Health care reform - more evaluation results

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The new Health Insurance Act (Zorgverzekeringswet) has been in effect since January 1, 2006. The implementation of this act is just the first step in a reform process that is planned to last to at least 2012. This report gives a short overview of the reform and discusses some of its effects on consumer behaviour, insurer behaviour, its impact on choice and on healthcare expenditure and its redistributive effects.

Purpose of health policy or idea

The ongoing reform has several purposes:

1. to make health care more efficient;
2. to improve the quality of health care; 
3. to make health care more demand-driven (consumer-driven);
4. to make health care more innovative. 

The main incentives used are: introduction of market competition; enhancing the room for contracting between health insurers and provider agents; enhancing consumer choice; public reporting on hospital performance (hospital ranking).

Groups affected

Hospitals and other provider agents, health insurers, consumer/ patients

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Controversies are likely to increase in the near future.

Political and economic background

The market reform of health care forms part of a wider process of introducing market elements in the provision of (public) services. Some other policy areas where market elements have been implemented over the last two decades are: public transport, telecommunication, energy (water supply excluded), notary ship and work rehabilitation. The market reform in health care is built upon the assumption that competition and consumer choice can significantly improve the quality and efficiency of health care. However, to avoid adverse consequences for solidarity and universal access, competition is strictly regulated (this is why the term regulated competition is used). Despite these regulations, there have always been concerns on the consequences of competition for solidarity and universal access, if not on the short run then anyway in the longer run.

The impact of the current financial crisis upon the reform is unclear yet. On the one hand, there are plans to extend the scope of competition to better benefit from competition. On the other hand, there are growing concerns that competition will drive up costs because of a volume effect. It is unclear how the market reform will develop further in the future. It is however a matter of fact that the confidence in the benefits of markets has been declining over the last years. A notable observation in this respect is that lifting the ban on the incomes of medical specialists in 2008 caused a steep increase of their total income by about 500 million Euro. The Minister of Finance declared that he was not amused about this development.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The origins of the health care reform process have been described in report "Health insurance reform 2006". The basic idea is to introduce regulated competition in health care. Regulation by means of 'public constraints' is needed to preserve solidarity, to guarantee universal access to health care and to keep health care financing sustainable in future. In order to optimise competition, various supervisory agents, including the Dutch Competition Authority, the Dutch Care Authority and the Public Health Inspectorate, monitor the market process.

Initiators of idea/main actors

• Government

• Providers

• Payers

• Patients, Consumers

• Private Sector or Industry

Stakeholder positions

The reform is still supported by the majority of hospitals and physicians, but it is important to note that one can also hear critical voices.

• Some hospitals with plans for major capital investments in the near future are scaling back these plans (or considering to do so) because of the potentially damaging financial consequences of the new arrangement for capital investments.
• Health insurers advocate quick further steps in market reform. They want more room for bilateral contracting with hospitals and other health care providers.
• As far as consumers are concerned, the overall picture is mixed. Nevertheless, the national consumer/patient association has declared itself consistently pro reform, because competition is likely to strengthen the position of the consumer/patient in health care.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
Hospitals	very supportive		strongly opposed
Physicians	very supportive		strongly opposed
Payers
Health insurers	very supportive		strongly opposed
Patients, Consumers
Consumers	very supportive		strongly opposed
Private Sector or Industry
Employers	very supportive		strongly opposed
Workers	very supportive		strongly opposed

Influences in policy making and legislation

The legislative process concerning the reforms described in section "Adoption and implementation" is under way.

Actors and influence

Government
Ministry of Health	very strong		none
Providers
Hospitals	very strong		none
Physicians	very strong		none
Payers
Health insurers	very strong		none
Patients, Consumers
Consumers	very strong		none
Private Sector or Industry
Employers	very strong		none
Workers	very strong		none

Positions and Influences at a glance

Adoption and implementation

The new Health Insurance Act as well as the Act of Licensing Care Provider Institutions have been in force since January 2006. But as spelt out, various concrete market decisions have recently been taken or are still to be taken.

The following market-making policy decisions are underway:

• Revision of the hospital planning system. A rigid hospital planning is considered to conflict with the strife for more competition in hospital care. Therefore, in January 2006 the Hospital Planning Act (Wet Ziekenhuisvoorzieningen) has been abolished, which granted the government the right to decide on the capacity of each hospital. This liberalisation of the hospital planning is intended to make hospitals self-responsible for their capacity decisions. This piece of legislation has been replaced with the Act on Licensing of Care Provider Institutions (Wet Toelating Zorginstellingen: WTZi). The new law is intended to enhance the room of hospitals and other provider agents for autonomous capacity decisions. Criteria for licensing are the quality and transparency of hospital administration and financial management (the new law provides the government with some formal competences to regulate the capacity of hospitals if it considers the accessibility of hospital care to be jeopardised). The planning of costly and high-tech hospital facilities remains to be centrally regulated. In sum: the scope of the WTZi is somewhat uncertain yet.
• Reform of the arrangement for capital investments in 2008. The reform included a significant revision of the rules for capital investments. Under the previous arrangement hospitals needed approval for capital investment plans, whereas costs of rent and depreciation were included in the inpatient per diem rate. Neither hospitals nor banks providing long-term loans did incur a financial risk. Competition requires hospitals to incur a risk on capital investments. The solution for this problem is to introduce a normative mark-up for investments upon the DBC-rate (the Dutch equivalent of DRG-payments to hospitals). In this model the hospital's room for investments varies with the volume and price of its activity. Policymakers expect that it will make hospitals more critical in capital investments and encourage them to operate as a market agent in financing their capital investments. Banks, private investors and other financial agents will also incur a risk and, hence, be stimulated to innovate their product portfolio.
  The reform may have far-reaching implications. Some hospitals may go bankrupt, but it is unlikely this will happen for political reasons. A hospital bankruptcy may also have a disruptive impact on the delivery of hospital care. It is plausible to assume that the government wants to avoid such effects by means of a staging in approach or creating a kind of safety net procedure. However, so far no concrete measures have been taken yet, though recently the Minister was deeply involved in the financial rescue-operation of what he termed a system-hospital, that is a hospital that cannot be missed (just like system-banks!). Interestingly, the situation is quite different in nursing and home care, where one big supplier recently went bankrupt. However, there were simultaneous measures to organise a start-up.
• Revision of the new hospital payment system by means of DBCs (Diagnosis Treatment Combinations; diagnosebehandelingscombinaties). At this moment the number of DBC's is about 30.000. The new hospital payment system is considered as too complex and therefore needs substantial revision which is planned for 2010. The new payment system is essential for the introduction of competition, because hospitals and health insurers are required to bilaterally negotiate on the price of (in theory) each DBC. As a consequence, these prices can vary per hospital/ insurer.
• Extending the room for negotiations on hospital prices between health insurers and hos­pital management by increasing the number of DBCs selected for free price negotiations. The number of DBCs for which free negotiations are possible was set at 10% in 2005-2007. This percentage was elevated to 20% in 2008 and 33% in 2009. It is still the intention of the government to elevate the percentage up to 60-70% but whether this will happen is unclear. Not that for the remaining percentage of hospital care, central price-regulation is still applied and will be applied in future.  The list of hospital services open to price negotiations mainly includes elective (planned) hospital services.
• An important element of the WTZi is that the ban of for-profit hospital care is planned to be lifted in 2012. Lifting the ban is essential to attract private capital resources for hospital care. Yet, the government opts for a cautious approach. An important argument to postpone this market-making decision is that in its view the conditions for for-profit hospital care are not yet fulfilled. The new case-mix based payment system must be fully operative and hospitals must operate as risk-bearing entities that may go bankrupt. The government is also concerned that an immediate lift of the ban may lead to situations in which the economic value of hospitals that was created in the past with public resources in a risk-free environment may leak to the commercial sector. The position of the new government on this market-making reform is uncertain yet.

Monitoring and evaluation

The effects of the new legislation are closely monitored by the government, a number of independent regulatory agencies (formal monitoring), consumer organisations and other organisations in society (informal monitoring).

Over the last few years, the Dutch Care Authority has published a number of mid-term monitoring reports. Similar reports were published by VEKTIS and CBS.

Dimensions of evaluation are 

• consumer mobility
• the number of persons without insurance (uninsured)
• price effects
• cost control
• market concentration effects (mergers)
• performance of provider organisations
• quality of health care
• structure of health insurance market
• structure of market for hospital care
• income effects
• waiting times

Results of evaluation

This section presents some of the most important effects of the 2006 Health Insurance Act (HIA) known so far. They give an impression of what has been achieved. In our view, however, it is too early yet to draw conclusions on the ultimate impact of HIA. There are several reasons for being cautious in drawing conclusions. Firstly, it often takes some time before the real impact can be assessed and interpreted. Secondly, it is important to mote that the impact of HIA also depends on other reform programs. To illustrate, we simply refer to the fact that the capability of insurers to negotiate prices for hospital services heavily depends upon the scope of price competition which, in turn, depends on the market making decisions to be taken by the government. Another relevant factor in this respect is the further development of the new hospital funding model by means of case-based payments. Finally, we must emphasise the unfolding character of the current reform of Dutch health care. The introduction of HIA in 2006 is only an important element of the reform. Various market-making decisions are yet to be taken. This implies that there is still uncertainty on the eventual design of market competition and, by implication, on its (ultimate) effects. 

Effects on consumer behaviour

The following table summarises information on consumer behaviour during the last year before the reform and the first three years after the reform

Consumer behaviour before and after the introduction of HIA

	2005	2006	2007	2008
Voluntary deductible -         yes -         no	-- --	6,2 93,9	5,3 94,7	5,2 94,8
Complementary health insurance before HIA -         sickness fund subscribers -         private insurance subscribers Complementary health insurance after reform	91,9 98,4 --	-- -- 92,6	-- -- 92,9	-- -- 92,0
Group health plan before HIA -         sickness fund subscribers -         private insurance subscribers -         average (own calculation) Group health plan after HIA	16,3 52,0 23,3 --	-- -- -- 53,0	-- -- -- 57,3	-- -- -- 59,2
Consumer mobility before HIA -         sickness fund subscribers -         private insurance subscribers Consumer mobility after HIA	7,5 15,4 --	-- -- 18	-- -- 4,4	-- -- 3,5

Sources: Health Monitors of Vektis; Health Insurance Monitors of NZa

Voluntary deductible

The percentages of subscribers opting for a voluntary deductible are consistently very low. They probably illustrate the high degree of risk aversion among Dutch subscribers. A further explanation may be that subscribers consider the premium reduction in exchange for a voluntary deductible to be relatively low.

Complementary health plans

These plans are very popular. The coverage of extra dental care is frequently mentioned as an important reason to purchase a complementary plan. Patients with chronic illness tend to scrutinise complementary plans from the specific perspective of their illness ('what is in for me?').

Group health plans

The figures on group health plans illustrate their popularity. However, the market share of group plans negotiated by patient associations has always remained quite small (about 1 percent). The interest for these plans of subscribers and health insurers does not generally seem particular strong (with the exception of one insurer). Much also depends upon whether the risk equalisation scheme includes the relevant morbidity parameter. If not, the insurer is not likely to be interested in a patient group contract because of predictable loss.

Consumer mobility

The figures on consumer mobility suggest a shock effect of HIA. Contrary to what most insiders had expected, in 2006 almost one-fifth of all subscribers switched to another insurer. Switching rates were relatively high among young subscribers, subscribers with high education and subscribers with high self-reported health. After 2006, however, mobility turned out to be only a one-off effect, despite significant differences in the premium rates of health insurers. It is not easy to interpret this decline of mobility. Does it indicate a high level of satisfaction or high transaction costs? Are subscribers concerned not to be accepted for complementary health insurance (see section on complementary health insurance).

Uninsured and defaulters

Another effect concerns the number of uninsured. Any resident who fails to purchase a basic health plan is automatically uninsured. According to Statistics Netherland, the number of uninsured was 170.000 in 2008 which equals about 1% of the population. Unfortunately, this figure cannot be compared to earlier figures because of reporting problems. The government has developed a monitoring program to track the uninsured as soon as possible. It also uses administrative penalties to keep the number of uninsured as low as possible.

Uninsured persons must be distinguished from defaulters, defined as subscribers who failed to pay their premium for a period of at least six months. The number of defaulters has siginificantly risen to 280.000 persons by the end of 2008. This is a 16 percent increase in only one year. The government agreed with health insurers on a monitoring program to track defaulters as soon as possible. Several instruments are used to compel them to pay their premium. However, insurers cannot dispel defaulters from their list. They agreed with the government that they will bear the financial risk over the first six months of defaulting after which period the government takes over this risk.

Health insurance allowances

In order to preserve the income solidarity in the new health insurance scheme low-income categories have been granted a health insurance allowance paid by the government to compensate for the steep increase of the nominal premium rate of the basic health insurance scheme. The costs of the health insurance allowance for low incomes are estimated at 2.5 billions in 2006. They are estimated to increase further to 4 billions in 2009. Presently about 60 % of the households is receiving an allowance and that percentage is expected to grow to 70% in 2010. As this cannot go on, the government as part of its financial crisis package is now working on change in the regulations to curb the steep cost increase.

Consumer satisfaction

Consumer satisfaction on health insurance is high. On a scale from 0 to 10, the consumer quality (CQ) index varied from 7,4 for the insurer with the lowest score to 8,7 for the insurer with the highest score. Only 8,9 percent of the respondents said to be dissatisfied. 

Effects on insurer behaviour

Consolidations

HIA made the traditional dividing line between sickness funds and private health insurers obsolete. Hence, it came as no surprise that in 2006 the number of insurers fell from 57 to 33 because of consolidations between sickness funds and private insurers. Note, however, that the number of health insurers had already been falling over a much longer period of time (58 percent over the period 1985-2005). Important reasons to consolidate in the pre-HIA period were the need for greater administrative efficiency and effective risk pooling and the strive of each insurer to reinforce its market position.

Consolidations have led to significant market concentration. Presently, the total market share of the four biggest insurance concerns is about 89 percent. Not surprisingly, there is some concern (not shared by the Dutch Healthcare Authority NZa) that this concentration may undermine competition and consumer choice, in particular in those areas where the HHI-index (an indicator for the amount of competition) is more than 1800. 

Risk selection

HIA contains a formal ban on risk selection for basic health insurance. Therefore, it is no surprise that insurers do not engage in explicit risk selection. However, there may be some subtle forms of risk selection:

1. Insurers may deny a group contract to what they see as groups with a predictable loss. There is no evidence for this practice because, so far, efforts of insurers were directed at protecting and extending market share. However, group contracts may evolve as an instrument for risk selection in future.
2. One insurer launched a new health plan by the end of 2007. Subscribers accept to visit only eleven hospitals for non-acute care which have been contracted by the insurer as preferred provider. In exchange for their restricted choice they pay a lower premium. This plan is only attractive to young people reporting their health as very good. It is not an attractive plan for a young couple with children. Importantly, the plan also contains the provision that a subscriber in case of an illness requiring frequent medical consumption may immediately terminate the plan and switch to a 'normal' health plan. In order words, it may elicit opportunistic behaviour.
3. There is some concern that health insurers may use complementary health insurance as an indirect tool for risk selection. As said before, HIA does not include a formal ban on risk selection for these plans. In 2006 and 2007, insurers announced that they would apply open enrolment except for their most inclusive and expensive plans. They did so because of their strategy of protecting and extending market share. However, in 2008 the percentage of insurers asking applicants to fill in a medical questionnaire more than doubled from 12 to 25 insurers after it had declined from almost 50 percent in 2004 to 10 percent in 2006 (Roos & Schut, 2008). There is also some evidence that subscribers do not switch to another insurer for their basic health plan because they fear not to be accepted for complementary plan by the new insurer. In other words, complementary health insurance may (increasingly) restrict consumer choice.

Purchasing

An important effect of HIA concerns the development of purchasing. A cornerstone of the current market reform regards the reconfiguration of the role of health insurers. In the market model, they not only function as an agent to guarantee access to health care and cover the costs of medical care, but are also expected to play an active role in purchasing health care on behalf of their subscribers. This is the so-called agency role of insurers. By contracting with provider agents insurers are expected to improve the quality and efficiency of health care rendered. To empower them, insurers are in principle no longer obligated to contract each provider agent. Selective contracting has become a formal option.

Experience so far indicates that purchasing is still in its infancy. As yet, selective contracting hardly exists. The explanation of this state of affairs is complicated and falls beyond the scope of this report. We mention a few important factors. First, insurers still miss good information on the quality of health care, despite significant progress in measuring the quality of care. Recently, some insurers started to use this information to contract preferred providers for some specific forms of care. A second factor concerns the (quasi-) monopolistic position of hospitals in some regions. Not contracting these hospitals has been a totally unrealistic option so far. Third, insurers have abstained from selective contracting because of their concern that it could damage their market reputation. Fourth, insurers consider it extremely difficult to steer their subscribers in need of medical care. They believe that only positive incentives work. For that reason, some insurers are now letting off patients the mandatory deductible if they go to a preferred provider.

Premium setting               

HIA has elicited fierce competition in both basic and complementary health insurance. The strategy of insurers to protect and extend market share forced them to calculate competitive premium rates. Because of the very competitive structure of the market for group contracts, they granted substantial premium discounts. For instance, the average discount for employer-based group contracts grew from 7 percent in 2006 to 8 percent in 2008 and some employers managed to negotiate a 10 percent. The discount for open-group contracts averaged at 6.2 percent in 2007. Not surprisingly, patient organisations were less successful in negotiating discount (4.2 percent in 2007). Discounts were also sizeable in complementary health insurance.

In fact, many premiums generated a net loss. In its role as oversight agency the Royal Dutch Bank (DNB) found that the aggregate technical result of the basic health insurance scheme amounted to 563 millions of euro in 2006 and 507 millions in 2007. DNB also reported for 2006 a loss of 23 millions of euro in complementary health insurance in 2006, which was in fact quite remarkable given the high profitability of complementary health insurance in the pre-reform period. The loss in 2006 was followed by a positive result of 93 millions in 2007 due to the strategy of insurers to raise premiums and, if necessary, to restrict the consumption of complementary services.

Unfortunately, it is difficult to compare the nominal premium rates for basic health insurance over a longer period of time. This is mainly due to the replacement of the no-claim arrangement with a mandatory deductible. Other changes including the extension of the benefit package of HIA also complicate such a comparison.

Administrative efficiency

The following table clearly indicates that HIA has improved administrative efficiency. Administrative costs taken as a percentage of total costs did significantly drop. Note that the administrative costs of complementary health insurance, though falling, are relatively high compared with the costs of the basic health insurance scheme. There is also evidence that insurers have significantly lowered their marketing costs. Marketing costs in 2006 and 2007 were extremely high. Presently, the market has significantly stabilised (see insurer mobility) and insurers believe that marketing has become less important than it was in the recent past. Also note that marketing is less important on the market for collective contracts (about 60% has enrolled in such a contract).  

Administrative costs of insurers as percentage of total costs 

	2003	2004	2006	2007
Before HIA Sickness funds Complementary plans sickness funds Private insurers	4,0 22,8 12,1	4,01 18,3 12,3	-- -- --	-- -- --
After HIA Basic health insurance Complementary health insurance	-- --	-- --	4,8 15,7	4,6 14,6

Based upon the Health Care Monitors of Vektis (own calculations).

Other effects

Freedom of choice and transparency

HIA is intended to increase the consumer freedom of choice on the health insurance market. The extent of freedom is affected by many factors including the range of choices available to consumers. So far, the range of choices in basic health insurance has remained limited. The differences between the health plans offered tend to be marginal which is of course due to a great extent to the extensive public regulation of these plans. The choice options in complementary health insurance are much bigger, but the conditional sale arrangements of insurers may reduce the choice options. A further complication concerns the lack of transparency. Many consumers complain about the great difficulties in understanding and comparing their options. To support them, website have been constructed which provide systematic comparative information on health plans (e.g. www.independer.nl).  

Redistributive effects

Earlier we stated that HIA is also intended to achieve a more equitable distribution of the financial burden in health care financing. Prior to 2006, the dual structure of the Sickness Fund Scheme and private schemes had created inequitable anomalies in the distribution of the costs of health insurance. Unfortunately, we have no insight in the redistributive effect of HIA. Group plans are an important source of complexity in this respect because of the variation in discounts insurers offer for groups to sign a group contract. However, it is reasonable to assume that individual subscribers 'pay the bill' because they do not benefit from a discount.

Impact on health care expenditures

Figure 2 above gives a bird eye's overview of the evolution of health care spending in the first (care funded through the Exceptional Medical Expenses Act, eg. long-term care), second (care funded through HIA) and third compartment (complementary health insurance). The figure demonstrates that the growth of health care expenditures has flattened since 2006 and even fell in 2007. This is a remarkable result because of the fact that the coverage of some health services was shifted from the AWBZ to HIA. The pattern is similar for AWBZ-related expenditures. However, the growth curve is somewhat misleading for 2006 and 2007, not only because of the shift of services from AWBZ to HIA but also because of the fact that the coverage of family help was removed in 2007 from the benefit package of AWBZ and shifted to local government.

To disentangle the effect of HIA upon health care expenditures is quite complicated because of the impact of many confounding factors such as the ageing of the population, decisions on the benefit package of HIA and the advance of medical technology. Nevertheless, there are some signs of a positive effect on the prices of hospital care. The Health Care Authority reported in 2008 that the negotiating power of health insurers in contracting health care had reinforced. It found that the real prices of hospital care that have been subject to price competition since 2005 declined in 2007. The price increase of hospital services for which price competition has been possible since 2008 appeared to be moderate. Not surprisingly, insurers with a big regional market share are capable to negotiate lower prices than insurers with only a small market share. Contracting so-called Independent Treatment Centres presumably plays an important role in this respect. The number of these centres increased from 31 centres in 2000 to about 160 centres in 2006. They usually deliver high volume routine care including cataracts, hip and knee replacement, diagnostic and many other services.

Unfortunately, we do not know whether these price effects will remain a lasting effect of competition and whether there is any form of cost shifting occurring. Furthermore, it is important to stress that competition may have (or is already having) an upward effect upon the volume of care. The question remains if insurers will be strong enough to effectively counteract the potential danger of supply-induced demand propelled by market competition and the interests of private investors to expand the market for health care (Note: The interest of private investors for health care is increasing, because they see as a growth sector. Even though the ban on for-profit hospital care has not been lifted yet and it is still unclear what the government will decide on this issue, two hospitals in financial trouble have been taken over by private investment companies.

Vertical integration

Recently, a regionally-operating insurer announced to take a 40 percent participation in a consortium being formed to overtake a hospital in its region that is in financial trouble. This participation was heavily criticised in the Parliament because of its damaging effect on patient choice and the 'double role' of the insurer. Nevertheless, the Minister of Health declared to consider vertical integration (integration of the insurance function with the delivery function) to be an interesting innovation in Dutch health care. An example of a more light form of vertical integration concerns an insurer which started to invest in centres for primary care.

Expected outcome

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Cost Efficiency	very low		very high

Only waiting times have declined significantly and therefore the impact on quality is neutral.

References

Sources of Information

Bartholomée Y, Maarse (2008), Course and impact of market reform in Dutch Health Care uncertain, Intereconomics, 43(4):189-94

Bartholomée Y, Maarse H, Health insurance reform in the Netherlands. In:Eurohealth, 2006;12(2):7-9, 2006 

Maarse J, Ter Meulen R (2006), Consumer choice in Dutch health insurance after reform. Health Care Analysis,14: 37-49. 

Maarse J, Bartholomée Y (2007), A public-private analysis of the new Dutch health insurance system. The European Journal of Health Economics, 8(1):77-82

Maarse J, Normand CH (2009), Market competition in European hospital care. In: B. Rechel, S. Wright, N. Edwards, B. Dowesdill, M. McKee (eds), Investing in hospitals of the future: 105-124. 

Van de Ven W, Schut FT (2008), Universal mandatory health insurance in the Netherlands: a model for the United States. Health Affairs, 27(3): 771-781. 

www.nza.nl 

www.cbs.nl

www.vektis.nl

Reform formerly reported in

Health reform - one year after implementation Process Stages: Implementation, Evaluation

Health Insurance Reform 2006 Process Stages: none

Mandatory deductible in basic health insurance Process Stages: Implementation

Author/s and/or contributors to this survey

Maarse, Hans

Suggested citation for this online article

Maarse, Hans. "Health care reform - more evaluation results". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/nl/a13/1