DE KLANTGERICHTE BUREAUCRATIE

DE KLANTGERICHTE BUREAUCRATIE Zorgverzekeraar VGZ, een gevalsstudie

Afbeelding: schilderij, aangeleverd als foto

J.M.Blinkhof

DE KLANTGERICHTE BUREAUCRATIE Zorgverzekeraar VGZ, een gevalsstudie

J.M.Blinkhof

Wijchen 2007

Blinkhof, Johanna Maria De klantgerichte bureaucratie. Zorgverzekeraar VGZ, een gevalsstudie ISBN-10: 90-9021183-7 ISBN-13: 978-90-9021183-1 © 2007, J.M.Blinkhof Niets van deze uitgave mag worden vermenigvuldigd en/of openbaar gemaakt door middel van druk, fotokopie of welke andere wijze dan ook, zonder voorafgaande schriftelijke toestemming van de uitgever. Illustratie omslag: Vormgeving omslag:

Emile Curfs Martien Frijns

Dit proefschrift is mogelijk gemaakt met financiële steun van Zorgverzekeraar VGZ

DE KLANTGERICHTE BUREAUCRATIE Zorgverzekeraar VGZ, een gevalsstudie

Een wetenschappelijke proeve op het gebied van Managementwetenschappen

Proefschrift ter verkrijging van de graad van doctor aan de Radboud Universiteit Nijmegen, op gezag van de rector magnificus prof. dr. C.W.P.M. Blom, volgens besluit van het College van Decanen, in het openbaar te verdedigen op donderdag 8 februari 2007 om 15.30 uur precies door Johanna Maria Blinkhof geboren op 8 augustus 1961 te Boxtel

Promotor: Copromotor:

Prof. dr. B. Dankbaar Dr. E. Chr.Curfs, VGZ-IZA-TRIAS

Manuscriptcommissie:

Prof. dr. J.J. Boonstra, Universiteit van Amsterdam Prof. dr. P.P. Groenewegen, Universiteit Utrecht Prof. dr. J. van Hoof, voorzitter

Voor Chris † en Niels, onze tweeling

Inhoud

1

Voorwoord

ix

INLEIDING EN OPZET VAN HET ONDERZOEK

1

1.1 1.2 1.3 1.4 1.5 1.6 1.7 2

3

Introductie Doel en afbakening van het onderzoek Opzet van het onderzoek Een gevalsstudie Het gebruik van het INK-managementmodel Maatschappelijke en wetenschappelijke relevantie Leeswijzer

1 4 8 11 14 21 23

BUREAUCRATIE EN KLANTGERICHTHEID

25

2.1

Organisatie en omgeving

25

2.2 2.2.1 2.2.2 2.2.3

De organisatie in haar omgeving De contingentietheorie Andere benaderingen Effectieve organisatiestructuren

30 31 34 36

2.3 2.3.1 2.3.2 2.3.3 2.3.4

De bureaucratische organisatie Kenmerken van de bureaucratische organisatie Drie configuraties van Mintzberg Kritieken De populaire betekenis van bureaucratie

40 41 44 50 53

2.4 2.4.1 2.4.2 2.4.3 2.4.4 2.4.5 2.4.6

Alternatieven voor de bureaucratische organisatie De slecht geleide bureaucratie De lerende bureaucratie De interactieve organisatie De post-entrepreneurial organisatie De infocratie Samenvatting

55 55 56 60 67 68 70

2.5 De klantgerichte organisatie 2.5.1 Het begrippenkader

70 72

2.6

77

De klantgerichte bureaucratie

ZORGVERZEKERAARS IN EEN TURBULENTE TIJD

83

3.1 De ontwikkeling van het Nederlandse zorgverzekeringsstelsel 3.1.1 De ontwikkelingen tot 1986 op hoofdlijnen 3.1.2 De periode 1987 tot 2006

83 83 94

v

3.2 3.2.1 3.2.2 3.2.3 3.2.4

4

5

6

De veranderende omgeving Andere spelregels Veranderend krachtenveld De invloed van Europa De omgeving van zorgverzekeraars getypeerd

106 107 111 124 125

3.3 De omgevingseisen 3.3.1 Eisen van de toezichthouders 3.3.2 Eisen van de klanten

130 130 131

3.4

141

Een tussenstap: de klantgerichte zorgverzekeraar

ZORGVERZEKERAAR VGZ

147

4.1

Introductie Zorgverzekeraar VGZ

147

4.2 4.2.1 4.2.2 4.2.3 4.2.4 4.2.5

De organisatieontwikkeling van VGZ Van regionale naar functionele aansturing: 1989 - 1993 CONDOR: 1994 - 1995 Stabilisatie en een nieuwe koers: 1996 - 1999 De ontwikkeling van resultaatgerichtheid: 2000 - 2003 Op weg naar de standaardverzekering: 2004 en 2005

153 154 159 167 176 182

FUNCTIES NADER BEKEKEN

189

5.1 5.1.1 5.1.2 5.1.3

Verzekeren van zorg Organisatieontwikkeling van de verkoopfunctie Het verkoopproces Resultaten van de verkoopfunctie

192 192 199 200

5.2 5.2.1 5.2.2 5.2.3

Inkopen van zorg Organisatieontwikkeling van de zorginkoopfunctie Het zorginkoopproces Resultaten van de zorginkoopfunctie

202 202 210 216

5.3 5.3.1 5.3.2 5.3.3

De administratieve functie Organisatieontwikkeling van de administratieve functie Het administratieve proces Resultaten van de administratieve functie

219 219 231 232

5.4 Klantcontacten 5.4.1 De telefonie geprofessionaliseerd

233 234

5.5

237

Samenvatting

ZORGVERZEKERAAR VGZ, EEN ANALYSE

241

6.1 6.2 6.3 6.4 6.5

241 244 256 261 269

Waardering van de omgeving door VGZ Beleid en strategie Resultaten van Zorgverzekeraar VGZ Score op de dimensies van de bureaucratische organisatie De ontwikkeling van de klantgerichtheid vi

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Summary

Summary The customer-oriented bureaucracy Health Insurer VGZ, a case study Motivation and research question In 1987, the Committee on the Structure and Financing of Health Care, also known as the Dekker Committee, published a report entitled Bereidheid tot verandering (1987) ('The willingness to change'). This report recommended changing the control mechanism in health care in order to 'create an efficient system that is sufficiently flexible to match the supply of care and demand for care in society'. Planning-oriented thinking, which dominated the 1970s and 1980s, is in this report replaced by the principle of regulated market operation. The Dekker Committee's plans were to a large extent accepted by the Dutch government, which then began to prepare a revision of the care system. This plan had considerable consequences for the health insurance funds. In 1987, the health insurance funds mainly functioned as implementing bodies. They were supervised by the National Health Insurance Council, which closely monitored the implementation of legislation. Practically all the health insurance funds operated as monopolists in a legally determined regional operating area. People were obliged to register with a health insurance fund in their place of residence; they had no freedom of choice. In 1987, the health insurance funds were relatively small organizations. There was no competition and they had hardly any financial responsibility. At the time, such an organization was often called 'administration office'. Despite the fact that the proposed system revision was cancelled in 1993/1994, the playing field, the rules and the field of influence changed dramatically for the health insurance funds between 1987 and 2006. In the chosen research period, most of the regionally operating health insurance funds were transformed into nationally operating health insurers. Various organizations merged into increasingly larger units. The research question posed in the present study concerns the adaptability of the health insurance funds with regard to the changing environmental requirements and the efficacy of this organizational development in terms of customer orientation and customer satisfaction. The following line of thought provided a sense of direction in this respect (see also Figure 1). The desire for more customer orientation and cost savings

Does this go together?

Increasing bureaucracy

Is a motive for: The introduction of regulated market operation

Goes together with:

Causes:

Increase in scale of health insurers

Figure 1: The relation between bureaucracy and customer orientation

The political desire to achieve cost savings and provide more options for the customers led to the introduction of regulated market operation in the Dutch health care sector and, more specifically, in the health insurance market. The health insurance funds' financial responsibilities gradually increased, and in 1992, the legally determined operating areas were abandoned in order to provide the people insured with the health insurance funds greater freedom of choice. These measures resulted in an increase in scale: the health insurance funds merged with each other and with private medical insurance companies, 421

Summary

and most of them opt for a national operating area. This is how the health insurers that will implement the new care insurance act as of 1 January 2006 came into being. Increase in scale is usually accompanied by an increase in bureaucracy in the scientific sense of the word: a larger organization has a more extensive organizational structure (more hierarchy and specialization) and develops more formalized and standardized working methods. At the same time, the health insurers need to operate in a more customer-oriented manner in order to keep ahead of the competition. But can bureaucracy and customer orientation go hand in hand? The literature in the field has also shown that bureaucratic organizations do not really thrive in a dynamic environment. Many authors say the innovative ability of such organizations is too small. So how did the above-mentioned transformation process take place? This study focuses on the developments at health insurer VGZ. The reason for doing so is that VGZ carried out an extensive reorganization programme called CONDOR in 19941995, with a view to restructuring the entire VGZ organization in order to better meet the rapidly changing environmental requirements. Quality improvement, customer orientation and cost control governed this reorganization. The company's top management agreed to record the lessons learned in a scientifically sound manner. The research design that was eventually developed considers the VGZ case study therefore from two angles: the health insurance funds' ability to adapt to a changing environment and the harmonization of bureaucracy and customer orientation in one organization. Eventually, the research question was delineated as follows: • the research was aimed at the period from 1987 to 2006 and particularly focused on the compulsary insured within the health insurance fund. The initial year (1987) was marked by the publication of the above-mentioned report by the Dekker Committee. The year 2005 was chosen as the final year, because the implementation of the new health care insurance act on 1 January 2006 would mean the definitive end of all health insurance funds; • the health insurer's environment is brought down to four types of actors: the government, the supervisory bodies, the insured (and the care providers); • the health insurance functions discussed here are the sales function, the care purchase function, the administrative function, and the information provision function. It is these functions that make up the primary process of a health insurer and differentiate a health insurer from other large organizations. The relevant relations in this study are the relation between the environment and the health insurer's organization (1), the relation between the health insurer's organizational structure and operational processes, on the one hand, and the results thereby achieved, on the other (2), and the confrontation of these results with the formulated environmental requirements (3) (see Figure 2). Feedback (3)

Organization structure and operations of health insurers:

Health insurers’ environment: (1) Government Supervisors Insured parties

Results of health insurers: (2)

Providing information Selling policies Purchasing care Administrative function

Figure 2: The relations studied 422

Fulfilment of legal requirements Customer satisfaction

Summary

The research question answered in this study is formulated as follows: 'How did health insurer VGZ deal with the changing environmental requirements of the government, the supervisory bodies and the customers in the period from 1987 to 2006 with regard to the core functions: providing information, selling policies, purchasing care and the administrative function? Was the company effective in this respect in terms of customer orientation and customer satisfaction?' Research design This research question was worked out into 17 sub-questions, which were answered according to the following research design (see Figure 3).

Literature search (Ch. 2) Exploration of the health insurers’ environment (Ch. 3)

VGZ case study (Ch. 4, 5, 6) Expectations Comparative study involving three other health insurers (Ch. 7)

(Section 3.4)

Results and comparison with the expectations (Ch. 8)

Figure 3: Research design

By means of a literature research, insights were gathered with regard to the way in which the relationship between an organization and its environment can be considered. A description of this literature research can be found in Chapter 2. The definitions of the concepts of 'bureaucracy' and 'customer orientation' can also be found there. The criticism of bureaucratic organizations has been described by discussing authors who developed alternatives for the bureaucratic organization and by investigating the popular meaning of bureaucracy. For the purpose of this study, the concept of bureaucracy has been defined as a neutral concept: a bureaucratic organization is a form of organization that scores high on the dimensions derived from Weber's ideal type (centralization, hierarchy, formalization, standardization and specialization). The popular meaning of 'bureaucracy' has to do with the organization's performance: customers associate a bureaucratic organization with such notions as 'being slow, formalistic, inefficient, rigid, lack of initiative, etc.' Subsequently, using the literature, the possibilities for an organization to de-bureaucratize and improve its customer orientation were investigated. Next, the health insurers' environment was explored (as described in Chapter 3). This exploration provided insight into the relevant actors, the changing rules, and the changing field of influence in which the health insurers operate. The differentiated environmental sectors were typified on the dimensions indicated by Mintzberg (1997): a stable versus dynamic environment, a simple versus complex environment, an integrated versus diversified market, and a favourably inclined versus hostile environment. Finally, the thesis describes the requirements set by the supervisors, the insured and the collectivities with regard to the health insurers' functioning. To be able to study and assess the connections between the relevant relations and concepts, the INK management model was used, and more specifically, the model's entrepreneurial axis (see Figure 4). The five dimensions of bureaucratic organization were placed in the organizational areas of this model. To be able to assess whether a health insurer adequately responded to the changing environmental requirements in the research period, criteria were set in the result areas of the model. These criteria determine the 423

Summary

success of the sales function, the care purchase function, the administrative function in the information provision function. The core of this research consists of the VGZ case study described in chapters 4, 5 and 6. In order to provide a broader basis for the conclusions drawn in these chapters, a limited comparative research was carried out involving three other health insurers: CZ Actief in gezondheid, Agis and Menzis.

People Hierarchy Specialization

Leadership Centralization Hierarchy

People results

Processes Policy and strategy

Specialization Formalization Standardization

Customer results Number of insured Views of the insured

Society results Views of the supervisors

Resources

Key performance results Views of the Board: Achievement of organizational objectives Solvency Nominal premium

Innovation and Learning

Figure 4: The customer-oriented bureaucracy represented using the INK management model

Findings The health insurers' environment The people interviewed at VGZ, CZ Actief in gezondheid, and Agis stated that the environment in 2005 was more dynamic, complex, diversified and hostile in all its differentiated sectors than in 1987. The health insurers' behaviour in the research period can be explained quite well with the aid of the contingency theory. According to the interviewed people, the most important external situational factors for the health insurers in the research period from 1987 to 2006 were: • the increased financial responsibility for both the management costs and the care costs, in combination with steeply increasing care costs; • the abandonment of the health insurers' regional operating areas in 1992; • the increased competition between health insurers; • the gradual collectivization of the health insurance market; • the ‘narrow’ convergence between compulsory health insurance and private medical insurance; • the ‘broad’ convergence between care and social security; • the changing relation with the insured due to the increased competition between health insurers, the increased collectivization of the insurance market, new and stricter requirements set by insured individuals and collectivities with regard to the health insurer's functioning and the increased knowledge of the insured parties as a result of information campaigns; 424

Summary

• •

• • • • •

the change from supply management to demand management in health care; the increased business-like approach of care providers, due to the new requirements set with regard to the role of the health insurers in the purchase of care and the management of care costs and care innovation, the gradual termination of the contracting obligation, the liberalization of the rates for some types of care, and the introduction of competition in the second and third compartments of the Dutch health insurance system; the modernization of the Exceptional Medical Expenses Act (AWBZ) and the creation of care administration offices in 1998 for the implementation of the AWBZ; the emergence of waiting lists in health care; rapid technological developments; the modernization of the supervision and the increasing demands for transparency; and finally, the influence of 'Europe' on Dutch legislation and the health insurers' functioning.

Effective organizational structures Mintzberg (1997) states that, in an effective organization, the design parameters are closely related to the internal and/or external situational factors and to each other (the extended configuration hypothesis). The responses of the health insurers to the changing environment can be summarized as follows: increase in scale (bar a few exceptions) followed by integration and concentration, professionalization of the operation of all four core functions mentioned in this study, the development of new products and services, and engaging in joint ventures with other health insurers, with pension funds and with care providers. On the basis of the results achieved on the chosen criteria (Figure 4), this response may be said to have been adequate in most cases:

Was the health insurers’ response in the research period ‘adequate’? Sales function Care purchase function Administrative function Information provision function

According to the supervisor

According to the insured

No opinion Good/sufficient Good No opinion

Good No opinion Good Good

According to the organization itself Varying Varying Good Good

Both the external and internal situational factors are important for the development of an organization. The following conclusions are based on the VGZ case study.

Internal situational factors

Effect on the five dimensions of a bureaucratic organization

Institutional setting of tasks: Implementation of legislation, extended with new tasks, responsibilities, powers and accountability requirements

The sales and care purchase functions were initially organized as a professional bureaucracy and acquire more and more the characteristics of a machine bureaucracy. The administrative and information functions were initially organized as a machine bureaucracy. These functions became more humanized by drastic computerization and the formation of small teams.

425

Summary

Age of the organization: Ageing

More formalization and standardization

Size of the organization: Expanding

More specialization More formalization and standardization

Technical system: More extensive and state-of-the-art

More formalization and standardization

Power relations within a health insurance company

Varying dominance of the four core functions

A more dynamic and complex environment does not lead to 'organic' structures in health insurance companies. For health insurers, the institutional setting of tasks cannot be realized in any other way than by machine bureaucracy. Health insurer VGZ has become more bureaucratic in the scientific sense of the word. However, in the twenty-first century, the negative image of the bureaucratic organization structure has been neutralized to a large extent, and a modern machine bureaucracy has emerged. This organization, in combination with a new substantiation of the five dimensions, is quite able to serve the changing and dynamic environment adequately. Despite the increase in scale, the focus has not shifted away from the customer as far as the most important functions are concerned. In this sense, one can indeed speak of a 'customer-oriented bureaucracy'.

426

Curriculum Vitae

Annemarieke Blinkhof is geboren op 8 augustus 1961 in Boxtel. Na het V.W.O. en de HEAO Bedrijfseconomie in Den Haag werkte zij achtereenvolgens bij het Academisch Ziekenhuis Leiden als informatieanalist, de Provinciale Kruisvereniging Zuid Holland als bedrijfseconomisch medewerker, Klaasse Versluijs Adviseurs in Gouda als organisatieadviseur en het Westeinde Ziekenhuis in Den Haag als kwaliteitscoördinator. Vanaf 1998 werkt zij als beleidsmedewerker kwaliteit/medewerker planning en control bij Zorgverzekeraar VGZ, vanaf 2004 de VGZ-IZA Groep en vanaf 2006 VGZ-IZA-Trias.

427