The financialization of healthcare in the Netherlands
|11 October 2017
|Martijn van der Steen
In the last decade, the Dutch government has embraced a neo-liberal agenda to deal with the rapidly rising costs of public healthcare. As a result, the characteristics of the healthcare sector have changed to include the emulation of a ‘market’ for care, government control which is predominantly financial in nature, and the use of woefully generic and poorly understood concepts such as entrepreneurship in care.
These changes have also had profound effects on the nature of the work of medical professionals. Like any profession, the work of medical professionals has always been typified by a considerable degree of decision autonomy, a high level of private knowledge, and strong ‘clan’-based control, where professionals monitor the performance of their peers.
However, the neo-liberal stance of the government has introduced new professional groups, such as accountants, financial controllers, and managers in healthcare organisations. These professionals are tasked with controlling the medical profession on dimensions other than health care. Put differently, the autonomy of medical professionals is increasingly challenged by administrative controls.
The proponents of these elaborate administrative controls argue that they help curb healthcare expenditure, as they provide alternative criteria against which the performance of healthcare providers is evaluated. In this way, the control over the healthcare sector remains firmly in the hands of the government and the insurance companies, but, by drawing on the rhetoric of a free market and entrepreneurship, control is exercised at a distance.
The control toolkit of these parties is mostly financial by nature, which comes with various benefits. Administrators and bureaucrats do not need to have full knowledge of medical processes to control them, and the financialisation of care enables comparisons between inherently different treatments. The use of financial controls is thus based on the promise of increasing efficiency in healthcare organisations.
However, most commentators seem to have overlooked the long-term effects on the medical profession at large. The attempts to influence the decision space of medical professionals can be expected to have unpredictable consequences.
Like any profession, medical professionals will always have much discretion in the domain of healthcare. As their skills, knowledge and information are specific to the medical profession, there are always spaces that cannot be controlled by administrative controls. Moreover, medical professionals are not passive receptacles of impersonal bureaucracies: they respond, often using the autonomy at their disposal.
So far, there have been some events reported in the press which illustrate how medical professionals may respond to the increasing administrative controls. In 2013, NRC Handelsblad reported how some psychiatrists adjust diagnoses of patients for administrative purposes. To enable their patients to receive therapeutic treatments for longer periods, these psychiatrists felt compelled to diagnose them with an illness which would be reimbursed by health care insurance companies. In 2015, the Volkskrant reported that hundreds of medical professionals in the mental health care sector boycotted some or all healthcare insurance companies because they did not want to be subjected to their extensive controls.
Over time, medical professionals may continue to respond to attempts to intrude into their decision autonomy. If the past is any indication, it is likely that the government and insurance companies will respond by specifying additional rules and procedures in attempts to limit the decision space of the medical profession. An avalanche of more stringent controls may ensue. When this happens, society runs the risk that these professionals spend more and more of their time on managing the systems that are imposed in the name of efficient resource allocation, but which can have the opposite effect.