The idea that healthcare insurers can create efficient markets by negotiating prices with providers is appealing. But do they really have the clout?

The idea is key to the Dutch healthcare reforms. German statutory funds are also starting to negotiate procedures. There is some evidence that the Dutch have managed to reduce prices - costs in the 34% of the market where they are free to do so have barely risen in the last few years and the insurers have successfully hammered generic drug prices into the ground.

But insurers have limited power. In Germany patient flow is determined by the recommendations of specialists, powerful doctors who specialise in particular conditions and sit outside the hospital system.

And patients in Germany, the Netherlands and Switzerland simply don't fully trust insurers. If an insurer has negotiated a special deal which means that the patient can save EUR100 by opting for a particular supplier many patients will smell a rat.

Insurers are well aware of this. The last thing they want is any reputational damage. So Dutch and German insurers often soft pedal on special offers. And Dutch insurers are still giving hospitals which have been slow to move to cheaper ambulatory surgery 2-3 years to sort themselves out.

One answer is for the insurer to invest in building brand and reputation. This is what Bupa has done in Spain and the UK. It has moved to a position where people take out Bupa cover because they think that Bupa can get them access to the best treatment. But it would be hard for a Dutch or German statutory insurer with very limited margins to invest heavilly in such an approach.

So insurers in most countries are weak players compared to pharma, doctors or even hospitals. As a Swiss insurer glumly told me once: "everytime we sit down to discuss drug prices, big pharma says it will pack its bags if the government drops prices. Then the government caves in."

These do not seem likely to be organisations capable of driving ruthless and radical reform through Europe's healthcare systems.