A four modes approach to ration health care
Typically, modern health care systems are faced with the presence of conflicting policy goals, like managing the increasing health care costs and providing equal access to the health care that is needed (Cutler 2002). Therefore, the Dutch health care system moved over time from an etatist policy program to a market-oriented program. A process called rationing of health care is often applied to maintain health care costs. To date, health insurance is governed by the market, not the state. This modification of the health care system simultaneously changed the role of the health insurer (Zorgverzekeringswet, 2006). They are responsible for providing their clients good quality health care for the lowest price. This is arranged in a process called “zorginkoop” (to buy health care), which leads to selective contracting of health care providers. Price, quality, amount, and type of health care are described in these contracts (RVZ 2008:7). As a consequence, some health care providers are contracted by the health insurer and some not.
Multiple conflicting interests are present in this case. The NZa promotes selective contracting of health care providers based on transparent quality criteria, keeping the health care providers conscious about price and quality (Stafleu van Loghum, 2011). However, health care providers doubt that this will lead to higher quality of care since these quality criteria are insufficiently scientifically proven. A second doubt is the quality of the used data (Stafleu van Loghum, 2011). Furthermore, patients and patient groups are concerned about the access of health care and freedom of choice.
According to Streeck and Schmitter (1985), the Community, the Market, and the State are the three models of social order that have dominated in social science. All three have their specific conflicts. Applicable to the case above are the conflict in economic markets. Namely, the conflict of sellers and buyers (Streeck and Schmitter, 1985), e.g. the conflict between health insurer (seller) and the insured (buyer) or the health insurer (buyer) and the health care provider (seller).
“The sharpest and most potentially destructive conflicts are generated when the principles, actors, media of exchange, resources, motives, decision rules, and lines of cleavage from the different ‘orders’ compete with each other for the allegiance of specific groups, for the control of scarce resources, for the incorporation of new issues, for the definition of rules regulating exchanges between them and so forth”(Streeck and Schmitter, 1985:123). Meaning that the main threats come not from within the social mode but from without. These destructive conflicts can also arise in the market of health care insurance. For example a conflict between Market and State: until the 1970s the Dutch health policy was a corporatist policy program, which goal was to create universal access to basic health care services (Schut 1995). Selective contracting of hospitals by insurers would threaten the access to health care. As becomes clear by this example, the three social orders have become dependent from each other and can affect each other (Streeck and Schmitter, 1985). The State provides authoritative regulation that makes selective contracting in the health care market possible.
However, Streeck and Schmitter (1985) state that these three modes of governance are insufficient to analyse policy processes. They suggest a fourth mode of governance, the Association, that can be used as an analytical tool to assess governance structure, under the assumption: “if you want to get the governance right, you need to manipulate the structures.” (lecture Meurs, 28-11-2012). To analyse policy processes, four modes of governance are also preferred by Tenbensel (2005). Though, he identifies two additional modes to Hierarchies (State) and Markets which he calls Networks and Communities. He points out that the...
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