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Please
cite
this
article
in
press
as:
Stadhouders
N,
et
al.
Effective
healthcare
cost-containment
policies:
A
systematic
review.
Health
Policy
(2018),
https://doi.org/10.1016/j.healthpol.2018.10.015
ARTICLE IN PRESS
G Model
HEAP-4003;
No.
of
Pages
9
Health
Policy
xxx
(2018)
xxx–xxx
Contents lists available at ScienceDirect
Health
Policy
journal homepage: www.elsevier.com/locate/healthpol
Effective
healthcare
cost-containment
policies:
A
systematic
review
Niek
Stadhoudersa,∗,1,
Florien
Krusea,1,
Marit
Tankea,
Xander
Koolmanb,
Patrick
Jeurissena,c
aScientific
Institute
for
Quality
of
Healthcare,
Radboud
University
Medical
Center,
Nijmegen,
the
Netherlands
bTalma
Institute,
Department
of
Health
Sciences,
VU
University
Amsterdam,
Amsterdam,
the
Netherlands
cMinistry
of
Health,
Welfare
and
Sport,
The
Hague,
the
Netherlands
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
5
June
2018
Received
in
revised
form
1
October
2018
Accepted
25
October
2018
Keywords:
Healthcare
costs
Cost
containment
Policy
evaluation
Health
reform
Systematic
review
a
b
s
t
r
a
c
t
Unsustainable
growth
in
healthcare
expenditure
demands
effective
cost-containment
policies.
We
review
policy
effectiveness
using
total
payer
expenditure
as
primary
outcome
measure.
We
included
all
OECD
member
states
from
1970
onward.
After
a
rigorous
quality
appraisal,
we
included
43
original
studies
and
18
systematic
reviews
that
cover
341
studies.
Policies
most
often
evaluated
were
payment
reforms
(10
studies),
managed
care
(8
studies)
and
cost
sharing
(6
studies).
Despite
the
importance
of
this
topic,
for
many
widely-used
policies
very
limited
evidence
is
available
on
their
effectiveness
in
con-
taining
healthcare
costs.
We
found
no
evidence
for
21
of
41
major
groups
of
cost-containment
policies.
Furthermore,
many
evaluations
displayed
a
high
risk
of
bias.
Therefore,
policies
should
be
more
routinely
and
rigorously
evaluated
after
implementation.
The
available
high-quality
evidence
suggests
that
the
cost
curve
may
best
be
bent
using
a
combination
of
cost
sharing,
managed
care
competition,
reference
pricing,
generic
substitution
and
tort
reform.
©
2018
The
Authors.
Published
by
Elsevier
Ireland
Ltd.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1.
Introduction
The
share
of
gross
domestic
product
(GDP)
spend
on
healthcare
is
increasing
in
all
member
countries
of
the
Organisation
for
Eco-
nomic
Cooperation
and
Development
(OECD),
from
4.6%
of
GDP
in
1970
to
9.0%
of
GDP
in
2016
[1].
Despite
a
temporary
slow-
down
in
the
growth
of
healthcare
spending
during
the
fiscal
crisis,
the
pace
of
healthcare
growth
is
again
accelerating
in
many
OECD
countries
[1].
Growth
is
driven
by
a
combination
of
factors:
age-
ing
populations
and
work-force,
technological
advances,
changing
preferences
due
to
higher
incomes,
higher
wage
growth
due
to
lag-
ging
productivity
growth,
and
increased
coverage
[2].
Healthcare
expenditure
is
financed
primarily
collectively
[3].
The
capacity
to
fund
further
health
spending
growth
through
increases
in
taxes
and
premiums
seems
limited
[4].
Hence,
expanding
healthcare
budgets
may
increasingly
pressure
public
spending
in
other
areas,
such
as
education
or
infrastructure
[5].
Furthermore,
the
healthcare
sec-
tor
is
prone
to
inefficiencies
such
as
unnecessary
care,
waste
in
healthcare,
unwarranted
clinical
practice
variation,
administrative
∗Corresponding
author
at:
Postbus
9101,
6500
HB
Nijmegen,
Geert
Grooteplein
21,
the
Netherlands.
E-mail
address:
Niek.Stadhouders@radboudumc.nl
(N.
Stadhouders).
1Shared
first
authorship.
burdens,
fraud
and
abuse
[6].
The
combination
of
the
limited
capa-
bility
of
both
the
government
and
the
economy
to
keep
financing
high
healthcare
growth,
plus
the
awareness
about
the
existing
inef-
ficiencies
in
healthcare,
provides
policymakers
with
a
compelling
argument
to
contain
healthcare
costs.
Various
countries
have
sought
to
address
high
healthcare
cost
growth
through
myriad
policies
[7–9].
Many
EU
countries,
for
example,
have
been
experimenting
with
strict
cost
containment
policies
during
the
fiscal
crisis
[10].
Salaries
were
reduced
in
France
and
Ireland
[11],
and
Greece
likewise
implemented
policies
to
cut
physician’s
wages
and
fees
by
25%
[12].
Health
budgets
were
reduced
in
Italy,
Spain,
Portugal
and
Ireland,
amongst
other
coun-
tries
[11].
Latvia
and
Bulgaria
reduced
the
health
budget
by
over
20%
[11].
Although
health
systems
differ,
cost-containment
poli-
cies
have
been
remarkably
similar
across
countries
[13].
And
while
the
effects
may
be
context-dependent,
still
countries
could
learn
from
each
other’s
experiences,
especially
regarding
effectiveness
[14–16].
A
large
number
of
cost
containment
policies
have
been
iden-
tified,
targeting
all
aspects
of
the
health
system,
such
as
prices,
volumes,
supply,
demand
and
market
processes
[13].
However,
the
adaptability
of
the
health
system
may
complicate
attaining
the
goal
of
containing
total
costs.
For
example,
price
reductions
may
invoke
volume
increases
[17–19],
or
compensation
in
other
areas
[20,21].
Essentially,
intervening
in
market
processes
may
invoke
https://doi.org/10.1016/j.healthpol.2018.10.015
0168-8510/©
2018
The
Authors.
Published
by
Elsevier
Ireland
Ltd.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Please
cite
this
article
in
press
as:
Stadhouders
N,
et
al.
Effective
healthcare
cost-containment
policies:
A
systematic
review.
Health
Policy
(2018),
https://doi.org/10.1016/j.healthpol.2018.10.015
ARTICLE IN PRESS
G Model
HEAP-4003;
No.
of
Pages
9
2
N.
Stadhouders
et
al.
/
Health
Policy
xxx
(2018)
xxx–xxx
Table
1
PICOS
inclusion
criteria.
Population
Health
sectors
of
OECD
countries
Intervention
Implementation
of
a
cost
containment
policy
Comparator
Comparison
over
time,
between
regions
or
between
groups
of
insured
Outcome
Reduction
in
level
or
growth
of:
•
Total
expenditure
•
Sector
expenditure
•
Public
expenditure
•
Total
health
insurance
premiums
Study
design
Empirical
policy
evaluations
adverse
behavioural
responses
[22,23].
Therefore,
whether
poli-
cies
are
effective
in
containing
total
spending
remains
an
empirical
query.
To
our
knowledge,
a
robust
overview
of
the
available
evidence
is
lacking.
The
few
reviews
undertaken
focus
on
areas
such
as
phar-
maceuticals
[24]
or
hospitals
[25],
Medicare
and
Medicaid
[26],
payment
reform
[27,28],
and
efficiency
[29].
None
of
these
reviews
has
systematically
appraised
the
reliability
and
risk
of
bias
of
the
included
articles.
Moreover,
most
reviews
do
not
assess
the
evi-
dence
from
a
societal
perspective.
Instead,
most
studies
in
this
field
take
either
a
patient
or
provider
perspective.
Patient
level
policies
may
reduce
patient
treatment
cost,
but
may
forego
the
provider
response
to
use
the
access
capacity
for
additional
care
for
other
patient
groups.
Similarly,
provider
level
policies
(e.g.
hospi-
tals
implementing
policies
to
reduce
their
operating
costs)
may
fail
to
incorporate
additional
burdens
that
may
fall
on
primary
care
providers
or
other
hospitals
[30].
From
a
provider
or
patient
per-
spective,
reductions
in
treatment
costs
may
increase
efficiency,
but
due
to
possible
spillovers
to
other
sectors,
providers
or
patients,
the
effect
on
total
expenditure
is
ambiguous
[31].
This
review
takes
a
societal
perspective,
focusing
on
expenditures
of
all
payers
and
patients.
The
aim
of
this
review
is
threefold:
(1)
to
summarise
exist-
ing
literature
on
the
effectiveness
of
healthcare
cost-containment
policies;
(2)
to
identify
knowledge
gaps;
and
(3)
to
inform
policy-
makers
on
promising
cost-containment
policies.
2.
Materials
and
methods
We
performed
a
systematic
review
to
identify
evidence
on
the
effectiveness
of
known
policy
options
to
control
payer
expenditure.
Our
approach
follows
the
Centre
for
Reviews
and
Dissemina-
tion
guidance
protocol
for
undertaking
reviews
in
healthcare
[32].
Standard
rapid
review
procedures
were
followed
with
respect
to
handsearching
journals,
expert
consultations
and
article
transla-
tions
[33].
Inclusion
criteria
are
defined
according
to
the
Patient,
Intervention,
Comparator,
Outcome,
Study
design
(PICOS)
frame-
work
(Table
1)
[34].
Our
primary
outcome
measure
is
total
expenditures,
covering
all
payers,
health
sectors
and
patient
out-of-pocket
payments.
Expen-
ditures
of
individual
payers,
such
as
governments
(in
National
Health
Service
systems),
healthcare
insurers
(in
Social
Health
Insur-
ance
systems)
or
governmental
organisations
like
Medicare
and
Medicaid,
are
also
included
as
outcome,
although
this
inclusion
contains
the
risk
of
cost
shifting
to
other
payers
or
private
spending.
Furthermore,
sector
expenditures,
e.g.
pharmaceutical
spending,
are
included
as
outcome,
although
this
risks
cost
shifting
to
other
sectors.
Therefore,
from
a
societal
perspective
these
outcome
mea-
sures
may
be
less
reliable
than
total
expenditures.
Single
hospital
expenditures
or
single
patient
group
expenditures
are
excluded
as
outcome
measures
due
to
the
very
high
risk
of
cost
shifting.
Effective
cost
containment
is
defined
as
lower
total
expendi-
ture
or
payer
expenditure
compared
to
a
control
group,
including
before-after
comparisons
within
the
same
population
and
compar-
ison
to
a
similar
population
(e.g.
insured
population
of
insurers,
regions
or
countries)
[35].
Our
study
population
is
defined
as
the
insured
population
(enrolees)
of
one
or
more
payers,
either
private
or
public.
This
excludes
studies
using
per
patient
expenditure,
per
provider
expenditure,
volumes
or
prices
as
sole
outcome
measure.
Containing
the
cost
per
unit
of
service,
i.e.
improving
efficiency
[29],
is
policy
relevant
as
well,
but
beyond
the
scope
of
this
review,
as
are
other
policy
aims
such
as
quality,
equity
and
access.
This
review
only
includes
OECD
countries.
Using
inductive
pilot
searches,
relevant
keywords
were
defined
for
all
inclusion
criteria.
A
twofold
strategy
was
employed:
a
search
for
cost-containment
policies
in
general
and
a
specific
search
for
individual
policies
that
were
identified
as
cost-containment
poli-
cies
[13].
The
final
search
string
(see
Appendix
A),
was
amended
with
database
specific
glossary
terms
(MeSH
terms).
The
follow-
ing
databases
were
searched
(June
2016):
Pubmed,
Medline,
The
Cumulative
Index
to
Nursing
and
Allied
Health
Literature
(CINAHL),
Web
of
Science
and
Econlit.
After
adding
relevant
articles
from
a
second
cost-containment
literature
database
[13],
7209
unique
articles
were
collected.
After
excluding
irrelevant
articles
based
on
title
and
abstract,
276
articles
were
screened
in
full
text
indepen-
dently
by
two
researchers.
References
of
the
excluded
reviews
were
checked
for
relevant
articles
and
screened
using
a
similar
process
as
the
original
articles
(see
Appendix
B
for
the
Preferred
Reporting
Items
for
Systematic
Reviews
and
Meta-Analyses
(PRISMA)
flow
diagram).
We
extracted
relevant
information
of
the
included
articles
and
assessed
the
quality.
To
this
aim,
we
reviewed
ten
quality
assess-
ment
tools
[36–45].
Based
on
these
validated
frameworks,
we
designed
a
quality
assessment
tool
specifically
for
policy
evalua-
tions
(Appendix
C).
We
use
five
quality
domains:
content
validity,
selection
bias,
confounding
bias,
measurement
bias
and
reliability.
Literature
reviews
were
assessed
separately
using
A
MeaSurement
Tool
to
Assess
systematic
Reviews
(AMSTAR)
[46].
The
results
of
the
included
systematic
reviews
were
incorporated
directly
in
the
narrative
synthesis
without
a
separate
assessment
of
the
papers
included
in
that
review
[47].
Two
reviewers
independently
per-
formed
quality
assessments
and
review
assessments.
To
structure
our
results,
we
use
an
existing
framework
of
mutually
exclusive
groups,
covering
both
macro-policies
and
micro-interventions
[13].
Comparing
our
results
with
this
frame-
work
allows
detection
of
knowledge
gaps,
which
may
inspire
future
policy
evaluations.
Although
other
categorisations
of
cost-
containment
policies
exist
[48–53],
this
categorisation
was
deemed
most
suitable
to
detect
knowledge
gaps.
3.
Results
In
total,
72
policies
from
43
empirical
papers
and
18
system-
atic
reviews
were
included.
The
18
systematic
reviews
covered
a
total
of
341
studies.
Of
the
61
included
articles,
1
took
a
societal
perspective,
while
60
studies
took
a
payer
or
sector
perspective.
Overall,
the
included
papers
were
of
mixed
quality.
Of
the
43
empir-
ical
papers,
29
articles
scored
low
on
at
least
one
of
the
five
quality
domains.
Systematic
review
ratings
ranged
from
3
out
of
12
to
12
out
of
12
points
on
the
AMSTAR
scale.
We
were
unable
to
per-
form
a
meta-analysis
due
to
the
methodological
heterogeneity
and
context
dependency
of
the
studies
[54].
Therefore,
results
for
each
intervention
are
discussed
separately.
First,
we
summarise
the
lit-
erature.
Next,
we
identify
knowledge
gaps.
Last,
we
synthesise
the
results.
Please
cite
this
article
in
press
as:
Stadhouders
N,
et
al.
Effective
healthcare
cost-containment
policies:
A
systematic
review.
Health
Policy
(2018),
https://doi.org/10.1016/j.healthpol.2018.10.015
ARTICLE IN PRESS
G Model
HEAP-4003;
No.
of
Pages
9
N.
Stadhouders
et
al.
/
Health
Policy
xxx
(2018)
xxx–xxx
3
3.1.
Literature
overview
Appendix
D
summarises
our
results,
structured
according
to
each
of
the
four
primary
policy
groups:
budgets,
price
controls,
volume
controls
and
market-oriented
policies,
where
–
due
to
the
large
number
of
articles
–
the
last
category
is
further
subdivided
into
market
structure
policies,
market
conduct
policies
and
mar-
ket
performance
policies.
We
briefly
discuss
the
findings
for
each
intervention.
3.1.1.
Budgets
Budgeting
total
or
sector
expenditures
is
a
widespread
policy
measure
[55,56].
Despite
their
intuitive
appeal,
budgets
are
not
necessarily
effective
in
containing
spending.
For
example,
budget
constraints
may
be
considered
soft
if
hospitals
expect
a
government
bail-out
in
case
of
overspending
[57–59].
Therefore,
effectiveness
of
budgets
as
a
cost
containment
tool
is
an
empirical
question.
How-
ever,
we
could
only
include
two
studies
at
the
payer
level.
The
introduction
of
the
Balanced
Budget
Act
in
the
US
(1997)
limited
total
spending
on
Medicare
by
112
billion
dollar
[60].
In
response,
the
Centre
for
Medicare
and
Medicaid
Services
introduced
a
series
of
cost-containment
measures,
such
as
price
reductions
and
pay-
ment
reform.
After
two
years,
hospitals
with
higher
exposure
to
Medicare
patients
ended
up
with
on
average
9%
lower
revenues
than
hospitals
with
low
Medicare
exposure,
without
declines
in
actual
volume
[60].
A
systematic
review
(2
studies)
evaluated
the
effectiveness
of
GP
drug
budgets;
a
significant
reduction
in
phar-
maceutical
expenses
of
27%–70%
was
found
in
the
UK,
while
a
non-significant
reduction
of
18%–27%
was
reported
in
Ireland
[61].
3.1.2.
Price
controls
Price
controls
include
limits
on
reimbursements
(price
setting,
fee
schedules,
price
negotiations
or
reference
pricing)
and
con-
trols
of
production
factors
(wages,
profits,
capital
or
pharmaceutical
inputs).
The
price
of
pharmaceuticals
in
turn
may
be
set
based
on
prices
in
other
countries
(external
reference
pricing)
or
based
on
prices
of
comparator
drugs
(internal
reference
pricing).
We
found
two
studies
on
price
limits,
one
study
on
profit
controls,
one
review
on
reference
pricing
(16
studies),
one
study
on
external
reference
pricing,
one
review
on
generic
substitution
(8
studies)
and
one
additional
study
on
generic
substitution.
Hospital
price
cuts
due
to
the
US
Omnibus
Budget
Reconcili-
ation
Act
(1989)
has
been
estimated
to
reduce
spending
by
6%
for
every
10%
reduction
in
price
[62].
Reductions
in
US
Medicare
home-
care
prices
as
a
result
of
the
Home
Health
Interim
Payment
System
(1997)
have
shown
to
reduce
both
use
and
costs
of
homecare
with-
out
any
effect
on
mortality
[63].
A
systematic
review
found
no
evidence
for
pharmaceutical
profit
controls
for
Ireland
[64].
One
systematic
review
(16
studies)
concluded
that
internal
ref-
erence
pricing
lowered
payer
spending
in
most
cases,
but
also
increased
patient
cost
sharing,
resulting
in
a
marginal
reduction
in
total
expenditure
[64].
A
Danish
reform
(2005),
replacing
external
reference
pricing
with
internal
reference
pricing,
reduced
phar-
maceutical
spending
by
10%
[65].
One
review
found
lower
costs
in
four
of
its
eight
included
studies
on
substitution
from
brand-
name
drugs
to
clinically
equivalent
counterparts
(generics),
while
no
difference
was
found
in
clinical
outcomes
[66].
The
authors
com-
mented
that
although
acquisition
costs
of
the
target
drug
declined,
increases
in
inpatient
and
outpatient
utilisation
compensated
for
this.
This
specific
review
did
not
take
into
account
the
possibility
that
pharmaceutical
companies
may
increase
prices
of
other
drugs
as
a
result
of
generic
substitution
[67].
Contrary
to
these
findings,
a
study
on
mandatory
generic
substitution
between
1997
and
1999
found
drug
cost
reductions
of
$36
to
$52
(a
significant
8%
reduction)
per
health
plan
member
[68].
3.1.3.
Volume
controls
We
found
evidence
for
17
interventions
that
aim
to
con-
trol
volumes
from
seven
studies
and
ten
reviews
(179
studies).
Four
interventions
target
supply,
and
thirteen
interventions
tar-
get
demand
for
care,
specifically
cost
sharing
(6
interventions)
and
benefit
restrictions
(5
interventions).
Already
in
1974
the
RAND
Health
Insurance
Experience
(HIE)
demonstrated
in
a
large
randomised
controlled
trial
that
cost
shar-
ing
can
contain
expenditure
[69,70].
We
included
six
papers
that
confirmed
this
finding.
One
review
(12
studies)
found
that
high-
deductible
consumer
directed
health
plans
(CDHC)
reduced
plan
expenditure
with
5%–15%,
corrected
for
enrolee
characteristics
[71].
Plans
with
high
coinsurance
also
bared
lower
expendi-
ture
[72].
One
review
(29
studies)
concluded
that
both
user
charges
and
coinsurance
lower
drug
expenditures
[64].
A
sec-
ond
review
(19
studies)
reported
drug
cost
savings
even
after
a
small
increase
in
copayments,
but
also
found
reduced
access
to
necessary
medications
[73].
In
addition,
insurance
plans
with
higher
drug
copayments
were
found
to
have
27%
lower
phar-
maceutical
expenditures.
Additionally,
two-tier
plans
with
higher
copayments
for
branded
drugs
had
lower
spending
than
single
tier
plans
(7–22%).
Extra
copayments
for
non-preferred
brands
had
an
additional
cost-decreasing
effect
(2–7%)
[68].
Also
for
independent
practice
associations,
increasing
pharmaceutical
copayments
from
$5.00
to
$7.50
resulted
in
an
estimated
12%
reduction
in
pharma-
ceutical
expenditures.
For
Health
Maintenance
Organisations,
the
reduction
of
pharmaceutical
expenditure
(3%)
was
non-significant,
suggesting
either
that
copayments
were
less
effective
in
managed
networks
or
that
pharmaceutical
adherence
was
better
guarded
by
these
plans
[74].
Prior
authorisation
policies
and
utilisation
review
policies
may
contain
costs
by
reducing
overtreatment.
A
review
on
prior
autho-
risation
(6
studies)
found
drug-related
cost
savings
[75].
One
study
demonstrated
that
drug
utilisation
review
programs
reduced
total
drug
expenditures
by
7%
[76].
According
to
a
recent
review
(6
stud-
ies),
prescription
caps
contain
expenditures.
However,
access
to
essential
drugs
may
decrease
[64].
Mixed
results
were
found
for
benefit
restrictions.
One
review
(9
studies)
on
prescribing
restrictions
found
either
lower
costs
(6
studies),
no
significant
effect
(2
studies),
or
even
higher
costs
(1
study)
[77].
A
second
review
(30
studies)
found
that
reimbursement
restrictions
predominantly
contain
costs
but
could
lower
patient
outcomes
[64].
A
third
review
(12
studies)
on
benefit
restrictions
found
no
effect
on
total
costs,
primarily
due
to
substitution
towards
other
therapies
[73].
A
fourth
review
(59
studies)
on
managed
care
formulary
restrictions
found
policies
to
be
effective
in
34%,
neutral
in
37%
and
ineffective
in
29%
of
the
studies
[78].
One
additional
study
from
South
Korea
found
no
significant
effects
after
delisting
certain
drugs
[79].
The
effectiveness
of
patient
education
to
limit
demand
is
also
mixed.
A
review
(2
studies)
found
no
cost
savings
after
a
patient
education
program
in
Spain;
in
North
America
direct-to-
consumer
advertisements
to
reduce
use
of
certain
specific
drugs
even
increased
expenditures
for
these
drugs
[64].
However,
a
ran-
domised
health
promotion
intervention
for
enrolees
of
a
large
Californian
health
plan,
consisting
of
health
assessments,
educa-
tion
material
and
participant
motivation,
reduced
claims
by
$3.2
to
$8.0
million,
between
1989
and
1991
[80].
3.1.4.
Market
structure
policies
We
found
22
interventions
from
16
studies
and
6
reviews
(101
studies)
aiming
to
adjust
market
structure
to
contain
costs.
Most
studies
target
payer
structure,
e.g.
by
stimulating
use
of
managed
care
organizations
(MCOs).
Earlier
studies
showed
predominantly
cost-containing
effects
of
MCOs.
A
10%
increase
in
MCO
market
penetration
reduced
pre-
Please
cite
this
article
in
press
as:
Stadhouders
N,
et
al.
Effective
healthcare
cost-containment
policies:
A
systematic
review.
Health
Policy
(2018),
https://doi.org/10.1016/j.healthpol.2018.10.015
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mium
growth
by
7%
[72].
MCOs
were
estimated
to
have
between
8%
and
15%
lower
costs
in
competitive
regional
markets
[81].
Higher
MCO
market
penetration
led
to
annual
hospital
savings
of
7%
in
Cal-
ifornia
[82].
MCO
penetration
seems
to
have
spillover
effects;
a
1%
increase
in
MCO
market
share
is
associated
with
a
0.9%
decrease
in
fee-for-service
(FFS)
insurance
costs
[83].
Due
to
the
managed
care
backlash
in
the
US,
MCOs
lost
importance
for
the
private
mar-
kets
[83],
although
Medicare
and
Medicaid
continued
to
rely
on
managed
care
as
alternative
service
providers.
However,
studies
that
evaluated
Medicaid-managed
care
models
found
no
significant
effects
on
total
costs
[84,85].
European
experiences
with
managed
care
are
also
mixed.
A
study
from
Switzerland
found
large
cost
reductions
due
to
managed
care,
up
to
16%
compared
to
tradi-
tional
insurance
[86].
This
could
be
due
to
patient
selection,
as
the
effect
on
other
insurers
has
not
been
taken
into
account.
For
German
insurers,
evidence
for
patient
selection
in
managed
care
contracts
was
found.
Managed
care
contracts
increased
the
costs
of
pharmaceuticals
in
neighbouring
regions
and,
as
a
result,
total
pharmaceutical
expenditure
increased
by
0.2%
to
0.8%
following
each
percent
increase
in
managed
care
penetration
[87].
For
other
forms
of
payer
reforms,
limited
evidence
was
found.
One
study
found
short-term
cost
reductions
of
30%
to
40%
due
to
mental
health
carve-outs,
explained
by
a
combination
of
financial
incen-
tives,
reputation
effects,
patient
selection
and
case
management
[88].
Payers
could
reduce
cost
by
altering
provision
structures
and
types
of
providers.
One
study
found
4%
cost
savings
after
a
Swiss
insurer
offered
telecare
as
substitute
of
regular
care
[86].
An
inter-
vention
in
Florida
to
provide
hospice
care
and
cancer
care
to
nursing
home
residents
reduced
government
spending
by
8%
[89].
No
sig-
nificant
cost
reductions
were
found
for
patient-centered
medical
homes
(PCMHs)
[90,91].
Reviews
on
rehabilitation
care
(0
studies)
[92]
or
mental
health
community
care
(42
studies)
[93]
also
found
no
cost
savings.
Such
results
indicate
that
it
may
be
challenging
to
launch
these
provision
models
that
lower
costs
in
the
short
term
whilst
also
improving
quality
[91].
As
countries
have
been
searching
for
the
optimal
level
of
govern-
ment
involvement,
waves
of
decentralisation
and
recentralization
have
been
observed
across
Europe
[94,95].
For
example,
in
the
UK,
commissioning
centralized
to
district
health
authorities
in
1974
[96],
decentralized
to
NHS
thrusts
and
fundholding
in
1991
and
to
primary
care
trusts
2001,
and
recentralized
in
2013
with
the
conception
of
clinical
commissioning
groups
[97].
Even
in
tradi-
tionally
decentralized
countries,
e.g.
Finland
and
Denmark,
a
trend
towards
centralization
has
been
discerned
[98,99].
Decentralisa-
tion
has
been
proposed
as
a
measure
to
contain
costs
[13].
However,
conflicting
evidence
was
found.
A
multi-country
analysis
found
between
12%
and
25%
higher
cost
growth
among
more
decen-
tralised
systems
[100].
A
study
on
decentralisation
in
the
Spanish
NHS
found
short-term
cost
increases
of
9%–16%,
but
thereafter
a
diminished
cost
growth
of
0.5%–1%
on
an
annual
basis
[101].
Registered
nurses,
nursing
assistants,
pharmacists
or
primary
care
physicians
may
perform
some
tasks
and
procedures
tradition-
ally
performed
by
medical
specialists
more
cheaply.
One
review
(11
studies)
found
that
substitution
of
tasks
towards
nursing
assis-
tants
and
pharmacists
may
lower
expenditure,
although
the
quality
of
the
evidence
is
deemed
too
low
to
draw
general
conclusions
[102].
A
second
review
(3
studies)
report
marginally
lower
costs
of
delegating
tasks
to
primary
care
physicians
on
emergency
care
departments
[103].
Non-profit
and
public
providers
seem
to
operate
with
lower
expenses.
One
review
(8
studies)
found
that
for-profit
providers
on
average
charge
19%
higher
prices
than
non-profit
providers
[104].
A
second
review
(37
studies)
found
23
economic
compar-
isons
that
favoured
non-profit
ownership,
5
that
favoured
for-profit
ownership
and
9
that
were
inconclusive
[105].
A
final
study
found
for-profit
MCOs
to
be
more
costly
per
member,
although
their
results
were
not
consistent
[106].
3.1.5.
Market
conduct
policies
Evaluations
of
policies
aiming
to
reduce
cost
by
influencing
market
conduct
primarily
focused
on
the
effects
of
competition,
payment
reform
and
care
coordination.
In
the
latter
category,
a
number
of
case
management
programs
have
been
evaluated.
The
Illinois
Health
Connect
and
Your
Healthcare
Plus
intervention
pro-
duced
savings
of
7%
and
9%,
respectively
[107].
A
Medicaid
primary
care
case
management
program
showed
maximal
program
savings
of
7%
in
Medicaid
expenditure
[108].
An
evaluation
of
Medicare
case
management
for
high-risk
patients
found
cost
savings
of
$7.7
mil-
lion
over
three
years,
rendering
a
Return
on
Investment
ratio
(ROI)
of
1.40.
Reductions
in
readmissions
and
increases
in
appropriate
medication
were
found
[109].
A
health
management
program
of
a
large
California
employer
saved
between
$8.4
million
and
$8.8
mil-
lion,
rendering
a
ROI
ratio
of
between
4.56
and
4.73
[110].
Although
one
study
showed
per
patient
cost
decreases
of
$89
for
high
risk
patients
due
to
case
management,
these
savings
were
insufficient
to
cover
the
total
costs
of
the
program
[111].
For
other
forms
of
care
coordination,
less
evidence
was
available.
One
study
demonstrated
that
GP
continuity
in
Belgium
lowered
expenditure
by
11%
[112].
Competition
has
proven
to
contain
costs
in
California
dur-
ing
the
1980s
and
1990s.
A
study
on
pro-competitive
reforms
found
cost
decreases
of
12%
in
high
competition
regions
[113].
Lower
growth
of
expenses
could
also
be
noted
in
comparison
with
states
that
relied
on
non-competitive
strategies
[114].
Cost
con-
tainment
retained
over
the
long-term,
even
increasing
bankruptcy
risk
for
public
hospitals
[115].
Contrary
to
the
California
experi-
ence,
another
study
found
that
neither
competition,
nor
regulation
contained
expenditures.
Supply-side
factors
(e.g.
per
capita
supply
of
hospital
beds
and
prevalence
of
specialists)
were
found
to
be
the
main
determinants
of
expenditure
growth
[116].
One
recent
study
on
hospital
competition
in
the
UK
found
no
effect
on
expenditures,
although
positive
effects
on
quality
of
care
were
found
[117].
Payment
reforms
aim
to
align
incentives
of
providers
and
pay-
ers.
In
Switzerland,
expenditures
of
capitated
networks
were
6%
lower
than
networks
paid
on
a
fee-for-service
base
[86].
For
Med-
icaid,
capitating
GP
payments
reduced
utilisation,
but
increased
expenditures
by
$75
per
patient
due
to
the
high
payments
neces-
sary
to
include
a
sufficient
number
of
physicians
into
the
program
[118].
Experiences
from
Medicaid
mental
health
capitation
in
Col-
orado
showed
moderate
cost
reduction
for
the
first
two
years,
ranging
from
0.5%
for
for-profit
providers
to
0.2%
for
non-profit
providers;
however,
after
two
years
the
effects
turned
insignificant
[119].
Interestingly,
cost-containment
effects
were
larger
forprofit
providers,
while
for-profit
status
is
associated
with
higher
costs.
This
stipulates
that
for-profit
providers
may
react
more
strongly
to
financial
incentives.
A
literature
review
(9
studies)
on
the
fis-
cal
effects
of
P4P
found
mixed
effects;
the
three
most
rigorous
evaluations
did
not
find
any
significant
savings
[120].
However,
a
more
recent
study
on
P4P
for
GPs
found
1%
lower
expenditures
as
well
as
higher
quality
of
care
[121].
Another
review
found
no
cost
evaluations
of
target
payments
for
general
physicians
[122].
Prospective
payments
and
DRG
payments
fix
per-patient
prices
irrespective
of
the
number
of
activities
per
diagnosis.
For
a
com-
prehensive
overview
of
the
implementation
of
DRGs
in
Europe,
see
Busse
et
al.
(2011)
[123].
Following
the
implementation
of
Medicare
PPS
in
1984,
significant
reductions
in
hospital
expen-
diture
were
found
[124,125].
However,
DRGs
replacing
per
diem
payment
in
New
Jersey
showed
no
significant
cost
reductions,
as
price
reductions
were
offset
by
volume
increases
[126].
While
DRGs
may
increase
efficiency
[127],
evidence
on
total
spending
is
mixed.
Implementation
of
a
Medicare
prospective
payment
system
for
home
care
in
2000
comprised
a
fixed
per
patient
payment
and
a
Please
cite
this
article
in
press
as:
Stadhouders
N,
et
al.
Effective
healthcare
cost-containment
policies:
A
systematic
review.
Health
Policy
(2018),
https://doi.org/10.1016/j.healthpol.2018.10.015
ARTICLE IN PRESS
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Policy
xxx
(2018)
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5
variable
component,
depending
on
treatment
intensity.
The
fixed
component
was
increased
by
the
reform,
while
the
variable
compo-
nent
was
reduced.
In
net,
the
reform
slightly
increased
utilisation
and
expenditure,
suggesting
that
incentives
to
increase
the
num-
ber
of
patients
seem
to
have
outweighed
the
incentives
to
contain
per-patient
costs
[63].
3.1.6.
Market
performance
policies
According
to
theory,
structure
and
conduct
of
the
market
determine
the
market
outcome
[128].
However,
health
sector
per-
formance
can
be
improved
irrespective
of
market
structure
and
conduct
by
targeting
inefficiencies
outside
the
primary
health
production
process,
like
reducing
administrative
costs,
waste
or
fraud.
Of
all
policies
targeting
non-health
costs,
only
evaluations
of
health
IT
and
tort
reform
were
found.
A
literature
review
on
health
IT
adoption,
such
as
electronic
health
records,
com-
puterised
physician
order
entry,
and
clinical
decision
supports,
found
cost-containment
effects,
specifically
administrative
costs
and
pharmaceutical
expenses,
in
43
out
of
a
total
of
57
evaluations
[129].
Tort
reform
has
been
shown
to
decrease
defensive
medicine
and
liability
premiums,
lowering
expenditure
in
the
US
by
2%–4%
[130,131].
4.
Synthesis
Although
interventions
were
very
heterogeneous,
some
general
trends
are
visible.
We
found
evidence
that
cost
sharing
contained
total
health
expenditure
[71,72]
as
well
as
pharmaceutical
expendi-
ture
[64,68,73,74].
Evaluations
of
case
management
interventions
predominantly
showed
cost
savings
[107–110].
However,
most
of
these
programs
do
rely
on
voluntary
participation
by
patients,
thus
risking
selection
bias.
Insurer
competition
has
been
found
to
contain
costs
in
California
[113–115].
Furthermore,
unnecessary
treatments
may
be
reduced
by
prior
authorisation
[75]
and
utili-
sation
review
[76].
Controlling
access
to
care,
e.g.
by
caps
on
the
number
of
prescriptions
[64],
could
also
help
to
contain
pharma-
ceutical
expenditure.
Lastly,
price
limits
and
budgets
may
also
be
effective
in
containing
total
payer
expenses
[60–63].
Other
policies
show
more
contradicting
results.
Payer
struc-
ture
policies
for
example,
specifically
those
promoting
managed
care
organizations,
has
shown
to
either
lower
costs
[72,81–83,86],
increase
costs
[87]
or
have
no
effect
on
costs
[84,85].
Payment
reform
and
prospective
payments
in
some
cases
seem
to
lower
costs
[86,119,121]
but
in
other
instances
they
increase
costs
[63,118]
or
have
no
effect
on
costs
[120,122,126].
For-profit
pro-
vision
seems
to
increase
expenses,
although
not
consistently
[104–106].
Despite
the
fact
that
many
countries
rely
on
benefit
package
restrictions
to
contain
pharmaceutical
expenditure,
evi-
dence
did
not
consistently
indicate
cost
savings
[64,73,77–79].
4.1.
Identification
of
knowledge
gaps
To
identify
gaps
in
the
literature,
the
results
are
plotted
in
the
overview
of
cost-containment
policies
by
Stadhouders
et
al.
(2016).
Fig.
1
shows
that
no
evaluations
were
found
in
21
of
41
categories.
For
price
controls,
evidence
on
fee
schedules
and
price
negotiations
is
lacking.
Regarding
supply
side
volume
controls,
we
found
no
evi-
dence
for
capacity
controls,
such
as
limits
on
the
number
of
beds
or
the
number
of
providers
through
certificate-of-needs
policies,
or
for
labour
restrictions,
such
as
limiting
the
number
of
practi-
tioners.
For
demand
controls,
no
evidence
evaluating
the
effects
of
prevention
on
a
payer
level
has
been
included.
Additionally,
no
evaluations
of
policies
limiting
the
pace
of
costly
innovations
were
found.
In
the
category
of
market
structure
policies,
we
were
unable
to
include
evaluations
of
antitrust
policy,
such
as
merger
controls,
or
risk
redistribution,
such
as
risk
equalisation
programs.
No
eval-
uations
were
found
on
the
effects
of
consumer
choice,
contracting
policies
or
patient
choice
in
the
category
of
market
conduct
poli-
cies.
Lastly,
no
papers
were
included
on
administrative
reductions,
fraud
control,
waste
reduction
programs,
managerial
improvement
policies,
transparency
increases
or
cost-reducing
innovations.
4.2.
High-quality
evidence
to
guide
policymaking
General
effects
of
cost-containment
policies
are
difficult
to
distil
due
to
the
non-random
nature
of
the
interventions
and
the
depen-
dency
on
context.
Therefore,
we
base
our
policy
recommendations
on
the
most
robust
evidence.
Of
43
studies,
13
had
low
to
medium
risk
of
bias
and
high
to
medium
content
validity
and
reliability.
High-quality
studies
were
more
likely
to
find
no
effect.
No
effect
was
found
for
delisting
of
benefits,
decentralisation,
case
manage-
ment,
managed
care
and
hospital
competition
[79,101,111,117].
However,
some
high-quality
papers
do
find
significant
cost-
saving
effects.
Firstly,
cost
sharing
could
reduce
costs.
One
study
found
that
deductibles
and
coinsurance
are
associated
with
lower
premium
growth
rates
[72].
Another
study
found
(tiered)
copay-
ments
to
be
effective
[68].
Secondly,
both
managed
care
and
competition
have
the
potential
to
reduce
costs.
A
10%
increase
in
HMO
market
share
reduced
premium
growth
with
6.5%
between
1985
and
1992
[72].
In
addition,
long-term
effects
of
cost
contain-
ment
through
competitive
reforms
were
found
[115].
Cost
sharing
and
competitive
reform
may
go
hand-in-hand;
managed
care
might
increase
competition,
and
competition
on
premiums
may
benefit
plans
with
high
cost
sharing
[132].
Also
for
reductions
of
phar-
maceutical
spending,
high-quality
evidence
is
available.
Internal
reference
pricing
reduced
pharmaceutical
spending
in
Denmark
by
over
10%
[65].
Closely
related,
generic
substitution
was
shown
to
reduce
pharmaceutical
spending
by
8%
[68].
Lastly,
two
high-
quality
studies
point
to
the
potential
of
cost
reductions
in
specific
areas
such
as
end-of-life
care
and
tort
reform
[89,130].
5.
Discussion
Cost
containment
in
healthcare
is
a
leading
policy
challenge.
Hence,
identifying
effective
policies
is
vital,
but
articles
evaluat-
ing
policies
on
a
macro-level
are
limited
and
often
lack
sufficient
rigor.
Low
numbers
of
evaluations
per
policy
make
it
challeng-
ing
to
infer
effect
sizes
as
well
as
time-
country-,
and
health
system
dependency
[133].
Many
policy
options
seem
understud-
ied
and
this
includes
routine
strategies
such
as
budgeting
and
price
setting.
All
OECD
countries
would
benefit
from
collective
efforts
to
experiment
with,
and
rigorously
evaluate
promising
poli-
cies.
As
policies
are
often
similar,
country
heterogeneity
may
be
viewed
as
a
strength.
Many
different
approaches
have
been
taken
to
tackle
rising
expenditure.
Policymakers
should
harvest
from
the
wide
range
of
experiences,
in
order
to
identify
the
opportunities
and
challenges
of
various
policy
tools.
Countries
could
then
fine-
tune
cost-containment
policies
to
their
own
setting,
identifying
and
accounting
for
divergent
and
paramount
contextual
factors.
Considering
the
above,
the
lack
of
evaluations
of
effectiveness
is
disappointing.
Despite
a
broad
search
strategy
and
not
overly
limiting
exclu-
sion
criteria,
only
61
papers
were
included.
Several
factors
might
account
for
this.
First,
it
may
be
challenging
to
isolate
the
effect
of
many
policy
interventions.
For
example,
most
containment
poli-
cies
are
part
of
a
broader
reform
package
[134].
Also,
some
policies
exert
effects
in
the
long
run
which
may
be
difficult
to
isolate.
Even
for
policies
that
prove
effective
in
the
short
run,
it
is
questionable
whether
any
significant
effect
endures
in
the
long
run.
Second,
poli-
cies
may
have
been
rigorously
evaluated
but
not
included
in
our
Please
cite
this
article
in
press
as:
Stadhouders
N,
et
al.
Effective
healthcare
cost-containment
policies:
A
systematic
review.
Health
Policy
(2018),
https://doi.org/10.1016/j.healthpol.2018.10.015
ARTICLE IN PRESS
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HEAP-4003;
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6
N.
Stadhouders
et
al.
/
Health
Policy
xxx
(2018)
xxx–xxx
Fig.
1.
Summary
of
findings
and
effects
per
policy
group.
search
strategy,
for
example
because
these
evaluations
were
not
published
in
the
peer-reviewed
literature
or
have
been
written
in
another
language.
Of
the
61
papers
included
in
this
review,
44
are
from
the
US.
This
bias
could
be
alleviated
by
inclusion
of
evalu-
ations
published
outside
the
peer-reviewed
literature
or
in
other
languages.
Last,
and
probably
most
important,
a
large
number
of
studies
evaluated
costs
from
the
patient
or
provider
perspective
and
not
from
the
perspective
of
the
payers.
Including
such
studies
would
greatly
increase
the
number
of
papers,
although
the
evi-
dence
would
be
much
less
robust
because
cost
substitution
may
be
mistaken
for
cost
containment.
This
review
gives
a
broad
overview
of
the
literature,
point-
ing
towards
effectiveness
of
certain
specific
policies
such
as
cost
sharing,
managed
care
competition,
reference
pricing,
generic
sub-
stitution
and
tort
reform.
However,
some
reservations
should
be
made
regarding
desirability
of
these
measures.
Cost
sharing,
for
example,
may
reduce
both
necessary
and
unnecessary
care
[135–137].
Second,
it
could
disproportionally
affect
access
by
low
income
groups,
which
may
be
undesirable
from
an
ethical
per-
spective
[138].
It
is
also
highly
unpopular
with
the
electorate
and
thus
comes
with
political
barriers.
Thirdly,
cost
sharing
shifts
costs
to
patients,
thereby
limiting
the
effect
on
total
healthcare
costs.
Lastly,
cost
sharing
could
have
spillover
effects
to
other
payers
when
providers
increase
treatment
intensity
of
remaining
patients
[139].
Control
of
pharmaceutical
expenditure
by
reference
pricing
and
generic
substitution
is
promising.
However,
attention
should
be
given
to
the
possibilities
of
pharmaceutical
companies
shifting
costs
to
unregulated
areas
[67],
or
patients
shifting
to
more
expen-
sive
treatments
[73].
Tort
reform
appears
an
issue
specific
to
the
US.
A
substantial
body
of
evidence
favours
better
coordination
of
care
as
an
effective
way
to
contain
cost.
This
was
one
of
the
few
policies
where
mostly
positive
effects
on
the
quality
of
care
were
reported.
However,
studies
on
care
coordination
often
con-
tained
a
high
risk
of
bias
due
to
self-selection
into
the
program
of
patients
and
organisations
that
have
a
high
propensity
to
obtain
a
positive
effect.
Therefore,
the
actual
implementation
of
proven
concepts
of
care
coordination
to
other
settings
may
be
challenging
[140].
Furthermore,
case
management
often
comes
with
substan-
tial
upfront
costs
[141].
Although
politically
appealing,
this
strategy
faces
difficult
implementation
barriers
on
a
short
horizon
with
many
different
steps
and
is
often
highly
dependent
on
specific
local
conditions.
Most
studies
show
mixed
and
context-dependent
results.
For
example,
payment
reforms
are
often
thought
to
have
substantial
cost
saving
potential
[142].
However,
no
such
effect
was
found
consistently,
suggesting
that
payment
schemes
should
be
designed
with
great
care
to
prevent
undesirable
provider
responses
and
to
sort
out
positive
effects
on
costs
and
quality.
Evidently,
policies
are
interconnected
and
embedded
in
a
broader
health
system
and
some
may
be
reinforced
or
counteracted
by
other
policies
[29].
For
example
competition:
under
certain
conditions,
competition
may
contain
costs
and
specific
types
of
payers
(e.g.
MCOs)
may
reinforce
this;
however,
a
higher
penetration
of
for-profit
providers
may
lead
to
higher
costs.
Moreover,
the
effect
of
competition,
profit
status
or
payer
types
may
depend
on
the
payment
system
in
place.
Mapping
policy
interrelations
and
institutions
should
be
an
important
part
of
future
research
on
this
topic.
The
adoption
of
cost-containment
policies
likely
depends
on
other
policy
goals
such
as
quality
of
care,
equity
and
efficiency.
In
many
instances,
the
pursuit
of
a
cost-containment
strategy
may
come
at
the
cost
of
one
or
more
of
these
goals.
This
would
require
balance
of
cost-containment
efforts
with
other
important
health
system
goals.
Future
research
should
inquire
into
policy
outcomes
on
all
relevant
policy
metrics
and
design
combinations
that
sort
out
an
optimal
effect.
6.
Concluding
remarks
We
collected
evidence
on
the
effectiveness
of
cost-containment
policies
from
a
payer
perspective,
and
included
43
original
studies
and
18
systematic
reviews
evaluating
72
different
cost-
containment
policies.
We
compared
policy
evaluations
to
policies
identified
in
the
literature.
Of
the
41
groups
of
cost
containment
policies,
21
were
not
evaluated,
and
even
within
the
remaining
groups
several
policies
remain
unevaluated.
The
existing
evidence
shows
that
the
effectiveness
of
cost
containment
policies
varies
greatly
between
policies,
underlining
the
need
for
evidence.
Future
policy
evaluations
should
focus
on
the
effectiveness
of
fee
sched-
Please
cite
this
article
in
press
as:
Stadhouders
N,
et
al.
Effective
healthcare
cost-containment
policies:
A
systematic
review.
Health
Policy
(2018),
https://doi.org/10.1016/j.healthpol.2018.10.015
ARTICLE IN PRESS
G Model
HEAP-4003;
No.
of
Pages
9
N.
Stadhouders
et
al.
/
Health
Policy
xxx
(2018)
xxx–xxx
7
ules,
wage
controls,
capacity
controls,
prevention
and
reductions
in
administrative
costs.
Special
attention
should
be
given
to
the
payer
and
societal
perspective
as
many
evaluations
do
not
take
into
account
cost
shifting
possibilities
by
providers
and
patients.
We
summarised
the
available
evidence,
providing
a
broad
overview
of
the
literature
on
effective
cost-containment
policies.
Most
evaluations
were
performed
for
MCO
competition,
payment
reforms,
cost
sharing
and
care
coordination.
High-quality
evidence
favors
cost
sharing,
managed
care
competition,
reference
pricing,
generic
substitution
and
tort
reform
as
effective
policies
to
contain
costs.
Policymakers
aiming
to
contain
costs
should
resort
to
these
policies
to
maximise
chances
of
success.
Acknowledgements
The
authors
are
grateful
for
the
contributions
of
Patricia
Sánchez-González,
Nicholas
Crawford,
Katalin
Gaspar,
Maurits
van
Tulder,
Raymond
Ostelo
and
Michiel
de
Boer.
No
funding
was
received
for
this
research.
There
were
no
conflicts
of
interest.
Appendix
A.
Supplementary
data
Supplementary
material
related
to
this
article
can
be
found,
in
the
online
version,
at
doi:https://doi.org/10.1016/j.healthpol.2018.
10.015.
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