Regulated competition and citizen participation: lessons from Israel

Citizen engagement in healthcare procurement decision-making by healthcare insurers: recent experiences in the Netherlands

BACKGROUND

In insurance-based healthcare systems, healthcare insurers are interested in engaging citizens in care procurement to contract healthcare services that matter to people. In the Netherlands, an amendment to the Health Insurance Act was set forth in 2021 to formalize and strengthen the engagement of the insured population with healthcare insurers' procurement cycles. This study explores the role of Dutch healthcare insurers in operationalizing citizen engagement in procurement cycles before changes occur linked to the amendment to the Health Insurance Act.

METHODS

A phenomenological qualitative design was employed in two phases: (1) we consulted academics and policy experts on the role of healthcare insurers regarding citizen engagement; (2) we conducted focus groups with representatives of healthcare insurers to understand how citizens' engagement is being operationalized. Transcripts of the interviews with experts and detailed notes of focus group meetings were analysed using a qualitative inductive approach. Selected excerpts were analysed on discourse and content and organized by a coding scheme following a rigorous and accelerated data reduction technique.

RESULTS

We identified four strategies used by healthcare insurers to operationalize citizen engagement: (1) broadening their population health orientation; (2) developing and improving mechanisms for engaging citizens; (3) strengthening features of data governance for effective use of value-driven data; (4) implementing financial and incentive mechanisms among healthcare providers in support of value-based healthcare. However, regulated market mechanisms and low institutional trust in healthcare insurers undermine their transition from merely funding healthcare towards becoming people-centred value-based healthcare purchasers.

CONCLUSION

Dutch healthcare insurers seem to be strengthening the community orientation of their functioning while enhancing the end-to-end experience of the insured. The expected practical effects of the amendment to the Health Insurance Act include broadening the role of the council of insurees in decision-making processes and systematically documenting the efforts set forth by healthcare insurers in engaging citizens. Further research is needed to better understand how the regulated competitive market could be hampering the engagement of citizens in healthcare procurement decision-making and value creation from the citizens' perspective.

Shared decision-making in Israel: status, barriers, and recommendations

Shared decision making (SDM) - involving patients in decisions relevant to their health - has been increasingly influential in medical thought and practice around the world. This paper reviews the current status of SDM in Israel, including efforts to promote SDM in the legislation and healthcare system, its influence in medical training and the national health plans, and funding for SDM-related research. Published studies of SDM in Israel are also reviewed. Although informed consent and patients' right to information are regulated by Israeli law, little provision is made for SDM. Further, there are few organized programs to promote SDM among medical professionals or the public, and governmental support of SDM-related research is minimal. Nonetheless, patients have begun to influence litigation in both formal and informal capacities, medical schools have begun to incorporate courses for improving physician-patient communication into their curricula, and the largest national health plan has initiated a plan to increase public awareness. A review of the limited research literature suggests that although patients and physicians express a desire for greater patient involvement, they often have reservations about its implementation. Research also suggests that despite the positive effects of SDM, such an approach may only infrequently be applied in actual clinical practice. In conclusion, though not actively promoting SDM at present, Israel's universal coverage and small number of health plans make rapid, widespread advances in SDM feasible. Israeli policymakers should thus be encouraged to nurture burgeoning initiatives and set plausible milestones. Comparing the status of SDM in Israel with that in other countries may stimulate further advancement.

Nursing students and the issue of voice: a qualitative study

AIMS AND OBJECTIVES

This paper reports the findings of part of a larger study that explored the empowerment of nursing students in clinical practice. The focus here is on the phenomenon of 'voice' and the extent to which nursing students are able to exercise voice during their clinical practice experiences.

BACKGROUND

There is evidence to suggest that nursing students are 'silenced' in clinical practice and that they are unable to make their voices heard, even when they witness poor nursing practice.

METHODS

This study explored the experiences of thirteen nursing students in the UK as they progressed through their undergraduate nursing programme. The study was underpinned by hermeneutic phenomenology. Data were generated through annual, semi-structured interviews and focus group discussions.

FINDINGS

In situations that called for nursing students to 'speak up' they did one of two things: exit or voice. However, there was bridging of these actions in the form of 'negotiating voice'.

DISCUSSION

Theoretically, findings of this study can be understood in relation to Hirschman's notions of 'exit and voice'. However, rather than being dichotomised extremes, an exit-voice continuum is proposed.

CONCLUSIONS

Students are often silenced in clinical practice, but to overcome this they negotiate situations in an attempt to be heard. This paper provides new insight into the means by which nursing students can be supported to avoid the exit option, in favour of exercising voice.

Perspectives on health technology assessment: response from the patient's perspective

Health technology assessment (HTA) involves values and judgments, but there have been few attempts to seek the views of members of the public or to ensure that they have access to the results. Patients and citizens can make an important contribution to HTA by determining priorities for assessment, designing and conducting assessments and appraisals, receiving and using the findings, and engaging in debates about policy priorities and rationing. Those responsible for HTA should make greater efforts to involve the public and ensure that the findings are accessible to patients for use when making treatment choices.

Consumer choice of social health insurance in managed competition

OBJECTIVE

To promote managed competition in Dutch health insurance, the insured are now able to change health insurers. They can choose a health insurer with a low flat-rate premium, the best supplementary insurance and/or the best service. As we do not know why people prefer one health insurer to another, we investigated their reasons for selecting their health insurer and assessed the importance of the supplementary benefit package and the flat-rate premium.

METHODS

A self-administered questionnaire was completed by 468 of a total of 884 (52.9%). Data were compared among three groups. The first group comprised those who left one health insurer for another (exit). The second group had joined the health insurer (entry) and the third group comprised those who did not switch (stayers).

RESULTS

Those in the entry group were statistically significantly less satisfied with their former insurance organization than those in the other groups (exit and stayers) with the insurance organization under investigation. They were also less satisfied than the other groups in respect of the flat-rate premium. Those in the exit group were younger and seemed to be in better health. In general, the insured were only aware of small differences between health insurance funds and the three groups did not differ from each other in this respect. About a quarter of the entry group reported the flat-rate premium as a reason for selecting a particular health insurance fund. However, the most frequently reported reason, for both exit and entry, was the benefit package of the supplementary insurance.

CONCLUSIONS

In the absence of clear differences between insurance organizations, the advantages of managed competition maybe too difficult to achieve.