Table 4 Open in new tab OverOverview of...

Table 4

OverOverview of informal documentation issued by the ACM

Case number	Year	Healthcare sectors	Type of collaboration	Type of document	Efficiencies claimed by collaborating parties	(Risk of) anticompetitive behaviour	Decision/advice (ACM)
[13]	2005	Healthcare purchasing	Joint purchasing agreement	Informal opinion on request	More scope for price competitionEstablish balance between supply and demand	Temporary elimination of price competition through preference clause (6 months), reduced ability to differentiate	Limited restriction of competition through the temporary nature
[14]	2006	Hospitals, healthcare purchasing	Regional consultative body on product and capacity agreements	Informal opinion on request	Improved coordination of price and capacity after expiry of obligation to contract	Agreements may restrict competitionExchange of competition-sensitive information	Competition Act is not applicable as the consultative body is seen as mandatory for the execution of government policy, and power of decision lies with the government
[15]	2013	Pharmacies, hospitals	Joint purchasing agreement	Informal opinion on request	Improved monitoring of medicationMore efficient prescribingImproved measurement of performance	Cross-market agreement between noncompeting pharmacies	Competition Act is not applicable as the agreement only includes noncompeting pharmaciesCurrent market share of the cooperative association is lower than bagatelle threshold in Article 7 of Competition Act, thus Competition Act does not apply.
[16]	2013	Hospitals	Collaborations in general	General guidance	N/A	N/A	ACM attaches great importance to a well-executed ex-ante self-assessment which clearly substantiates whether the efficiencies outweigh the drawbacks of competition.Healthcare purchasers and patient associations should be involved
[17]	2014	Healthcare purchasing	Agreement on centralization of acute care	Informal opinion at ACM’s own initiative	Improved and more efficient acute care	Reduced freedom of choice for patients and insured parties resulting in a potential reduction in quality of care	Intended centralization potentially infringes Competition Act, due to reduced freedom of choiceReduced ability to differentiate and stand out of health insurersEfficiencies do not outweigh drawbacks for competition
[18]	2014	Healthcare providers, purchasers and municipalities in Long term care	Exchange of information between competing providers	General guidance	Legislative changes demand for exchange of information	Exchange of competition-sensitive information can restrict competition	For municipalities and procurement offices, the Competition Act does not apply and thus no restrictions imposed on the exchange of information.Between healthcare purchasers, exchange of information negotiated tariffs, cost prices, turnovers and strategic plans concerning operating areas is contrary to Competition Act.
[19]	2015	Healthcare purchasing	Joint purchasing agreement with participating hospitals	Informal opinion on request	Lower prices for TNFi medication potentially resulting in lower insurance premiums	Reduced ability to differentiate for participating hospitalsAgreement might impose entry barriers	The purchasing agreement for all insured persons does not appreciably restrict competition on the hospital market
[20]	2015	Hospitals	Joint negotiation and standardization of breast cancer care	Informal opinion on request	Standardize breast cancer care provision to increase quality and efficiencyJoint negotiation with insurers increases efficiency	Potential expansion of the collaboration agreement by adding new hospitals must be disclosed	Because the six hospitals are located across the Netherlands, they are not considered direct competitors.The agreement does not appreciably restrict competition as the agreement only includes noncompeting hospitals
[21]	2015	Healthcare purchasing	Joint purchasing agreement	Informal opinion on request	Risk of overcapacity or delay if all four proton therapy centres are contractedWithout joint purchasing, proton therapy in the Netherlands would not be viable	The joint purchasing agreement concerns almost all insured person in the Netherlands, and therefore reduces freedom of choiceAlso risk of increased travel time and restriction of supply	The purchasing agreement for all insured persons does appreciably restrict competition on the hospital market, and thus infringes the Competition Act.ACM does not informally approves the planJoint purchasing of foreign proton therapy centres is permissible under the Competition Act.
[22]	2015	GP care	Collaborations in general	Guidance	N/A	Restricting freedom of choice or innovationCollective boycotts or tariff agreements	ACM will only take action if collaboration harms patients or interests of insured persons.
[23]	2016	Healthcare purchasing/hospitals	Joint purchasing agreement for hospitals and healthcare purchasers	Informal opinion at ACM’ own initiative	Negotiating lower prices, higher discounts and better conditions with pharmaceutical companies	Potential reduction in quality and innovation efforts.	The agreement may be permissible under the Competition Act. To safeguard competition, three conditions apply:Joint purchasing only applies to a part of the total costs.Entry to the purchasing group must be possible.The purchasing group does not impose any obligations such as binding contracts, withdrawal barriers and purchase obligations
[24]	2016	Hospital	Centralization agreement on complex oncological surgery	Informal opinion on request	Better quality through higher annual volume of surgeryMeet minimum volume thresholds	Reduced freedom of choice for patients and health insurers.	ACM considers the agreement restricting competition to be permissible under the exemption criteria of Article 6(3).The centralization is the least restricting option. Sufficient competition on other domains remains possible.
[25]	2017	Home care	Regional consultative body on joint purchasing	Informal opinion on request	Stimulating innovation in home careNationwide coverage	The agreement would eliminate alternativesAbility to maintain prices above competitive levels	ACM considers the agreement restricting competition to be permissible under the exemption criteria of Article 6(3).
[26]	2018	Obstetric care	Regional collaborative agreement on healthcare provision	Guidance	Quality improvements through multidisciplinary consultations, regional investment, professional standards	Price agreements, distribution agreements on clients, entry barriers	Entry to the collaboration by other organizations must be possibleThe entry process must be transparent, objective and nondiscriminating
[27]	2019	Healthcare purchasing, healthcare provision	Healthcare provision and substation agreements	Guidance	Provide care at the most cost-efficient location, close to patient.	Entry barriers, exchange of competition sensitive information, price increases	ACM will not take action against or fine healthcare providers for these agreements provided all of the following five criteria are satisfied: (1) There is a widely supported and public vision for the region that outlines the allocation of care. (2) Agreements on allocation and intended goals are substantiated. (3) Healthcare providers, health insurers and patient associations are fully involved. (4) The agreements do not focus on restricting or hindering the entry or expansion of the agreement’ activities. (5) The agreements and intended goals and measurability are transparent and public.
[28]	2019	Hospitals	Expansion of collaboration described under [20]	Re-evaluation	Share best practices to improve quality of careReward quality improvements	Weakened market position of health insurers vis-à-vis the agreementSharing of financial information could push prices upwards	The agreement may restrict competitionHealth insurers should decide whether they will negotiate with independent hospitals or with the group of hospitals
[29]	2020	Healthcare purchasing	Covid-19: health insurer agreements on compensation of healthcare providers	Guidance	Avoid bankruptcy of healthcare providersMeet duty of continuity in care	N/A	Collaboration between purchasers is necessary to maintain supply of care servicesAn independent organization should assess the amount of compensationThe agreement should be temporary in nature
[30]	2020	Healthcare provision/manufacturing	Covid-19: agreement on distribution of essential medication	Guidance	Avoid medication shortages	Exchange of capacity information between manufacturers	No risks to competition due to temporary and mandatory nature of agreement
[31]	2020	Healthcare purchasing	Covid-19: agreement on allocation of additional costs	Guidance	Avoid increase in premiums of some health insurersMaintain level playing field between insurers	Reduced functioning of risk equalizationReduced incentive to purchase cost-efficient care	The functioning of the health system would be jeopardized without allocation of costs.Permissible due to temporary nature of agreement
[32]	2020	Hospitals	Allocation of care agreement following [26]	Guidance	Improve quality of careContain rising healthcare spending	Reduced freedom of choice for patients and health insurers.	Correct application of the JZOJP conditionsAllocation of care is closely monitored to avoid negative effects on affordability and accessibilityDocuments on underlying argumentation should be published publicly on the hospital’s website

Case number	Year	Healthcare sectors	Type of collaboration	Type of document	Efficiencies claimed by collaborating parties	(Risk of) anticompetitive behaviour	Decision/advice (ACM)
[13]	2005	Healthcare purchasing	Joint purchasing agreement	Informal opinion on request	More scope for price competitionEstablish balance between supply and demand	Temporary elimination of price competition through preference clause (6 months), reduced ability to differentiate	Limited restriction of competition through the temporary nature
[14]	2006	Hospitals, healthcare purchasing	Regional consultative body on product and capacity agreements	Informal opinion on request	Improved coordination of price and capacity after expiry of obligation to contract	Agreements may restrict competitionExchange of competition-sensitive information	Competition Act is not applicable as the consultative body is seen as mandatory for the execution of government policy, and power of decision lies with the government
[15]	2013	Pharmacies, hospitals	Joint purchasing agreement	Informal opinion on request	Improved monitoring of medicationMore efficient prescribingImproved measurement of performance	Cross-market agreement between noncompeting pharmacies	Competition Act is not applicable as the agreement only includes noncompeting pharmaciesCurrent market share of the cooperative association is lower than bagatelle threshold in Article 7 of Competition Act, thus Competition Act does not apply.
[16]	2013	Hospitals	Collaborations in general	General guidance	N/A	N/A	ACM attaches great importance to a well-executed ex-ante self-assessment which clearly substantiates whether the efficiencies outweigh the drawbacks of competition.Healthcare purchasers and patient associations should be involved
[17]	2014	Healthcare purchasing	Agreement on centralization of acute care	Informal opinion at ACM’s own initiative	Improved and more efficient acute care	Reduced freedom of choice for patients and insured parties resulting in a potential reduction in quality of care	Intended centralization potentially infringes Competition Act, due to reduced freedom of choiceReduced ability to differentiate and stand out of health insurersEfficiencies do not outweigh drawbacks for competition
[18]	2014	Healthcare providers, purchasers and municipalities in Long term care	Exchange of information between competing providers	General guidance	Legislative changes demand for exchange of information	Exchange of competition-sensitive information can restrict competition	For municipalities and procurement offices, the Competition Act does not apply and thus no restrictions imposed on the exchange of information.Between healthcare purchasers, exchange of information negotiated tariffs, cost prices, turnovers and strategic plans concerning operating areas is contrary to Competition Act.
[19]	2015	Healthcare purchasing	Joint purchasing agreement with participating hospitals	Informal opinion on request	Lower prices for TNFi medication potentially resulting in lower insurance premiums	Reduced ability to differentiate for participating hospitalsAgreement might impose entry barriers	The purchasing agreement for all insured persons does not appreciably restrict competition on the hospital market
[20]	2015	Hospitals	Joint negotiation and standardization of breast cancer care	Informal opinion on request	Standardize breast cancer care provision to increase quality and efficiencyJoint negotiation with insurers increases efficiency	Potential expansion of the collaboration agreement by adding new hospitals must be disclosed	Because the six hospitals are located across the Netherlands, they are not considered direct competitors.The agreement does not appreciably restrict competition as the agreement only includes noncompeting hospitals
[21]	2015	Healthcare purchasing	Joint purchasing agreement	Informal opinion on request	Risk of overcapacity or delay if all four proton therapy centres are contractedWithout joint purchasing, proton therapy in the Netherlands would not be viable	The joint purchasing agreement concerns almost all insured person in the Netherlands, and therefore reduces freedom of choiceAlso risk of increased travel time and restriction of supply	The purchasing agreement for all insured persons does appreciably restrict competition on the hospital market, and thus infringes the Competition Act.ACM does not informally approves the planJoint purchasing of foreign proton therapy centres is permissible under the Competition Act.
[22]	2015	GP care	Collaborations in general	Guidance	N/A	Restricting freedom of choice or innovationCollective boycotts or tariff agreements	ACM will only take action if collaboration harms patients or interests of insured persons.
[23]	2016	Healthcare purchasing/hospitals	Joint purchasing agreement for hospitals and healthcare purchasers	Informal opinion at ACM’ own initiative	Negotiating lower prices, higher discounts and better conditions with pharmaceutical companies	Potential reduction in quality and innovation efforts.	The agreement may be permissible under the Competition Act. To safeguard competition, three conditions apply:Joint purchasing only applies to a part of the total costs.Entry to the purchasing group must be possible.The purchasing group does not impose any obligations such as binding contracts, withdrawal barriers and purchase obligations
[24]	2016	Hospital	Centralization agreement on complex oncological surgery	Informal opinion on request	Better quality through higher annual volume of surgeryMeet minimum volume thresholds	Reduced freedom of choice for patients and health insurers.	ACM considers the agreement restricting competition to be permissible under the exemption criteria of Article 6(3).The centralization is the least restricting option. Sufficient competition on other domains remains possible.
[25]	2017	Home care	Regional consultative body on joint purchasing	Informal opinion on request	Stimulating innovation in home careNationwide coverage	The agreement would eliminate alternativesAbility to maintain prices above competitive levels	ACM considers the agreement restricting competition to be permissible under the exemption criteria of Article 6(3).
[26]	2018	Obstetric care	Regional collaborative agreement on healthcare provision	Guidance	Quality improvements through multidisciplinary consultations, regional investment, professional standards	Price agreements, distribution agreements on clients, entry barriers	Entry to the collaboration by other organizations must be possibleThe entry process must be transparent, objective and nondiscriminating
[27]	2019	Healthcare purchasing, healthcare provision	Healthcare provision and substation agreements	Guidance	Provide care at the most cost-efficient location, close to patient.	Entry barriers, exchange of competition sensitive information, price increases	ACM will not take action against or fine healthcare providers for these agreements provided all of the following five criteria are satisfied: (1) There is a widely supported and public vision for the region that outlines the allocation of care. (2) Agreements on allocation and intended goals are substantiated. (3) Healthcare providers, health insurers and patient associations are fully involved. (4) The agreements do not focus on restricting or hindering the entry or expansion of the agreement’ activities. (5) The agreements and intended goals and measurability are transparent and public.
[28]	2019	Hospitals	Expansion of collaboration described under [20]	Re-evaluation	Share best practices to improve quality of careReward quality improvements	Weakened market position of health insurers vis-à-vis the agreementSharing of financial information could push prices upwards	The agreement may restrict competitionHealth insurers should decide whether they will negotiate with independent hospitals or with the group of hospitals
[29]	2020	Healthcare purchasing	Covid-19: health insurer agreements on compensation of healthcare providers	Guidance	Avoid bankruptcy of healthcare providersMeet duty of continuity in care	N/A	Collaboration between purchasers is necessary to maintain supply of care servicesAn independent organization should assess the amount of compensationThe agreement should be temporary in nature
[30]	2020	Healthcare provision/manufacturing	Covid-19: agreement on distribution of essential medication	Guidance	Avoid medication shortages	Exchange of capacity information between manufacturers	No risks to competition due to temporary and mandatory nature of agreement
[31]	2020	Healthcare purchasing	Covid-19: agreement on allocation of additional costs	Guidance	Avoid increase in premiums of some health insurersMaintain level playing field between insurers	Reduced functioning of risk equalizationReduced incentive to purchase cost-efficient care	The functioning of the health system would be jeopardized without allocation of costs.Permissible due to temporary nature of agreement
[32]	2020	Hospitals	Allocation of care agreement following [26]	Guidance	Improve quality of careContain rising healthcare spending	Reduced freedom of choice for patients and health insurers.	Correct application of the JZOJP conditionsAllocation of care is closely monitored to avoid negative effects on affordability and accessibilityDocuments on underlying argumentation should be published publicly on the hospital’s website

Table 4

Open in new tab

OverOverview of informal documentation issued by the ACM

Case number	Year	Healthcare sectors	Type of collaboration	Type of document	Efficiencies claimed by collaborating parties	(Risk of) anticompetitive behaviour	Decision/advice (ACM)
[13]	2005	Healthcare purchasing	Joint purchasing agreement	Informal opinion on request	More scope for price competitionEstablish balance between supply and demand	Temporary elimination of price competition through preference clause (6 months), reduced ability to differentiate	Limited restriction of competition through the temporary nature
[14]	2006	Hospitals, healthcare purchasing	Regional consultative body on product and capacity agreements	Informal opinion on request	Improved coordination of price and capacity after expiry of obligation to contract	Agreements may restrict competitionExchange of competition-sensitive information	Competition Act is not applicable as the consultative body is seen as mandatory for the execution of government policy, and power of decision lies with the government
[15]	2013	Pharmacies, hospitals	Joint purchasing agreement	Informal opinion on request	Improved monitoring of medicationMore efficient prescribingImproved measurement of performance	Cross-market agreement between noncompeting pharmacies	Competition Act is not applicable as the agreement only includes noncompeting pharmaciesCurrent market share of the cooperative association is lower than bagatelle threshold in Article 7 of Competition Act, thus Competition Act does not apply.
[16]	2013	Hospitals	Collaborations in general	General guidance	N/A	N/A	ACM attaches great importance to a well-executed ex-ante self-assessment which clearly substantiates whether the efficiencies outweigh the drawbacks of competition.Healthcare purchasers and patient associations should be involved
[17]	2014	Healthcare purchasing	Agreement on centralization of acute care	Informal opinion at ACM’s own initiative	Improved and more efficient acute care	Reduced freedom of choice for patients and insured parties resulting in a potential reduction in quality of care	Intended centralization potentially infringes Competition Act, due to reduced freedom of choiceReduced ability to differentiate and stand out of health insurersEfficiencies do not outweigh drawbacks for competition
[18]	2014	Healthcare providers, purchasers and municipalities in Long term care	Exchange of information between competing providers	General guidance	Legislative changes demand for exchange of information	Exchange of competition-sensitive information can restrict competition	For municipalities and procurement offices, the Competition Act does not apply and thus no restrictions imposed on the exchange of information.Between healthcare purchasers, exchange of information negotiated tariffs, cost prices, turnovers and strategic plans concerning operating areas is contrary to Competition Act.
[19]	2015	Healthcare purchasing	Joint purchasing agreement with participating hospitals	Informal opinion on request	Lower prices for TNFi medication potentially resulting in lower insurance premiums	Reduced ability to differentiate for participating hospitalsAgreement might impose entry barriers	The purchasing agreement for all insured persons does not appreciably restrict competition on the hospital market
[20]	2015	Hospitals	Joint negotiation and standardization of breast cancer care	Informal opinion on request	Standardize breast cancer care provision to increase quality and efficiencyJoint negotiation with insurers increases efficiency	Potential expansion of the collaboration agreement by adding new hospitals must be disclosed	Because the six hospitals are located across the Netherlands, they are not considered direct competitors.The agreement does not appreciably restrict competition as the agreement only includes noncompeting hospitals
[21]	2015	Healthcare purchasing	Joint purchasing agreement	Informal opinion on request	Risk of overcapacity or delay if all four proton therapy centres are contractedWithout joint purchasing, proton therapy in the Netherlands would not be viable	The joint purchasing agreement concerns almost all insured person in the Netherlands, and therefore reduces freedom of choiceAlso risk of increased travel time and restriction of supply	The purchasing agreement for all insured persons does appreciably restrict competition on the hospital market, and thus infringes the Competition Act.ACM does not informally approves the planJoint purchasing of foreign proton therapy centres is permissible under the Competition Act.
[22]	2015	GP care	Collaborations in general	Guidance	N/A	Restricting freedom of choice or innovationCollective boycotts or tariff agreements	ACM will only take action if collaboration harms patients or interests of insured persons.
[23]	2016	Healthcare purchasing/hospitals	Joint purchasing agreement for hospitals and healthcare purchasers	Informal opinion at ACM’ own initiative	Negotiating lower prices, higher discounts and better conditions with pharmaceutical companies	Potential reduction in quality and innovation efforts.	The agreement may be permissible under the Competition Act. To safeguard competition, three conditions apply:Joint purchasing only applies to a part of the total costs.Entry to the purchasing group must be possible.The purchasing group does not impose any obligations such as binding contracts, withdrawal barriers and purchase obligations
[24]	2016	Hospital	Centralization agreement on complex oncological surgery	Informal opinion on request	Better quality through higher annual volume of surgeryMeet minimum volume thresholds	Reduced freedom of choice for patients and health insurers.	ACM considers the agreement restricting competition to be permissible under the exemption criteria of Article 6(3).The centralization is the least restricting option. Sufficient competition on other domains remains possible.
[25]	2017	Home care	Regional consultative body on joint purchasing	Informal opinion on request	Stimulating innovation in home careNationwide coverage	The agreement would eliminate alternativesAbility to maintain prices above competitive levels	ACM considers the agreement restricting competition to be permissible under the exemption criteria of Article 6(3).
[26]	2018	Obstetric care	Regional collaborative agreement on healthcare provision	Guidance	Quality improvements through multidisciplinary consultations, regional investment, professional standards	Price agreements, distribution agreements on clients, entry barriers	Entry to the collaboration by other organizations must be possibleThe entry process must be transparent, objective and nondiscriminating
[27]	2019	Healthcare purchasing, healthcare provision	Healthcare provision and substation agreements	Guidance	Provide care at the most cost-efficient location, close to patient.	Entry barriers, exchange of competition sensitive information, price increases	ACM will not take action against or fine healthcare providers for these agreements provided all of the following five criteria are satisfied: (1) There is a widely supported and public vision for the region that outlines the allocation of care. (2) Agreements on allocation and intended goals are substantiated. (3) Healthcare providers, health insurers and patient associations are fully involved. (4) The agreements do not focus on restricting or hindering the entry or expansion of the agreement’ activities. (5) The agreements and intended goals and measurability are transparent and public.
[28]	2019	Hospitals	Expansion of collaboration described under [20]	Re-evaluation	Share best practices to improve quality of careReward quality improvements	Weakened market position of health insurers vis-à-vis the agreementSharing of financial information could push prices upwards	The agreement may restrict competitionHealth insurers should decide whether they will negotiate with independent hospitals or with the group of hospitals
[29]	2020	Healthcare purchasing	Covid-19: health insurer agreements on compensation of healthcare providers	Guidance	Avoid bankruptcy of healthcare providersMeet duty of continuity in care	N/A	Collaboration between purchasers is necessary to maintain supply of care servicesAn independent organization should assess the amount of compensationThe agreement should be temporary in nature
[30]	2020	Healthcare provision/manufacturing	Covid-19: agreement on distribution of essential medication	Guidance	Avoid medication shortages	Exchange of capacity information between manufacturers	No risks to competition due to temporary and mandatory nature of agreement
[31]	2020	Healthcare purchasing	Covid-19: agreement on allocation of additional costs	Guidance	Avoid increase in premiums of some health insurersMaintain level playing field between insurers	Reduced functioning of risk equalizationReduced incentive to purchase cost-efficient care	The functioning of the health system would be jeopardized without allocation of costs.Permissible due to temporary nature of agreement
[32]	2020	Hospitals	Allocation of care agreement following [26]	Guidance	Improve quality of careContain rising healthcare spending	Reduced freedom of choice for patients and health insurers.	Correct application of the JZOJP conditionsAllocation of care is closely monitored to avoid negative effects on affordability and accessibilityDocuments on underlying argumentation should be published publicly on the hospital’s website

Case number	Year	Healthcare sectors	Type of collaboration	Type of document	Efficiencies claimed by collaborating parties	(Risk of) anticompetitive behaviour	Decision/advice (ACM)
[13]	2005	Healthcare purchasing	Joint purchasing agreement	Informal opinion on request	More scope for price competitionEstablish balance between supply and demand	Temporary elimination of price competition through preference clause (6 months), reduced ability to differentiate	Limited restriction of competition through the temporary nature
[14]	2006	Hospitals, healthcare purchasing	Regional consultative body on product and capacity agreements	Informal opinion on request	Improved coordination of price and capacity after expiry of obligation to contract	Agreements may restrict competitionExchange of competition-sensitive information	Competition Act is not applicable as the consultative body is seen as mandatory for the execution of government policy, and power of decision lies with the government
[15]	2013	Pharmacies, hospitals	Joint purchasing agreement	Informal opinion on request	Improved monitoring of medicationMore efficient prescribingImproved measurement of performance	Cross-market agreement between noncompeting pharmacies	Competition Act is not applicable as the agreement only includes noncompeting pharmaciesCurrent market share of the cooperative association is lower than bagatelle threshold in Article 7 of Competition Act, thus Competition Act does not apply.
[16]	2013	Hospitals	Collaborations in general	General guidance	N/A	N/A	ACM attaches great importance to a well-executed ex-ante self-assessment which clearly substantiates whether the efficiencies outweigh the drawbacks of competition.Healthcare purchasers and patient associations should be involved
[17]	2014	Healthcare purchasing	Agreement on centralization of acute care	Informal opinion at ACM’s own initiative	Improved and more efficient acute care	Reduced freedom of choice for patients and insured parties resulting in a potential reduction in quality of care	Intended centralization potentially infringes Competition Act, due to reduced freedom of choiceReduced ability to differentiate and stand out of health insurersEfficiencies do not outweigh drawbacks for competition
[18]	2014	Healthcare providers, purchasers and municipalities in Long term care	Exchange of information between competing providers	General guidance	Legislative changes demand for exchange of information	Exchange of competition-sensitive information can restrict competition	For municipalities and procurement offices, the Competition Act does not apply and thus no restrictions imposed on the exchange of information.Between healthcare purchasers, exchange of information negotiated tariffs, cost prices, turnovers and strategic plans concerning operating areas is contrary to Competition Act.
[19]	2015	Healthcare purchasing	Joint purchasing agreement with participating hospitals	Informal opinion on request	Lower prices for TNFi medication potentially resulting in lower insurance premiums	Reduced ability to differentiate for participating hospitalsAgreement might impose entry barriers	The purchasing agreement for all insured persons does not appreciably restrict competition on the hospital market
[20]	2015	Hospitals	Joint negotiation and standardization of breast cancer care	Informal opinion on request	Standardize breast cancer care provision to increase quality and efficiencyJoint negotiation with insurers increases efficiency	Potential expansion of the collaboration agreement by adding new hospitals must be disclosed	Because the six hospitals are located across the Netherlands, they are not considered direct competitors.The agreement does not appreciably restrict competition as the agreement only includes noncompeting hospitals
[21]	2015	Healthcare purchasing	Joint purchasing agreement	Informal opinion on request	Risk of overcapacity or delay if all four proton therapy centres are contractedWithout joint purchasing, proton therapy in the Netherlands would not be viable	The joint purchasing agreement concerns almost all insured person in the Netherlands, and therefore reduces freedom of choiceAlso risk of increased travel time and restriction of supply	The purchasing agreement for all insured persons does appreciably restrict competition on the hospital market, and thus infringes the Competition Act.ACM does not informally approves the planJoint purchasing of foreign proton therapy centres is permissible under the Competition Act.
[22]	2015	GP care	Collaborations in general	Guidance	N/A	Restricting freedom of choice or innovationCollective boycotts or tariff agreements	ACM will only take action if collaboration harms patients or interests of insured persons.
[23]	2016	Healthcare purchasing/hospitals	Joint purchasing agreement for hospitals and healthcare purchasers	Informal opinion at ACM’ own initiative	Negotiating lower prices, higher discounts and better conditions with pharmaceutical companies	Potential reduction in quality and innovation efforts.	The agreement may be permissible under the Competition Act. To safeguard competition, three conditions apply:Joint purchasing only applies to a part of the total costs.Entry to the purchasing group must be possible.The purchasing group does not impose any obligations such as binding contracts, withdrawal barriers and purchase obligations
[24]	2016	Hospital	Centralization agreement on complex oncological surgery	Informal opinion on request	Better quality through higher annual volume of surgeryMeet minimum volume thresholds	Reduced freedom of choice for patients and health insurers.	ACM considers the agreement restricting competition to be permissible under the exemption criteria of Article 6(3).The centralization is the least restricting option. Sufficient competition on other domains remains possible.
[25]	2017	Home care	Regional consultative body on joint purchasing	Informal opinion on request	Stimulating innovation in home careNationwide coverage	The agreement would eliminate alternativesAbility to maintain prices above competitive levels	ACM considers the agreement restricting competition to be permissible under the exemption criteria of Article 6(3).
[26]	2018	Obstetric care	Regional collaborative agreement on healthcare provision	Guidance	Quality improvements through multidisciplinary consultations, regional investment, professional standards	Price agreements, distribution agreements on clients, entry barriers	Entry to the collaboration by other organizations must be possibleThe entry process must be transparent, objective and nondiscriminating
[27]	2019	Healthcare purchasing, healthcare provision	Healthcare provision and substation agreements	Guidance	Provide care at the most cost-efficient location, close to patient.	Entry barriers, exchange of competition sensitive information, price increases	ACM will not take action against or fine healthcare providers for these agreements provided all of the following five criteria are satisfied: (1) There is a widely supported and public vision for the region that outlines the allocation of care. (2) Agreements on allocation and intended goals are substantiated. (3) Healthcare providers, health insurers and patient associations are fully involved. (4) The agreements do not focus on restricting or hindering the entry or expansion of the agreement’ activities. (5) The agreements and intended goals and measurability are transparent and public.
[28]	2019	Hospitals	Expansion of collaboration described under [20]	Re-evaluation	Share best practices to improve quality of careReward quality improvements	Weakened market position of health insurers vis-à-vis the agreementSharing of financial information could push prices upwards	The agreement may restrict competitionHealth insurers should decide whether they will negotiate with independent hospitals or with the group of hospitals
[29]	2020	Healthcare purchasing	Covid-19: health insurer agreements on compensation of healthcare providers	Guidance	Avoid bankruptcy of healthcare providersMeet duty of continuity in care	N/A	Collaboration between purchasers is necessary to maintain supply of care servicesAn independent organization should assess the amount of compensationThe agreement should be temporary in nature
[30]	2020	Healthcare provision/manufacturing	Covid-19: agreement on distribution of essential medication	Guidance	Avoid medication shortages	Exchange of capacity information between manufacturers	No risks to competition due to temporary and mandatory nature of agreement
[31]	2020	Healthcare purchasing	Covid-19: agreement on allocation of additional costs	Guidance	Avoid increase in premiums of some health insurersMaintain level playing field between insurers	Reduced functioning of risk equalizationReduced incentive to purchase cost-efficient care	The functioning of the health system would be jeopardized without allocation of costs.Permissible due to temporary nature of agreement
[32]	2020	Hospitals	Allocation of care agreement following [26]	Guidance	Improve quality of careContain rising healthcare spending	Reduced freedom of choice for patients and health insurers.	Correct application of the JZOJP conditionsAllocation of care is closely monitored to avoid negative effects on affordability and accessibilityDocuments on underlying argumentation should be published publicly on the hospital’s website

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