Marco Varkevisser is an assistant professor of Health Economics at the institute of Health Policy and Management (iBMG), Erasmus University Rotterdam. After graduating from the Erasmus School of Economics in 1998, his research focused on competition and regulation issues in various industries. Over the years he has specialised in competition and antitrust enforcement in health care markets.
Patient choice, competition and antitrust enforcement in Dutch hospital markets
— The ultimate goal of the market-based health care reform in the Netherlands is to increase the efficiency of health care provision by stimulating provider competition. This PhD thesis focuses on the feasibility of hospital competition in the Netherlands. Effective hospital competition first requires the availability of a sufficient number of substitutes. Since hospital consolidation reduces the number of choices, preventive merger control is of crucial importance. Antitrust enforcement agencies are, however, struggling with the assessment of proposed hospital mergers. Most importantly, more than in any other industry, geographic market definition is rather complicated in hospital markets. In addition to a sufficient number of hospital substitutes, effective competition at least also requires market transparency and patient responsiveness to observed quality differences. Little is known, however, about patient choice behaviour in the Netherlands. The aim of this thesis is to improve the understanding of patient choice, competition, and antitrust enforcement in Dutch hospital markets.
— Marco Varkevisser
Patient choice, competition and antitrust enforcement in Dutch hospital markets — Marco Varkevisser
Patient choice, competition and antitrust enforcement in Dutch hospital markets
Marco Varkevisser
ISBN 978-94-90420-03-1 Marco Varkevisser, 2009. All rights reserved. Chapters reprinted with kind permission of Cambridge University Press (chapter 3) and Springer Berlin / Heidelberg (chapters 4 and 5). Cover image taken by Stéphanie van der Geest and edited by Optima Grafische Communicatie BV. Printed by Optima Grafische Communicatie BV, Rotterdam.
Patient Choice, Competition and Antitrust Enforcement in Dutch Hospital Markets Keuzegedrag van patiënten, concurrentie en mededingingsbeleid in Nederlandse ziekenhuismarkten
Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus prof.dr. H.G. Schmidt en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op donderdag 14 januari 2010 om 13.30 uur door
Marco Varkevisser geboren te Leiderdorp.
Promotiecommissie Promotor Prof.dr. F.T. Schut
Overige leden Prof.dr. M.F.M. Canoy Prof.dr. M.C.W. Janssen Prof.dr. W.P.M.M. van de Ven
Contents Chapter 1
General introduction
Chapter 2
Hospital merger control: an international comparison
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Chapter 3
Defining hospital markets for antitrust enforcement: new approaches and their applicability to the Netherlands
53
Chapter 4
Why do patients bypass the nearest hospital? An empirical analysis for orthopaedic care and neurosurgery in the Netherlands
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Chapter 5
Assessing hospital competition when prices don’t matter to patients: the use of time-elasticities
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Chapter 6
Quality competition in regulated hospital markets: consumer information and patient choice for angioplasty
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Chapter 7
Summary and conclusion
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7
Samenvatting
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Dankwoord
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Curriculum Vitae
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PhD Portfolio
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Samenvatting
van (reis)tijdelasticiteiten momenteel de meest geschikte methode om de geografische omvang van ziekenhuismarkten af te bakenen. Deze nieuwe methode zou dan ook door de NMa moeten worden toegepast. De methode is ook van toegevoegde waarde voor de Nederlandse Zorgautoriteit (NZa) wanneer zij antwoord moet geven op de vraag of individuele ziekenhuizen al dan niet over aanmerkelijke marktmacht beschikken. 3. Om de voordelen van concurrentie tussen ziekenhuizen te kunnen realiseren is het noodzakelijk dat meer en betere kwaliteitsinformatie beschikbaar komt. Mede omdat de huidige prestatie-indicatoren van de Inspectie voor de Gezondheidszorg (IGZ) geen rekening houden met verschillen in zorgzwaarte, kan een toename van de onderlinge concurrentie ziekenhuizen onder de huidige omstandigheden aanzetten tot maatschappelijk ongewenst gedrag, zoals risicoselectie. 4. Om beter inzicht te krijgen in de werking van markten voor ziekenhuiszorg en de effecten van ziekenhuisfusies in het bijzonder, verdient het aanbeveling dat de NMa in nauwe samenwerking met de NZa een onderzoeksprogramma opstart naar het voorbeeld van een programma van de Amerikaanse FTC (Federal Trade Commission). Ten einde de ontwikkeling van innovatief onderzoek op dit gebied te stimuleren, is het van belang de hiervoor benodigde kwantitatieve gegevens beschikbaar te stellen voor wetenschappelijk onderzoek.
Curriculum Vitae
Curriculum Vitae Marco Varkevisser (1974) is an assistant professor of Health Economics at the institute of Health Policy and Management (iBMG), Erasmus University Rotterdam (EUR). After graduating from the Erasmus School of Economics in 1998, he started working as a research fellow at the Research Centre for Economic Policy (OCFEB), a joint venture of the Ministry of Economic Affairs, the Ministry of Finance, the Ministry of Social Affairs and Employment, De Nederlandsche Bank, and the Erasmus University Rotterdam. From 1998 to 2004, his research focused on competition and regulation issues in various industries (e.g. provision of drinking water, waste management, retail gasoline markets, health care markets). In 2004 he started working as a research fellow at the EUR research institute SEOR (until 2009) as well as iBMG. From 2005 to 2009 he worked on his dissertation. During this period Marco published articles in the European Journal of Health Economics, Health Economics, Policy and Law, and the International Journal of Health Care Finance and Economics. In addition to these international publications, he also published many articles in national journals (e.g. Economisch Statistische Berichten) and Dutch newspapers (Het Financieele Dagblad, Trouw, NRC Handelsblad). Since starting his dissertation, he has specialised in competition and antitrust enforcement in health care markets. Next to the research included in his PhD thesis, he also worked on projects for third-parties including the Ministry of Health, Welfare and Sports (VWS), the Netherlands Competition Authority (NMa), and the Dutch Healthcare Authority (NZa). As a teacher, Marco is involved in both iBMG’s bachelor programme and its master programme Health Economics, Policy and Law (HEPL). He teaches the economics of health care (bachelor), competition law and economics in health care (master), and the economics and financing of health care systems (master). Additionally, Marco supervised several bachelor and master theses. Marco is a member of the Board of Directors of the Dutch-Flemish Association for Health Economics (Vereniging voor Gezondheidseconomie) and editor-in-chief of its journal, the VGE Bulletin.
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PhD Portfolio
PhD Portfolio Name: University: Department: PhD period: Promotor:
Marco Varkevisser Erasmus University Rotterdam (EUR) institute of Health Policy and Management (iBMG) 2005-2009 Prof.dr. F.T. Schut
Presentations on competition and antitrust enforcement in health care (selection) -
VU University, Amsterdam, guest lecture Erasmus Honours Programme, Rotterdam, guest lecture Dutch Healthcare Authority (NZa), Utrecht, seminar Netherlands Competition Authority (NMa), The Hague, seminar Erasmus Honours Programme, Rotterdam, guest lecture 25th Academy Health Annual Research Meeting, Washington DC, poster presentation Health Economics Interest Group Meeting, Washington DC, oral presentation Bundeskartellamt, Bonn, seminar Erasmus University Rotterdam, seminar University of Oslo, guest lecture and seminar Netherlands Competition Authority (NMa), The Hague, workshop Dutch Healthcare Authority (NZa), Utrecht, seminar 6th European Conference on Health Economics, Budapest, oral presentation University of Bologna, guest lecture 5th World Congress of the international Health Economics Association, Barcelona, oral presentation
2009 2009 2009 2009 2008 2008 2008 2008 2008 2007 2007 2006 2006 2006 2005
Publications in English -
Leunis, A. and M. Varkevisser, ‘Internal medicine residents’ perceptions of the learning environment in Dutch teaching hospitals’, Medical Teacher, forthcoming
2009
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Boonen, L.H.H.M., S.A. van der Geest, F.T. Schut and M. Varkevisser, ‘Pharmaceutical policy in the Netherlands: from price regulation toward managed competition’, in A. Dor (ed.), Advances in Health Economics and Health Services Research, volume 22, forthcoming
2009
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PhD Portfolio
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Varkevisser, M., S.A. van der Geest and F.T. Schut, ‘Assessing hospital competition when prices don’t matter to patients: the use of timeelasticities’, International Journal of Health Care Finance and Economics, forthcoming Varkevisser, M., C.S. Capps and F.T. Schut, ‘Defining hospital markets for antitrust enforcement: new approaches and their applicability to the Netherlands’, Health Economics, Policy and Law, 3(1): 7-29 Varkevisser, M. and S.A. van der Geest, ‘Why do patients bypass the nearest hospital? An empirical analysis for orthopaedic care and neurosurgery in the Netherlands’, European Journal of Health Economics, 8(3): 287-295
Publications in Dutch (selection) Articles in national journals Varkevisser, M., S.A. van der Geest, M. Appelman en J.N. Struijs, ‘Regionale machtspositie zorggroepen baart zorgen’, Economisch Statistische Berichten, 94(4572): 701 Geest, S.A. van der en M. Varkevisser, ‘Kwaliteitsinformatie en de marktaandelen van IVF-centra’, Economisch Statistische Berichten, 93(4549): 756-758 Varkevisser, M. en F.T. Schut, ‘Consumentenbelang gaat boven concurrentenbelang (reactie)’, Economisch Statistische Berichten, 93(4534): 285 Varkevisser, M. en F.T. Schut, ‘NMa moet strenger zijn bij toetsen ziekenhuisfusies’, Economisch Statistische Berichten, 93(4532): 196-199 Geest, S.A. van der, I. Mosca, F. Pellikaan en M. Varkevisser, ‘In beweging voor de fysiotherapeut’, Economisch Statistische Berichten, 92(4516): 506508 Varkevisser, M., S.A. van der Geest, E. Maasland en F.T. Schut (2007), ‘Opleiden medisch specialisten moet transparanter’, Economisch Statistische Berichten, 92(4511): 340-342 Schut, F.T. en M. Varkevisser, ‘Zorgautoriteit moet niet alleen blaffen, maar ook kunnen bijten’, Economisch Statistische Berichten, 91(4479): 58-60 Varkevisser, M., N. Polman en S.A. van der Geest, ‘Zorgverzekeraars moeten patiënten kunnen sturen’, Economisch Statistische Berichten, 91(4478): 38-40
2009
2008
2007
2009
2008
2008
2008 2007
2007
2006
2006
PhD Portfolio
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Book contributions Schut, F.T. en M. Varkevisser, ‘Marktordening in de gezondheidszorg’, in F.T. Schut en F.F.H. Rutten (red.), Economie van de gezondheidszorg, leerboek voor universitair en hoger onderwijs, 247-288, Maarssen: Elsevier Gezondheidszorg Geest, S.A. van der, F.T. Schut en M. Varkevisser, ‘Gezondheidszorg’, in C.A. de Kam en A.P. Ros (red.), Jaarboek overheidsfinanciën 2006, 57-86, Den Haag: Sdu Uitgevers Geest, S.A. van der, F.T. Schut en M. Varkevisser, ‘Gezondheidszorg’, in C.A. de Kam en A.P. Ros (red.), Jaarboek overheidsfinanciën 2005, 97-121, Den Haag: Sdu Uitgevers Op-Eds Brouwer, W.B.F. en M. Varkevisser, ‘Voorrangszorg met voorrang mogelijk maken’, Het Financieele Dagblad, 11 mei Schut, F.T., M. Varkevisser en W.P.M.M. van de Ven, ‘In VS blijken fusies [van zorgverzekeraars en ziekenhuizen] succes voor patiënten’, NRC Handelsblad, 2 februari Varkevisser, M., W.B.F. Brouwer en R. van Duuren, ‘Bevrijd ziekenhuizen van juk winstverbod’, NRC Handelsblad, 17 december Schut, F.T. en M. Varkevisser, ‘Fusiedrang bedreigt ontluikende marktwerking’, Zorgvisie, nummer 11 / november Geest, S.A. van der en M. Varkevisser, ‘Verbeter informatie over farmacie’, Het Financieele Dagblad, 9 augustus Varkevisser, M., ‘Gehandicapte kan in instelling gelukkig zijn’, Trouw, 17 april Brouwer, W.B.F. en M. Varkevisser, ‘Vragen rond zorgstelsel liggen nog voor ons’, Trouw, 3 november Varkevisser, M., ‘Repareer met spoed de Ziekenfondswet’, Trouw, 7 juni
2009
2006
2005
2009 2009
2008 2008 2008 2007 2006 2005
Teaching at iBMG -
‘Economics and financing of health care systems’, master HEPL, lecturer and course coordinator (since 2009) ‘Algemene economie van de gezondheidszorg’, bachelor, lecturer ‘Law and economics of competition policy in health care’, master HEPL, lecturer ‘Zorgstelsel en zorgverzekering’, bachelor, lecturer Bachelor thesis, supervisor Master HEPL thesis, supervisor
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Marco Varkevisser is an assistant professor of Health Economics at the institute of Health Policy and Management (iBMG), Erasmus University Rotterdam. After graduating from the Erasmus School of Economics in 1998, his research focused on competition and regulation issues in various industries. Over the years he has specialised in competition and antitrust enforcement in health care markets.
Patient choice, competition and antitrust enforcement in Dutch hospital markets
— The ultimate goal of the market-based health care reform in the Netherlands is to increase the efficiency of health care provision by stimulating provider competition. This PhD thesis focuses on the feasibility of hospital competition in the Netherlands. Effective hospital competition first requires the availability of a sufficient number of substitutes. Since hospital consolidation reduces the number of choices, preventive merger control is of crucial importance. Antitrust enforcement agencies are, however, struggling with the assessment of proposed hospital mergers. Most importantly, more than in any other industry, geographic market definition is rather complicated in hospital markets. In addition to a sufficient number of hospital substitutes, effective competition at least also requires market transparency and patient responsiveness to observed quality differences. Little is known, however, about patient choice behaviour in the Netherlands. The aim of this thesis is to improve the understanding of patient choice, competition, and antitrust enforcement in Dutch hospital markets.
— Marco Varkevisser
Patient choice, competition and antitrust enforcement in Dutch hospital markets — Marco Varkevisser
