Mikkers Misja, Ryan Padhraig
Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin 2, Ireland.
BMC Health Serv Res. 2014 Sep 26;14:442. doi: 10.1186/1472-6963-14-442.
A persistent feature of international health policy debate is whether a single-payer or multiple-payer system can offer superior performance. In Ireland, a major reform proposal is the introduction of 'managed competition' based on the recent reforms in the Netherlands, which would replace many functions of Ireland's public payer with a system of competing health insurers from 2016. This article debates whether Ireland meets the preconditions for effective managed competition, and whether the government should implement the reform according to its stated timeline. We support our arguments by discussing the functioning of the Dutch and Irish systems.
Although Ireland currently lacks key preconditions for effective implementation, the Dutch experience demonstrates that some of these can be implemented over time, such as a more rigorous risk equalization system. A fundamental problem may be Ireland's sparse hospital distribution. This may increase the market power of hospitals and weaken insurers' ability to exclude inefficient or poor quality hospitals from contracts, leading to unwarranted spending growth. To mitigate this, the government proposes to introduce a system of price caps for hospital services.The Dutch system of competition is still in transition and it is premature to judge its success. The new system may have catalyzed increased transparency regarding clinical performance, but outcome measurement remains crude. A multi-payer environment creates some disincentives for quality improvement, one of which is free-riding by insurers on their rivals' quality investments. If a Dutch insurer invests in improving hospital quality, hospitals will probably offer equivalent quality to consumers enrolled with other insurance companies. This enhances equity, but may weaken incentives for improvement. Consequently the Irish government, rather than insurers, may need to assume responsibility for investing in clinical quality. Plans are in place to assure consumers of free choice of insurer, but a key concern is a potential shortfall of institutional capacity to regulate managed competition.
Managed competition requires a long transition period and the requisite preconditions are not yet in place. The Irish government should refrain from introducing managed competition until sufficient preconditions are in place to allow effective performance.
国际卫生政策辩论中一个持续存在的问题是，单一支付者体系还是多支付者体系能提供更优的绩效。在爱尔兰，一项主要的改革提议是借鉴荷兰近期的改革引入“管理式竞争”，从2016年起，这将用一个相互竞争的健康保险公司体系取代爱尔兰公共支付者的许多职能。本文探讨爱尔兰是否具备有效管理式竞争的先决条件，以及政府是否应按既定时间表实施改革。我们通过讨论荷兰和爱尔兰体系的运作来支持我们的论点。
尽管爱尔兰目前缺乏有效实施的关键先决条件，但荷兰的经验表明，其中一些条件可以随着时间的推移而实现，比如更严格的风险均等化体系。一个根本问题可能是爱尔兰医院分布稀疏。这可能会增强医院的市场势力，削弱保险公司将效率低下或质量差的医院排除在合同之外的能力，导致不必要的支出增长。为缓解这一问题，政府提议引入医院服务价格上限体系。荷兰的竞争体系仍在转型，现在判断其是否成功还为时过早。新体系可能促使临床绩效的透明度有所提高，但结果衡量仍很粗糙。多支付者环境对质量改进产生了一些抑制因素，其中之一是保险公司搭竞争对手质量投资的便车。如果一家荷兰保险公司投资改善医院质量，医院可能会向其他保险公司参保的消费者提供同等质量的服务。这提高了公平性，但可能会削弱改进的动力。因此，爱尔兰政府而非保险公司可能需要承担起投资临床质量的责任。已有计划确保消费者能够自由选择保险公司，但一个关键问题是监管管理式竞争的机构能力可能不足。
管理式竞争需要很长的过渡期，必要的先决条件尚未具备。在具备足够的先决条件以实现有效运作之前，爱尔兰政府应避免引入管理式竞争。
