Erasmus University Rotterdam, Rotterdam, The Netherlands.
Health Policy. 2013 Mar;109(3):226-45. doi: 10.1016/j.healthpol.2013.01.002. Epub 2013 Feb 8.
From the mid-1990s several countries have introduced elements of regulated competition in healthcare. The aim of this paper is to identify the most important preconditions for achieving efficiency and affordability under regulated competition in healthcare, and to indicate to what extent these preconditions are fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. These experiences can be worthwhile for other countries (considering) implementing regulated competition (e.g. Australia, Czech Republic, Ireland, Russia, Slovakia, US).
We identify and discuss ten preconditions derived from the theoretical model of regulated competition and assess the extent to which each of these preconditions is fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland.
After more than a decade of healthcare reforms in none of these countries all preconditions are completely fulfilled. The following preconditions are least fulfilled: consumer information and transparency, contestable markets, freedom to contract and integrate, and competition regulation. The extent to which the preconditions are fulfilled differs substantially across the five countries. Despite substantial progress in the last years in improving the risk equalization systems, insurers are still confronted with substantial incentives for risk selection, in particular in Israel and Switzerland. Imperfect risk adjustment implies that governments are faced with a complex tradeoff between efficiency, affordability and selection.
Implementing regulated competition in healthcare is complex, given the preconditions that have to be fulfilled. Moreover, since not all preconditions can be fulfilled simultaneously, tradeoffs have to be made with implications for the levels of efficiency and affordability that can be achieved. Therefore the optimal set of preconditions is not only an empirical question but ultimately also a matter of societal preferences.
自 20 世纪 90 年代中期以来，一些国家在医疗保健领域引入了监管竞争的要素。本文旨在确定在医疗保健监管竞争下实现效率和负担能力的最重要前提条件，并指出在比利时、德国、以色列、荷兰和瑞士这些国家这些前提条件的满足程度。这些经验可能对其他正在实施监管竞争的国家（如澳大利亚、捷克共和国、爱尔兰、俄罗斯、斯洛伐克和美国）具有借鉴意义。
我们从监管竞争的理论模型中确定并讨论了十个前提条件，并评估了这些前提条件在比利时、德国、以色列、荷兰和瑞士得到满足的程度。
在这些国家的医疗保健改革超过十年之后，没有一个国家完全满足所有前提条件。以下前提条件的满足程度最低：消费者信息和透明度、可竞争的市场、自由签约和整合以及竞争监管。这些前提条件在五个国家之间的满足程度存在很大差异。尽管在过去几年中，在改善风险均等化制度方面取得了重大进展，但保险公司仍然面临着严重的风险选择激励，尤其是在以色列和瑞士。不完善的风险调整意味着政府在效率、负担能力和选择之间面临着复杂的权衡。
考虑到需要满足的前提条件，在医疗保健领域实施监管竞争是复杂的。此外，由于并非所有前提条件都能同时得到满足，因此必须进行权衡，这对可实现的效率和负担能力水平产生影响。因此，最优的前提条件不仅是一个经验问题，最终也是一个社会偏好的问题。
