Towards a reinforced agency role of health insurers in Belgium and the Netherlands

This article describes some recent developments in health insurance in Belg ium and the Netherlands. Both countries are moving towards greater financia l responsibility of health insurers by means of risk-adjusted capitation pa yment systems. Although for the unwary observer it would appear as if both countries were following similar paths towards a common model, the authors make clear that rather different underlying rationales are driving these tr ends. In the Netherlands, the grand design 'Dekker proposal' for regulated competition has been replaced by a more gradual implementation of reforms w ith more limited scope. The ultimate goal remains a system of managed compe tition, albeit only for part of the health care services. In Belgium, prosp ective risk-adjusted capitation payment has always been at the heart of the original system in principle since its inception, but non-enforcement led to retrospective and inequitable financing in practice. Although the rhetor ic of managed competition has never been used explicitly in any Belgian off icial government policy document, it seems unlikely that putting the insure rs at financial risk without simultaneously also reinforcing their agency r ole by providing instruments for care management-like, for example, selecti ve contracting-is viable in the longer run without jeopardizing the solvenc y of the insurers. The authors conclude that although the logic of the mana ged competition model is appealing, the lack of conclusive empirical eviden ce of success elsewhere makes governments reluctant to surrender their trad itional cost containment tools. But making insurers financially accountable without simultaneously providing them with tools to take on the accountabi lity seems useless and illogical. (C) 1999 Elsevier Science Ireland Ltd. Al l rights reserved.