In 2023, a.s.r. was the sixth largest provider of health insurance on the Dutch market, based on the number of customers, with a market share of 4.3% (2022: 3.1%). In 2023, the four largest insurers had a joint market share of 84% (2022: 85.1%). The number of health policyholders increased by 41.4%, partly due to the composition of supplementary packages, including dental care and maternity care. In 2023, a.s.r. offered health insurance under the ‘a.s.r.’ and ‘Ditzo’ brands. On 17 April 2023, Ditzo was rebranded in "Ik kies zelf van a.s.r.".
The combined ratio of Health improved to 98.9% (2022: 101.2%), mostly resulting from growth of the business, which led to a lower expense ratio due to economies of scale. Last year, the commissions rate was higher due to acquisition costs made for the inflow of new customers in 2023.
(in %)
Markets
Two types of products are offered on the Dutch health insurance market: basic cover and supplementary cover. In the highly regulated health care market, all Dutch citizens are obliged to take out basic health insurance based on an annual contract. The contents of this basic cover are set by the government, but health insurers are permitted to add some variation in order to distinguish their products from each other. This mainly involves how claims are processed and the number of medical providers whose treatment is eligible for cover.
Insurers are obliged to accept anyone who is legally required to take out basic health cover as a policyholder. A state-managed risk equalisation system protects an insurer in case its customer base typically shows behaviour that is detrimental for its health situation, leading to higher costs for the insurer. The compensation paid to insurers depends on the anticipated costs, based on the characteristics of their customer base. This risk equalisation system is constantly being adjusted.
The number of policyholders who switch to another health provider at the end of the year remained unchanged at 6-7% for the past nine years. This year, however, the percentage rose to 8.5% (1.5 million policyholders), the highest number of person switching providers since the introduction of the Health Insurance Act in 2006.
Unlike basic health insurance, supplementary health cover is not compulsory. In 2023, 82.5% of policyholders on the Dutch market opted for supplementary health insurance (2022: 83.5%). Following an increase in this percentage in 2021 in response to the Covid-19 pandemic, the declining market trend which set in last year continued. Within a.s.r., the number of policyholders opting for supplementary health cover went up to 96.3 % in 2023 (2022: 95.5%). The number of claims made under this form of cover increased similarly.
Dilemma: Should a.s.r. reimburse experimental treatments?
One of the dilemmas a.s.r. faced in 2023 was whether or not to reimburse experimental health treatments. Patients suffering from a serious disease and with a poor prognosis often want to do everything they can to be cured or have a better quality of life. In some cases, there are treatments that have not (yet) been proven to be effective, but do give this group of patients a glimmer of hope. They grasp at this straw and request reimbursement for these treatments through their doctors.
a.s.r. would like to offer everyone a chance to improve their health, or a cure. It is quite understandable that someone who is seriously ill wants to do everything possible. At the same time, a.s.r. cannot and should not always reimburse such experimental care. As a health insurer a.s.r. has to comply with certain legislation and regulations. This means that only treatments included in the basic package may be reimbursed by health insurers from the basic insurance. Besides, health insurers have a social duty to keep healthcare accessible and affordable.
The central government has determined that only care whose effectiveness has been sufficiently established will be reimbursed from the basic package. For example, if a treatment is considered effective by the relevant medical profession or if there is scientific literature available that demonstrates this. This care then meets the ‘latest scientific knowledge and medical practice’. Experimental treatments usually do not comply with this (yet) and will therefore in principle not be reimbursed.
a.s.r. faces a fiendish dilemma here: is the experimental treatment, which may be a last straw for patients, effective or not? Attached to this dilemma is a patient’s hope, or their despair, on the one hand, and the health insurer’s social duty to keep healthcare affordable for all policyholders, on the other.
Although a health insurer is not really the one who should make the decision on compliance with the latest scientific knowledge and medical practice, a.s.r. sometimes has to consider a request for experimental treatment. When a.s.r. receives a request to reimburse an experimental treatment, it's consulting doctor will handle this request extremely carefully.
Products
The types of health cover offered in 2023 under the a.s.r. and "Ik kies zelf van a.s.r." (previously Ditzo) brands were as follows:
Basic insurance with a broad coverage of medical costs, as prescribed annually by the government. a.s.r. offers three types of basic health cover:
Contracted care policy, in which the insurer remunerates costs directly to contracted care providers;
Non contracted care policy, in which the customer is reimbursed for medical care payments, including for treatment from non contracted care providers;
A combination of the two, applied through a combination of both policies.
Supplementary health insurance to cover specific risks not included under basic health insurance, such as the costs of dental treatment, physiotherapy, orthodontic treatment and medical support abroad.
The most popular basic health cover on the Dutch market is the contracted care policy1. At year-end 2023, 76% of total policyholders had taken out a contracted care policy.
Strategy and achievements
In 2023, the strategy of a.s.r. was further refined in response to developments in the market and society, to provide cover for health care that is future-proof, i.e. cover that is and will remain efficient, affordable and accessible. In the revised strategy, sustainability has acquired an even greater prominence. In terms of sustainability, a.s.r. will continue to accelerate the sustainable transition through cooperation with suppliers, health care providers, customers and other health insurers. Furthermore, with the revised strategy a.s.r. aims to maintain a stable customer base, and to refrain from further growth.
a.s.r. also took further steps towards sustainability in 2023. The addition of the ‘find a sustainable care provider’ (de groene zorgzoeker) function to a.s.r.’s health care application makes it easier for customers to see which care providers are more sustainable. The search function enables customers to find health care providers in a particular location. Physical medical cards have also been replaced by digital versions, unless customers opted for keeping their physical card.
a.s.r. has developed various initiatives aimed at promoting future-proof health care, partly by encouraging policyholders to maintain a healthy lifestyle. Examples include the ‘take care of yourself’ (zorg voor jezelf) programme, in which a.s.r. provides free health care programmes which contribute to a healthy lifestyle. Three programmes rolled out in the past year were the ‘healthy habits' (gezonde gewoonte) programme, the 'eat more sustainably' (duurzamer eten) programme and the ‘I bounce back' (ik veer mee) programme.
The NPS-c measures customers satisfaction during contact moments, please refer to the result in the graph.
With an NPS-c of 35 in 2023 (2022: 49), customer satisfaction within Health fell, partly due to an unexpectedly high influx of customers which led to long waiting times, especially at the start of the year.
Customer-driven service remains a key element of the strategy, and is thus constantly being improved. a.s.r. has transformed its customer service in order to serve customers better and faster. The digitalisation strategy, which assists customers towards self-service and removes low impact contact, is also improving the speed and efficiency of customer service. Finally, more attention has been given over the past year to non-Dutch language customers, and a start has been made on improving the availability of information in English.
Outlook for 2024
a.s.r. expects customers to remain price-sensitive in 2024 due to the high level of inflation which persisted throughout 2023. As a result, premiums will again be decisive in the choices made by customers during the premium review season. The outcomes of the transfer season of the health insurance market at the end of 2023 show that a.s.r. faces a significant decrease in the number of insured for 2024. The primary reason for the substantial decrease is most likely the significant price difference compared to the least expensive insurance available in the market.
In 2024, a.s.r. will continue to take steps to keep health care future-proof in the form of continued accessibility, appropriateness and sustainability. In 2024, a.s.r. will further improve accessibility of health care through digital transformation and by continuing to provide the right contract information for both referral organisations and policyholders. a.s.r. will also continue to support the Integrated Health Care Accord (IZA) and contribute to the ongoing improvement of, and compliance with, agreements made in the IZA through the mid-term review. The implementation period for impactful transformations will run until 2027.
The government could potentially have a significant impact on the healthcare system and how the market operates. Accessibility and affordability of healthcare are under pressure, and remain high on the political agenda. Political interventions could potentially heavily impact the existing care system.
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- 1Vektis Zorgthermometer 2023