COST-CONTROL AND MEDICAL SPECIALIST PAYMENT - THE DUTCH ALTERNATIVE

The fee-for-service system is a growing problem for insurers and gover nments. The main reason for this is the open-ended character of this s ystem which makes cost-control a very difficult task. The pressures on the fee-for-service system are becoming more pronounced, especially i n countries such as Canada, Germany and the Netherlands which use budg et restrictions on national health care expenditure (macro caps). In t hese countries policy makers are searching for an alternative payment system and an appropriate definition of a corresponding status for doc tors. The alternative, however, does not have to lead automatically to a salaried status of doctors in the hospital organization. The Dutch experience of the change of the payment system for medical specialists illustrates the transition to a new 'negotiated order'. The introduct ion of the 'lump sum' and the sub-contractor relationship with the ins urance companies leaves the organizational autonomy of medical special ists intact. In exchange the medical specialists cooperate with the in surers in trying to control the costs of health care. In this process of strategic change, two factors are very significant: i.e. the new le adership of the local medical specialists and the governmental 'circum vention' of the powerful associations of doctors and insurers. (C) 199 8 John Wiley & Sons, Ltd.