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Healthcare dictatorship: the power of insurance companies

Fresh out of college, Contessa Achterberg started her own independent speech therapy practice in the east of the Netherlands, which has now been running for 28 years. As a devoted speech therapist, Achterberg has always aimed to spend time and resources on patients to deliver a high quality of care. However, in recent years, she has gotten the feeling that this is increasingly made difficult by healthcare insurance companies. Achterberg states that she “as an independent practitioner has no power against these big corporations”.

Health insurance market in the Netherlands

The power of health insurances has been deliberately increased in the Netherlands. The dispersion of smaller insurance companies have now been merged into four corporations (CZ, VGZ, Menzis and Zilveren Kruis Achmea), that according to EenVandaag, now hold 90% of the total health insurance market, making it a strong oligopoly. Additionally, the Dutch government, specifically Minister Schippers of Public Health, has increased the purchasing power of these companies. This means that insurances now have the power to offer contracts to care providers and deny part of the insurance coverage for patients if these providers do not sign those contracts. The Dutch healthcare authority (NZa) declared that this is done to ensure that “healthcare providers provide quality care for a reasonable price”. In this sense, the insurance companies have a monitoring role, placing restrictions on price and minimum levels of quality in order to get a contract. Although this is thus intended to be beneficial for patients, the actual effects of this power of insurances are very questionable.

Health insurance companies have cut the compensations for care providers and require them deliver evidence of the quality of their work. Naturally, it is also in the best interest of the insurances that all care providers sign, but in reality the relationships are highly unequal. Although larger institutions such as hospitals can bargain with the insurance companies, small and independent care providers such as speech therapist Achterberg have no power whatsoever, and are forced to either accept the terms of the contract, or not to sign. The only solution would be for these providers to unite and form one front against insurances. This, however, is not allowed, as it is legally considered to be formation of cartels. According to Achterberg, “insurances are not willing to discuss the terms of contracts with me, because they do not care whether I sign or not. If I do not sign, a dozen others will replace me”.

Puppets of the insurances?


The compensations offered by insurances are too low, only three-fourths of the rates set by the Dutch healthcare authority. When care providers sign such contracts, they are thus forced to cut costs. “There are several ways to do this, and they are all problematic. You can choose to cut down on your continuing professional education, but for me it meant that I had to reduce the time for patients per treatment,” explains a frustrated Achterberg. This means that she now treats patients for 25 minutes per session instead of 30 minutes. Achterberg truly regrets that she thus has to “spend time on administration that I would rather have spent on helping my patients”. And even despite this treatment time reduction, she often finds herself working overtime to meet the administrative requirements by insurances. The administrative work is mainly necessary to deliver proof of the quality and nature of their work to insurance companies. Physiotherapist Humbert Buur explains that he is extremely frustrated with these administrative tasks, stating that he is “judged based on administration, not on actual quality of therapy”.  In general, among all small and independent care providers, there is an atmosphere of distrust, in which care providers are scrutinized instead of appreciated. Buur signified this as “Filling out forms like in the Soviet Union … to prove I am doing my work”, and Achterberg explains that “I am not trusted by insurances, even though I have been doing this work for so many years”.

Nevertheless, the option not to sign the contract does not offer a proper solution either. Not signing a contract means that patients with that health insurance will only get partly reimbursed for their costs at that particular practice. Patients are then forced to either pay for the therapy themselves or to find another therapist. This is not only problematic for the patients, but also for the practitioners themselves. Achterberg states that “if I do not sign a contract but other speech therapists in the area do, I lose my patients”.  Thus, to preserve a stable income, not signing contracts is simply no option for most independent practitioners.

Insurance offers contract: “it’s just something to swallow”


It thus seems that the combined power of the insurance companies turned into a dictatorship, in which they have massive power on the practices of healthcare providers and their patients. As insurance companies are commercial corporations, it is highly questionable whether it is responsible to have them dictate a market as important as healthcare. Although we do need some way of monitoring the healthcare providers, making sure they offer quality care for a fair price, trusting this power to commercial entities is risky. As care providers are in the center of the healthcare market, both in direct contacts with patients as well as insurance companies, they should be the one to lead the discussions.

In the meantime, the care providers have no choice but to continue their work to their best efforts, while advocating against the forces of the commercialization of the healthcare market and the power of insurances. Most unfortunately, the situation will get even worse with new laws being processed under the free choice of doctors, which means that insurances will have even more power to force care providers to sign and even impose indirect or covert sanctions on them if they do not sign. If this law is passed, practitioners literally have no choice but to sign the contracts. “I still call myself an independent practitioner,” Achterberg states, “but I do not feel like I have any freedom of choice left”.


11 Responses to Healthcare dictatorship: the power of insurance companies

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