (in 2000) to 59 percent (in 2008). This is partly the result of a gradual increase of the threshold above which insurers receive a 90 percent compensation for all expenses per insured person per year, from 4,545 (in 2000) to 20,000 (in 2008). Despite the sophisticated risk-equalization model, insurers can easily identify unprofitable subgroups (Exhibit 1). Risk-selection activities targeted at these groups can therefore be profitable.

Insurers also have more tools for risk selection at their disposal than they had before 2006. First, they have more tools for managing care, which can also be used to select risks. Second, insurers have more room to define the precise entitlements of their insured groups, which can be used to select favorable risks. Third, insurers are allowed to sell mandatory health insurance together with any other type of non–life insurance (such as supplementary health insurance, sick leave insurance, and car insurance), which prior to 2006 was not allowed. In particular, supplementary health insurance can be an effective tool for risk selection, because insurers are allowed to reject applicants based on their health status. Fourth, insurers are free to give premium rebates to groups for the mandatory basic insurance, which prior to 2006 was not allowed. A group can have any risk composition, and the "organizer" of the group can selectively enroll preferred members only. Although the rebate for the basic insurance is at most 10 percent, insurers can give these groups any rebate on supplementary health insurance or other insurance products.

In the transition period of implementing the Health Insurance Act in 2006, "selection via supplementary insurance" was not an issue because, under pressure from Parliament, insurers collectively agreed not to refuse applicants for the standard supplementary insurance. Under public pressure, insurers extended this collective agreement for one year. Indeed, no evidence of risk selection via individual supplementary insurance was found in late 2006 and early 2007.¹⁶

Given the increasing incentives and expanding tools for risk selection, further improvements of the risk-equalization method are necessary to prevent insurers from engaging in risk selection, which occurs, for example, in Switzerland.¹⁷ The government intends to further improve the risk-equalization formula by adding new risk adjusters such as DCGs based on outpatient care, indicators of mental illness, and indicators of disability and functional restrictions, by multiyear rather than one-year DCGs and by more effective forms of ex post risk sharing that compensate insurers for high-risk people who have high expenses because of rare chronic diseases.¹⁸ The more government succeeds in improving the risk-equalization formula, the more chronically ill people will be the preferred clients for efficient insurers, because the potential efficiency gains per person are higher for the chronically ill than for the healthy.

Since 2006, several insurers have advertised special supplementary group insurance policies for diabetes patients. These special policies were developed in close cooperation with the national diabetes patient organization. In addition, several insurers are now actively involved in setting up disease management programs for diabetes patients. These activities appear to be the direct effect of the extension of the risk-equalization system with a risk adjuster for type 2 diabetes since January 2006.¹⁹ (Type 1 diabetes was already included as a risk adjuster.) In 2007, almost forty patient organizations representing people with various chronic conditions had obtained group contracts with insurers. On the other hand, at least sixteen patient organizations were not able to obtain such a group contract because the risk-equalization payments for these groups were insufficient, according to insurers.²⁰ Hence, in due course, the ability for patients with specific chronic conditions to negotiate favorable group contracts may provide a good indicator of the quality of the risk-equalization method.

Ideally, the risk-equalization formula should be refined to such an extent that insurers expect the costs of selection (including the cost of a bad reputation) to exceed its profits. By making the risk groups in the equalization more homogeneous, the costs of selection increase, while, on average, profits fall. In addition, the government or patient advocacy groups could also raise the cost of a bad reputation by frequently monitoring insurers’ behavior and publishing relevant consumer information.

Managed care. Competing insurers are expected to become prudent buyers of care on behalf of their insured populations. Although the supply side is still quite heavily regulated by the government, insurers and providers will gradually get more freedom to negotiate about prices, service, and quality of care. Since 2005, for example, prices for physiotherapy are no longer regulated. Insurers and hospitals are allowed to freely negotiate prices and selectively contract for a range of products (Diagnostic Treatment Combinations) accounting for about 20 percent (in 2008) of hospital revenues. In 2009, hospitals will be allowed to set prices for about 50 percent of hospital services under a government-determined price cap.

Insurers are allowed to integrate with health care providers and to provide care in their own facilities using their own staff (such as primary care centers and pharmacies). Each insured person has to register with a single GP, who is assumed to coordinate and preauthorize specialist care. Recently insurers have started to set up primary health care centers and pharmacies. Insurers may provide their gatekeeping GPs with incentives to stimulate integrated and coordinated care, resulting in integrated care organizations that give a prime role to primary care. Most legal obstacles to that type of integrated care organization have been abolished, partly by the Health Insurance Act. Some large insurers are experimenting with some form of bonuses for, and risk sharing with, GPs. For instance, one major insurer offered GPs a bonus for prescribing generics (omeprazole and simvastatin) instead of equivalent brand-name drugs. The bonus payment was unsuccessfully challenged in court by four major pharmaceutical companies.

So far it is an unanswered question to what extent an integration of financing and delivery of care will be acceptable to the Dutch population.

Consumer information. A few years ago, the Dutch government took the initiative to set up a Web site where consumers can get information about insurers and providers of care (http://www.kiesbeter.nl). Consumers can compare all insurers with respect to price, services, consumer satisfaction, and supplementary insurance (premiums and benefits). They can also compare hospitals on different sets of performance indicators, which have been developed by the Health Care Inspectorate (IGZ) since 2004. The provision of adequate consumer information is also one the main priorities of the newly established Netherlands Health Care Authority (NZa).

Conclusions And Policy Implications

Top Three Waves Of Health... National Health Insurance Based... Conclusions And Policy... NOTES

 
Knowledge of the Dutch health system may contribute to the broadening of U.S. policy debates. Americans may be interested in the Dutch system because it combines mandatory universal health insurance with competition among private health insurers. It is not a single-payer system. Since the early 1990s the Dutch government has been gradually implementing this model. In 2006 a major step was taken with the implementation of the Health Insurance Act. It is important to emphasize that the Dutch health care reform is a work in progress. So far the emphasis has been on the health insurance market. A major challenge now is to reform the still heavily regulated market for the provision of health care and to improve the quality of care and lower its cost. Major questions are whether the insurers in the Netherlands are really able to function as good purchasers of care, which forms of "managed care" will be acceptable to the public, and whether government will be prepared to give up its traditional tools for cost containment by reducing supply-side regulation. So far the jury is still out.

Looking at the health care systems of the Netherlands and the United States, complementary strengths and challenges can be observed. The Netherlands has implemented the institutional framework to combine universal access and consumer choice of insurers; its challenge is to create integrated delivery systems that provide high-quality care in response to consumers’ preferences. In the United States there are several examples of excellent integrated delivery systems, while the reform debate is dominated by the issue of the lack of universal access to basic health insurance coverage. Whether the best elements of both systems can be combined in the coming decade is a major challenge for health policymakers in both countries.

Editor's Notes

 
Wynand van de Ven is a professor of health insurance in the Institute of Health Policy and Management at Erasmus University in Rotterdam, the Netherlands. Frederik Schut (schut{at}bmg.eur.nl) is a professor of health economics at the institute.

This paper was presented at the workshop "The Structure of Health Plan Competition," at Stanford University, Stanford, California, 3–4 May 2007, as a part of the project FRESH-Thinking directed by Ezekiel J. Emanuel and Victor R. Fuchs (see http://www.fresh-thinking.org). The authors thank the workshop participants, Mark Merlis, Karen Davis, and Dov Chernichovsky for their comments on a previous draft. They thank the Commonwealth Fund for support through the Emerging Paradigms in Health Systems project. Any opinions expressed in this paper are those of the authors.

NOTES

Top Three Waves Of Health... National Health Insurance Based... Conclusions And Policy... NOTES

 

1. See R.B. Scotton, "National Health Insurance in Australia: New Concepts and New Applications," Working Paper no. 11 (Melbourne: National Centre for Health Program Evaluation, 1991); and D. Cutler, "Equality, Efficiency, and Market Fundamentals: The Dynamics of International Medical-Care Reform," Journal of Economic Literature 60, no. 3 (2002): 881–906.
2. J.K. Helderman et al., "Market-Oriented Health Care Reforms and Policy Learning in the Netherlands," Journal of Health Politics, Policy and Law 30, no. 1–2 (2005): 189–209.[Abstract]
3. A.C. Enthoven, "Consumer-Choice Health Plan: A National-Health-Insurance Proposal Based on Regulated Competition in the Private Sector," New England Journal of Medicine 298, no. 13 (1978): 709–720.[Abstract]
4. Self-employed people and retirees pay 5.1 percent.
5. For a one-person household, the annual care allowance is at most 552 (about US$814) in 2008. In 2006, 4.9 million households received a care allowance. Statistics Netherlands (Centraal Bureau voor de Statistiek, or CBS), "More than One Third of Adults Received Care Allowance," CBS Web Magazine, 13 March 2007, http://www.cbs.nl/en-GB/menu/themas/arbeid-sociale-zekerheid/publicaties/artikelen/archief/2007/2007-2135-wm.htm (accessed 1 February 2008). In total, there are 7.2 million households in the Netherlands. CBS, "More and Smaller Households in 2050," CBS Web Magazine, 19 April 2007, http://www.cbs.nl/en-GB/menu/themas/bevolking/publicaties/artikelen/archief/2007/2007-2175-wm.htm (accessed 1 February 2008).
6. See, for example, W.P. van de Ven and F.T. Schut, "Should Catastrophic Risks Be Included in a Regulated Competitive Health Insurance Market?" Social Science and Medicine 39, no. 10 (1994): 1459–1472.[CrossRef][ISI][Medline]
7. De Nederlandsche Bank, Statistisch Bulletin (Amsterdam: De Nederlandsche Bank, December 2007); and R. Douven and F.T. Schut, "Health Plan Pricing Behaviour and Managed Competition," CPB Discussion Paper no. 61,2006, http://www.cpb.nl/nl/pub/cpbreeksen/discussie/61 (accessed 1 February 2008).
8. De Nederlandsche Bank, Statistisch Bulletin.
9. Nederlandse Zorgautoriteit, "Monitor Zorgverzekeringsmarkt. De Balans 2007" (Utrecht: NZa, May 2007).
10. For a U.S.-based analysis, see S.A. Glied, J. Hartz, and G. Giorgi, "Consider It Done? The Likely Efficacy of Mandates for Health Insurance," Health Affairs 26, no. 6 (2007): 1612–1621.[Abstract/Free Full Text]
11. CBS, "Het aantal onverzekerden tegen ziektekosten 2006, nieuwe methode" (Voorburg/Heerlen: CBS, 2007).
12. First Chamber of Parliament, "Proceedings, 2007–2008," no. 11, 4 December 2007, 397–405.
13. Ministerie van Volksgezondheid, Welzijn en Sport, "Structurele aanpak wanbetalers," 23 May 2007, http://www.minvws.nl/kamerstukken/z/2007/structurele-aanpak-wanbetalers.asp (accessed 1 February 2008).
14. Second Chamber of Parliament, 2007–2008, 29689, no. 166, 12 November 2007.
15. W.P. van de Ven, R.C. van Vliet, and L.M. Lamers, "Health-Adjusted Premium Subsidies in the Netherlands," Health Affairs 23, no. 3 (2004): 45–55.[Abstract/Free Full Text]
16. D. de Bruijnand F.T. Schut, "Evaluatie Aanvullende verzekeringen" (Rotterdam: Erasmus Universiteit Rotterdam, 2007).
17. W.P. van de Ven et al., "Risk Adjustment and Risk Selection in Europe: Six Years Later," Health Policy 83, no. 2–3 (2007): 162–179.[CrossRef][ISI][Medline]
18. Regarding plans to improve the REF, see Second Chamber of Parliament 2005–2006, 29689, no. 99, 11–16; Second Chamber of Parliament 2006–2007, 29689, no. 129, 9; and Second Chamber of Parliament 2007–2008, 29689, no. 164, 8, and no. 165, 1–4. Regarding multiyear DCGs, see L.M. Lamers and R.C. van Vliet, "Multiyear Diagnostic Information from Prior Hospitalizations as a Risk-Adjuster for Capitation Payments," Medical Care 34, no. 6 (1996): 549–561.[CrossRef][ISI][Medline]Regarding ex post risk sharing, see E.M. van Barneveld et al., "Risk Sharing as a Supplement to Imperfect Capitation: A Tradeoff between Selection and Efficiency," Journal of Health Economics 20, no. 2 (2001): 147–168.[CrossRef][ISI][Medline]
19. Without adequate risk equalization, a health plan that has the best reputation for treating diabetes patients attracts many unprofitable patients and will be the victim of its own success. For such an example in practice, see N. Beaulieu et al., "The Business Case for Diabetes Disease Management for Managed Care Organizations," Forum for Health Economics and Policy 9, no. 1 (2006): 1–36.
20. F.T. Schut and D. de Bruijn, "Collectieve zorgverzekeringen en risicoselectie" (Rotterdam: Erasmus Universiteit Rotterdam, 2007).

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