Intended for healthcare professionals

Feature Market Reforms

Is competition law bad for patients?

BMJ 2011; 343 doi: (Published 20 July 2011) Cite this as: BMJ 2011;343:d4495
  1. Tony Sheldon, freelance journalist
  1. 1Utrecht, Netherlands
  1. tonysheldon5{at}

Five years after competition was introduced into the Dutch healthcare system, general practitioners’ attempts to provide collaborative care are coming under legal scrutiny, reports Tony Sheldon

As one Dutch general practitioner put it, “The law says we must compete, but for the patient we must cooperate—that’s the problem.” Five years into the Netherlands’ managed market, GPs are under investigation following “tip-offs,” home care providers have been fined, and doctors are angered at suspicion cast on their joint efforts to care for vulnerable patients.

The 2006 Health Insurance Act created a managed market of competing private insurance companies, providers of care, and patients, based around a single compulsory health insurance scheme for everyone. It intended to retain the social character of an obligatory health insurance scheme but underpinned by free market principles. Health insurers negotiate with providers on price, volume, and quality; patients are free to choose providers and insurers.

Meanwhile the government ensures that the market works properly, in particular through the Dutch competition authority (Nederlandse Mededingingsautoriteit). Under competition law it has the power to act against cartels and prohibit any abuse of a dominant market position by health providers and insurers.

So by 2008, the authority had announced the healthcare sector was “under intensified scrutiny” following “indications” of market sharing cartels. Within a year it had fined five providers of home care for dividing “service areas and clients among themselves,” thus “harming” clients’ choice.

Then in April last year it was the turn of GPs, when the authority arrived unannounced for a series of “dawn raids” on regional offices of the National Association of General Practitioners. Acting on tip-offs from clients and GPs, it was investigating possible “customer sharing” and obstruction of GPs who wished to set up new practices.

GPs allegedly had refused to accept new patients because …

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