Several European countries such as Germany, Switzerland and the Netherlands, have reformed their health care system based on managed competition [
1‐
4]. In health care systems that are based on managed competition, health insurers or other third parties, play an important role. They are supposed to prudently purchase care, on behalf of their enrolees. Health insurers also compete with each other, since enrolees are allowed to switch health insurers if they can get a better offer elsewhere. This is an incentive for health insurers to contract care providers based on price and quality of care in order to be able to offer attractive health plans. Additionally, they can compete by offering a high service quality [
5]. Care providers compete with each other to be contracted by health insurers. However, the bargaining power health insurers have towards care providers depends largely on their ability to channel their enrolees towards contracted care providers [
6,
7]. When they are successful in doing so, the market share of these contracted providers increases, which gives health insurers more bargaining power in negotiations with care providers.
There are different ways to channel enrolees towards contracted care providers. Those which have been researched include positive, and negative, financial incentives and quality incentives [
8]. With positive financial incentives enrolees are given a discount, bonus or an exemption to paying a deductible when they use a preferred care provider [
9]. Negative financial incentives mean that enrolees either have to pay a co-payment or they are not reimbursed, in full or in part, when they use a non-contracted care provider. Quality incentives may include, for instance, offering extended opening hours or a free health check at preferred care providers [
10]. Positive financial or quality incentives, so called ‘soft’ incentives, are found to be successful. For instance, in the choice of a pharmacy, a quality certificate and extended opening hours were found to be effective channelling incentives [
9,
10]. Yet, negative financial incentives are shown to be more effective. This is also the most implemented type of incentive [
8]. However, multiple studies show that enrolees feel negative about such incentives and do not want their health insurer to limit their choice of care provider [
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13]. This has led to the so called managed care backlash in the US, a collective resentment against managed care [
14]. For this reason, health insurers in the Netherlands are reluctant to implement selective contracting [
15]. Ideally, health insurers channel their enrolees towards preferred care providers in a positive manner, oriented towards the service, and in a way that does not emphasise a limitation in care provider choice. Therefore, it is important for health insurers to deliver a high quality of service since this can improve customer loyalty and satisfaction with the company [
16‐
18].
Health insurers are contacted by their enrolees many times every day. This provides an opportunity for health insurers to offer a good quality of service and improve the relationship with their enrolees [
19,
20]. A Dutch health insurance company saw these calls as an opportunity to channel enrolees towards preferred care providers, while, at the same time, increasing customer satisfaction. The idea is to channel enrolees to a preferred care provider when, for instance, they ask a question about the reimbursement of care. After answering the question, the employee has a chance to ask the enrolee if he or she has already chosen a specific care provider and to offer advice on which care provider to choose. This is offered as an extra service during the phone call. The health insurance company tried this out with one of their customer service call teams. Because of the prolonged collaboration between the research institute NIVEL and this health insurance company, the researchers were informed about this initiative and were given the opportunity to collaborate with the health insurance company and to design this study to measure the effects of this natural experiment. The research questions we aimed to answer were: Is it possible to channel enrolees towards preferred care providers by giving them free advice when they call customer service and what is the effect of this service on enrolees’ rating of the service quality?
Context
A health care system based on managed competition was implemented in the Netherlands in 2006. However, the implementation of selective contracting by health insurers has proceeded slowly since health insurers have been reluctant to implement selective contracting and negative financial incentives. This is because they feared their enrolees would distrust them and change insurers. Enrolees in the Netherlands are allowed to switch health insurers every year during a specific period [
21]. In 2014, article 13 of the Health Insurance Act was to be revised in order to allow health insurers to determine the level of reimbursement for non-contracted care providers. However, this was rejected by the First Chamber of parliament, which resulted in health insurers still being obliged to reimburse at least 75% of the costs of non-contracted care providers [
22]. This has made channelling enrolees towards contracted care providers more difficult [
23]. Some health insurers, however, still offer restrictive health plans where non-contracted care providers are reimbursed up to 75%. However, enrolees do not often choose these types of health plans [
24]. Additionally, it is the younger and healthier enrolees who are more likely to choose these restrictive health plans [
25]. This means that care providers hardly lose any business because of these contracts since most enrolees who use care, have health plans with a free choice of provider. This has negative consequences for the bargaining power of health insurers in relation to care providers. Thus, although it is important for health insurers to be able to channel their enrolees towards preferred care providers, they are hardly able to do so. Research showed that qualitative incentives can also have an effect upon enrolees’ care provider choice, although to a lesser degree than negative financial incentives. There was hardly any information found about whether health insurers in the Netherlands currently use these types of incentives.
In addition to offering a good quality of care for a good price, it is also very important for health insurers to create a good relationship with their enrolees in order to build loyalty. A way to channel enrolees towards preferred providers, while maintaining or building a good relationship with enrolees is therefore essential. The current study investigates whether it is possible to channel enrolees towards preferred care providers when they call customer service and to measure how far this affects enrolees’ assessment of the quality of service.