Challenging selective contracting: reforms for enhancing patient empowerment in healthcare.

Background: Health insurers and managed care organizations often limit patient choice to in-network care providers through selective contracting, involving procurement agreements with service providers or ownership of healthcare institutions. Patient choice reforms, i.e., reforms which expand hospital choice and reduce the power of the selective contracting, were introduced in a number of countries since the 1990s, in order to address long waiting times and enhance hospital competition based on quality, services, and availability. This study was motivated by Israel's 2023 health reform, which expanded patient choice by mandating broader hospital choice and enhancing transparency. This study examines reforms in selective contracting models in developed countries and assesses their impact on healthcare quality, accessibility, and socioeconomic disparities.

Methods: A search was conducted on PubMed, Google Scholar, OECD Library, and European Observatory using keywords related to healthcare reform, provider choice, and selective contracting. The search was limited to English-language articles published since 2001.

Results: Traditionally, NHS-based countries did not include patient choice in their systems. Reforms in countries like England and Portugal have since allowed patients choice between hospitals. In contrast, systems with multiple competing insurers, such as Germany, Switzerland, the Netherlands, and Israel, inherently incorporate some patient choice. Israel's 2023 health reform further broadened hospital choice, while maintaing selective contracting, and enhanced transparency. Patient choice is influenced by distance, quality, and availability. Patients often prefer nearby hospitals but will travel for higher quality care. Increased hospital competition generally improves care quality but may exacerbate socioeconomic disparities. Successful components of patient choice reforms include publishing comparative quality indicators and establishing national appointment scheduling systems. These initiatives increase transparency, improve patient decision-making, and drive hospital improvements.

Conclusions: Expanding patient choice in healthcare enhances system efficacy and patient empowerment. However, addressing socioeconomic disparities is essential to ensure equitable access to high-quality care. Future policies should focus on tools and strategies that cater to all patient groups, including accessible and easily understood comprehensive quality assessments and national appointment scheduling systems. Further research should cover a wider range of healthcare systems to understand the challenges and opportunities in patient choice reforms comprehensively.