Stuck in the middle?: A perspective on ongoing pro-competitive reforms in Dutch mental health care

- Dutch mental health has been in a state of reform since 2008.
- There are still no universally accepted quality indicators in the sector.
- Purchasers thus selectively contract providers through negotiations mainly based on price.
- To meet price requirements, providers drastically cut costs, potentially hampering quality.
- Municipalities purchase children's mental health care, increasing information asymmetry and transaction costs.

Pro-competitive reforms have been implemented in many Western healthcare systems, of which the Netherlands is a prominent example. While the pro-competitive reforms in the Dutch specialized care sector have drawn considerable academic attention, mental health care is often excluded. However, in line with other segments of specialized care, pro-competitive legislation has formed the core of mental health care reforms, albeit with several notable differences. Ever since mental health services were included in the Health Insurance Act in 2008, the Dutch mental healthcare sector has been in an ongoing state of reform. Numerous major and minor adaptations have continuously altered the services covered by the basic insurance package, the actors responsible for providing and contracting care, and definitions and measurements of quality. Most notably, insurers and municipalities, which are responsible for selectively contracting those providers that offer high value-for-money, seem insensitive to quality aspects. The question whether the Dutch mental health sector has inherited the best or the worst of a competitive and non-competitive system lingers and international policy makers contemplating reforming their mental health sector should take note.