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User-based public performance information

Partner Institute: 
University of Maastricht, Department of Health Organization, Policy and Economics (BEOZ)
Survey no: 
Groenewegen, Peter P.
Health Policy Issues: 
Quality Improvement
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no
Featured in half-yearly report: Health Policy Developments 11


The introduction of managed competition requires transparent information for users. Parallel initiatives to provide this information were taken by health insurers, MoH, Health Care Inspectorate, and provider organizations. Information, available on a public website, is based on user experiences, measured with standardized questionnaires, and for hospitals on clinical (process) indicators. Public performance information is now available for health plans and several types of services.

Purpose of health policy or idea

Managed competition is being gradually introduced in Dutch health care. For a system of managed competition to work, transparant information on the performance of health plans and service providers is necessary. This information is partly based on user evaluations of their health plan and of the health services used. The Minisrty of Health has stimulated the development of standardized information about user experiences.

The main aim of this policy is to make quality information, based on user experiences, available to the public.

Public performance information is an important instrument to stimulate managed competition. For patients it makes informed choice between health plans and health care providers possible. Insurers can use public performance in the purchasing process. Health care providers may benefit from user experiences for improvement projects.

Main points

Main objectives

Objective of this policy is to provide transparant public performance information, based on user experiences. A general format for user questionnaires has been developed. These questionnaires, now known as Consumer Quality Index (CQI), are being developed for specific sectors, such as nursing homes or hospitals, or for specific services, such as cataract surgery. Manuals for the development of new questionnaires, application in data collection and reporting have been developed.

Public performance information is published on a government sponsored website ( which is hosted by RIVM, the National Institute for Public Health and the Environment. The website is advertised among the general public to stimulate its use.

Type of incentives

Incentives for health insurers and health care providers to support data collection and public disclosure are non-financial. The fact that a number of insurers and providers are willing to disclose user experiences stimulates others to join.

The website is funded by the Ministry of Health. The development of new questionnaires is funded from different sources: ZonMw (the Netherlands Organization for Health Research and Development), health insurance organizations and provider organizations.

Groups affected

Patients, insurers, providers

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Characteristics of this policy

Degree of Innovation traditional innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low high very high
Transferability strongly system-dependent rather system-neutral system-neutral

Health care, especially in insurance based health care systems, has traditionally been dominated by professionals. Disclosure of performance information in general does not fit into professional dominated systems. In this sense the policy is innovative and a landmark for the transformation of a supply based service to a more user or patient centered system.

On the one hand it is remarkable that the implementation of this policy is consensual, as the style of Dutch health politics is changing, with the introduction of more market elements in health care. On the other hand, the same market elements are part of the successful implementation of the policy. As soon as a number of providers and health care institutions accept to have their performance information disclosed, those who don't will miss the opportunity of attracting users and run the risk of being perceived as unwilling to disclose information because of lack of quality.

Political and economic background

The introduction of managed competition in the Netherlands is a gradual process that started in the 1990's. It was speeded up by the reform of the health care insurance system, with the introduction of the Health Insurance Law (Wet zorgverzekering) in January 2006. Other relevant new legislation is the Law on Managed Competition (Wet marktwerking gezondheidszorg) and the founding of the Health Care Authority (Nederlandse Zorgautoriteit) as the health care market regulator.

The first user based performance information made public was information on user experience with their health plan in the months preceeding the insurance reform (November 2005). The aim was to provide comparative information for health plan choice.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Origins of health policy idea

There is no central policy of the Ministry of Health in the disclosure of performance information based on user experiences. The main actors in health care (providers, patients and insurers) are stimulated by the MoH to take responsibility for the process of developing and implementing this policy.

In the Dutch context there were three parallel origins of this health policy:

  • MoH policy development for the new insurance system; a special directorate was founded at the MoH, called Directorate Market and Consumers, that stimulates and coordinates policy initiatives
  • Some pro-active insurance organisations saw the necessity of obtaining reliable information for purchasing purposes and funded the first research to develop reliable and comparable questionnaires to measure user experiences
  • In the long-term care sector benchmarking projects were initiated by provider umbrella organizations that also collected information on user experiences; although this information was not originally meant to be publicly disclosed, effective pressure on the umbrella organizations resulted in public disclosure.

Initiators of idea/main actors

  • Government: MoH as a whole has strongly invested in insurance reform and introduction of managed competition; new Directorate MC stimulated public disclosure of performance information
  • Providers: More support from organizations of health care institutions, such as home care organizations, than from professional organizations of providers, such as physician organizations.
  • Payers: Small group of insurers initiated development of standardized user experience information. Data collection for yearly update of user experience with health plans is funded by all participating insurers.
  • Patients, Consumers: Patient organizations have been supportive of public disclosure
  • Media: Some media publish their own league tables of e.g. hospitals; this triggers other actors (especially providers) to invest in (co-)developing indicators for public disclosure. Newspapers have their own methodology (which makes comparison of the results very difficult). One journal only uses data of the Inspectorate plus some publicly available data. Another journal has hired a research office to do the job. They send questionnaires to doctors to ask their opinion on the quality of the hospital. Patient surveys are carried out by provider organisations (insurers may require them to do) and by insurers.
  • Others: Health Care Inspectorate facilitates national steering committees of patients, providers and insurers that have been initiated by the MoH and that negotiate about quality indicators for public disclosure

Approach of idea

The approach of the idea is described as:
new: At least it is new for the Netherlands. Not from an international perspective. First real data on website about user experiences with insurers in November 2005, on the eve of the change of the insurance system.

Innovation or pilot project

Else - Gradual introduction for different sectors and services.

Stakeholder positions

The MoH was clearly in favor of this development as part of the reform of the insurance system and the introduction of managed competition. The Insurers were also in favor, mainly from the point of view of producing relevant information for care purchasing. Providers were more reluctant; organizations of individual health care providers, such as physician organizations, more so than umbrella organizations of health care institutions. The latter were already involved in benchmarking studies (also stimulated by the government). Patient organisations were in favor. 

The MoH initiated steering committees consisting of patients, providers and insurers. The steering committees have been facilitated by the Health Care Inpectorate. Their work is linked to the development of so-called 'norms for responsible care' (normen verantwoorde zorg). Quality indicators are derived from these 'norms for responsible care'. Quality indicators to be reported publicly are partly based on user experiences and partly on clinical process and outcome indicators.

Norms for responsible care have been or are being developed for care for disabled, long-term care, mental health care and hospital care.

Actors and positions

Description of actors and their positions
Ministry of Healthvery supportivevery supportive strongly opposed
Directorate Market and Consumers (MC)very supportivevery supportive strongly opposed
Umbrella organizations of health care institutionsvery supportivesupportive strongly opposed
Professional organizations of providersvery supportiveneutral strongly opposed
Health insurersvery supportivevery supportive strongly opposed
Patients, Consumers
Patient organizationsvery supportivevery supportive strongly opposed
Newspapersvery supportiveneutral strongly opposed
Commercial websitesvery supportivesupportive strongly opposed
Health Care Inspectoratevery supportivevery supportive strongly opposed

Influences in policy making and legislation

The legal basis for disclosure of performance information was created in July 2006 with the introduction of  the Law on Managed Competition (Wet marktwerking gezondheidszorg). Article 38, section 4 states that health care providers have to disclose information on tariffs and on the quality of their services, in such a way that this information is easily comparable for consumers. Article 40, section 1 states the same about health insurers.

Legislative outcome


Actors and influence

Description of actors and their influence

Ministry of Healthvery strongstrong none
Directorate Market and Consumers (MC)very strongstrong none
Umbrella organizations of health care institutionsvery strongstrong none
Professional organizations of providersvery strongneutral none
Health insurersvery strongvery strong none
Patients, Consumers
Patient organizationsvery strongneutral none
Newspapersvery strongweak none
Commercial websitesvery strongneutral none
Health Care Inspectoratevery strongstrong none
Patient organizationsMinistry of Health, Directorate Market and Consumers (MC), Health Care InspectorateHealth insurersCommercial websitesUmbrella organizations of health care institutionsNewspapersProfessional organizations of providers

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Implementation of this policy is stimulated by the government and facilitated by the Health Care Inspectorate. Policy adoption and implementation is based on voluntary participation in steering committees that develop norms and indicators based on these norms. This approach reflects the long tradition of consensual policy making and implementation in the Netherlands. 

Information based on user experiences with health insurance and health care provision is an accepted element. The Consumer Quality Index (CQI) approach has been accepted as the national standard aproach to assessing user experiences. This was institutionalised by the foundation of the Centre for Consumer Experience in Health Care (Centrum Klantervaring Zorg, CKZ) in December 2006. Aims of CKZ are to coordinate the development of questionnaires, to supervise the measurement of consumer experiences and to guarantee comparable information.  

The research and development that resulted in CQI was funded by separate insurers and by programmatic support by ZonMw (Netherlands Organization for Health Research and Development). CQI questionnaires were developped on the basis of CAHPS (USA) and QUOTE (the Netherlands) questionnaires by NIVEL and AMC/Dep. of  Social Medicine.

Monitoring and evaluation

The Centre for Consumer Experience in Health Care (CKZ) itself will be evaluated in 2009. CKZ will make yearly overviews of user information that will contain elements that can be used for evaluation. ZonMw will continue to fund research on public disclosure of user based information, especially into its effects. The Health Insurance Law and Law on Managed Competition will be evaluated in 2009 and this evaluation might also address the policies around public disclosure of performance information.

Expected outcome

It is expected that public disclosure of performance information will be extended in the future. As a consequence the instrumental goals of this policy (making comparative information available to health care users) will be reached. It is much more difficult to say whether or not the ultimate goals which are related to the introduction of managed competition will also be reached. That will depend on the extent that health care users will use the information, and that health insurers and health care providers will react on this. The unintended effects of disclosing performance information have been studied and discussed in other countries, such as the US, and in the general literature (performance paradox).

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low low very high

The impact on quality and cost-efficiency depends on so many more influences than disclosure of performance information that it is very difficult to say how strong the impact of this specific policy will be.


Sources of Information

Publicly disclosed information on website:

Arah, O.A. et al. (2006). The psychometric properties of the Dutch version of the Hospital-level Consumer Assessment of Health Plans Survey instrument. Health Services Research, 41(1), 284-301.

Stubbe J.H., Gelsema T. & Delnoij D.M.J.  The Consumer Quality Index Hip Knee Questionnaire measuring patients' experience with quality of care after a total hip or knee arthroplasty. BMC Health Services Research, 2007, 7:60.

Stubbe J.J., Brouwer W. & Delnoij D.M.J. Patients' experiences with quality of hospital care: the Consumer Quality Index Cataract Questionnaire. BMC Ophthalmology 2007, 7:14.

Author/s and/or contributors to this survey

Groenewegen, Peter P.

NIVEL-Netherlands Institute for Health Services Research

Suggested citation for this online article

Groenewegen, Peter P.. "User-based public performance information". Health Policy Monitor, April 2008. Available at