Abstract
This study discusses the relationship between physicians and collective health-insurance funds at the national tier in the Netherlands and at the regional tier of ‘’Midden-Nederland’’. This region consists of the urban areas of Utrecht, Amersfoort and Zeist, i.e. the larger part of the Province of Utrecht and the western part
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of the Province of Gelderland. Historical research reveals the nature of the relationship between these parties, the manner in which it developed over the years and the factors that affected this relationship. National and regional development of the relationship are compared. Policy making and implementation of collective health-insurance funds with its attendant conformity and difference, nationally and regionally, are the central focal point.
Two types of relationship are distinguished: conflict relationships and harmony relationships. In the former the partners are hardly or not at all prepared to harmonise their objectives or adjust their interests and ideologies. If neither of the partners may dominate the other there is an inconclusive power game, a delicate balance of power. Harmony relationships aim at completely or partly coinciding objectives and partners are prepared to cooperate, a stable balance of power. Two groups of factors have affected the physicians-funds relationship: those factors that directly concern the relationship and external developments. The former are the ideas and the characters of the people involved, ideology, mutual dependency, social emancipation of the professions, power, collectivisation and concentration. External factors may be economic and social developments, such as economic growth and recession, war, occupation and peace, compartmentalisation, relationship with the authorities, influence of the trade unions, development of medical science and growth of health care.
After 1930 scale increase in the relationship became important. Examples of scale increase are umbrella organisations, mergers of organisations and increasingly central protection of interests. Three types of scale increase may be distinguished: collectivisation, concentration and regionalisation. Collectivisation is transferring power to higher bodies, such as umbrella organisations. Concentration is the merger of equivalent bodies. Regionalisation is composing a region with a coherent system of health-care provisions, resources and insurance.
After 1941 scale increase got a pragmatic character. Pragmatism implies that the physicians-funds relationship was increasingly decided by regulation, material interests and cooperation in policy making in health care rather than by the struggle for ideological principles or the administrative power of the funds as was the case in the previous period.
Until 1941 collective health-insurance funds, physicians and pharmacists, who had become a rather important second group of care providers in the relationship, had been free as to how to organise collective health-insurance funds: the collective health-insurance funds market. On 1 November 1941 the Collective Health Insurance Law was introduced and it put a stop to this market. As a consequence the influence of the central government on collective-health insurance funds and the relationship increased more and more.
The relationship may be divided into three periods: 1827 to 1908, 1908 to 1940 and 1940 to 1996.
Each period is a part of this study.
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