Abstract: The purpose of this paper is to provide commentary on the state of affairs regarding implementation of Dutch health insurance reform, focusing on whether such reform is conducive to pharmaceutical innovation. Design/methodology/approach The general characteristics of the Dutch healthcare system is outlined, together with a brief synopsis of the 2006 health insurance reform initiative. This is followed by a description of the four market intervention mechanisms and their implications for pharmaceutical innovation. Finally, these implications and the potential for policy transfer to other European countries are discussed. Findings The new Dutch health insurance system represents a novel approach that closely follows Enthoven's managed competition model. Certain features of the new system are conducive to pharmaceutical innovation. These positive features include more flexibility on the part of private insurers to deviate from the national formulary, speedier reimbursement appraisals, and more earmarked funding for certain highly innovative pharmaceutical products. Other features, however, appear detrimental to drug innovation. These include direct price controls, reference pricing, and the still highly centralized nature of decision making with respect to drug reimbursement. On the whole, one could say that, despite many challenges, Dutch health insurance reform is a step in the right direction that may prove to be a boon to biopharmaceutical innovation if further steps are taken to remove obstacles. Research limitations/implications It is premature to draw firm conclusions on whether Dutch health insurance reform is conducive to pharmaceutical innovation. The new system is at an early stage in its evolution. Further, one should be cautious about the extent to which lessons can be drawn from the new Dutch system for other European countries, given the limited size of the Dutch biopharmaceutical industry relative to some of its European neighbors. Originality/value While much is known about how changes in the drug regulatory framework impact pharmaceutical innovation, very little is known about how changes in health care insurance impact pharmaceutical innovation. This paper aims to fill that void by examining the impact of the new Dutch health insurance system on drug innovation.

Abstract: Being a celebrity sure ain’t what it used to be. Or, perhaps more accurately, the process of maintaining a stable star persona isn’t what it used to be. With the rise of new media technologies—including digital photography and video production, gossip blogging, social networking sites, and streaming video—there has been a rapid proliferation of voices which serve to articulate stars’ personae. This panoply of sanctioned and unsanctioned discourses has brought the coherence and stability of the star’s image into crisis, with an evermore-heightened loop forming recursively between celebrity gossip and scandals, on the one hand, and, on the other, new media-enabled speculation and commentary about these scandals and gossip-pieces.  Of course, while no subject has a single meaning, Hollywood has historically expended great energy and resources to perpetuate the myth that the star’s image is univocal. In the present moment, however, studios’s traditional methods for discursive control have faltered, such that celebrities have found it necessary to take matters into their own hands, using new media technologies, particularly Twitter, in an attempt to stabilise that most vital currency of their trade, their professional/public persona. In order to fully appreciate the significance of this new mode of publicity management, and its larger implications for contemporary subjectivity writ large, we must first come to understand the history of Hollywood’s approach to celebrity publicity and image management.A Brief History of Hollywood PublicityThe origins of this effort are nearly as old as Hollywood itself, for, as Richard DeCordova explains, the celebrity scandals of the 1920s threatened to disrupt the economic vitality of the incipient industry such that strict, centralised image control appeared as a necessary imperative to maintain a consistently reliable product. The Fatty Arbuckle murder trial was scandalous not only for its subject matter (a murder suffused with illicit and shadowy sexual innuendo) but also because the event revealed that stars, despite their mediated larger-than-life images, were not only as human as the rest of us, but that, in fact, they were capable of profoundly inhuman acts. The scandal, then, was not so much Arbuckle’s crime, but the negative pall it cast over the Hollywood mythos of glamour and grace. The studios quickly organised an industry-wide regulatory agency (the MPPDA) to counter potentially damaging rhetoric and ward off government intervention. Censorship codes and morality clauses were combined with well-funded publicity departments in an effort that successfully shifted the locus of the star’s extra-filmic discursive construction from private acts—which could betray their screen image—to information which served to extend and enhance the star’s pre-existing persona. In this way, the sanctioned celebrity knowledge sphere became co-extensive with that of commercial culture itself; the star became meaningful only by knowing how she spent her leisure time and the type of make-up she used. The star’s identity was not found via unsanctioned intrusion, but through studio-sanctioned disclosure, made available in the form of gossip columns, newsreels, and fan magazines.  This period of relative stability for the star's star image was ultimately quite brief, however, as the collapse of the studio system in the late 1940s and the introduction of television brought about a radical, but gradual, reordering of the star's signifying potential. The studios no longer had the resources or incentive to tightly police star images—the classic age of stardom was over.  During this period of change, an influx of alternative voices and publications filled the discursive void left by the demise of the studios’s regimented publicity efforts, with many of these new outlets reengaging older methods of intrusion to generate a regular rhythm of vendible information about the stars.The first to exploit and capitalize on star image instability was Robert Harrison, whose Confidential Magazine became the leading gossip publication of the 1950s. Unlike its fan magazine rivals, which persisted in portraying the stars as morally upright and wholesome, Confidential pledged on the cover of each issue to “tell the facts and name the names,” revealing what had been theretofore “confidential.”  In essence, through intrusion, Confidential reasserted scandal as the true core of the star, simultaneously instituting incursion and surveillance as the most direct avenue to the “kernel” of the celebrity subject, obtaining stories through associations with call girls, out-of-work starlettes, and private eyes.   As extra-textual discourses proliferated and fragmented, the contexts in which the public encountered the star changed as well. Theatre attendance dropped dramatically, and as the studios sold their film libraries to television, the stars, formerly available only on the big screen and in glamour shots, were now intercut with commercials, broadcast on grainy sets in the domestic space. The integrity—or at least the illusion of integrity—of the star image was forever compromised. As the parameters of renown continued to expand, film stars, formally distinguished from all other performers, migrated to television. The landscape of stardom was re-contoured into the “celebrity sphere,” a space that includes television hosts, musicians, royals, and charismatic politicians.  The revamped celebrity “game” was complex, but still playabout: with a powerful agent, a talented publicist, and a check on drinking, drug use, and extra-marital affairs, a star and his or her management team could negotiate a coherent image. Confidential was gone, The National Inquirer was muzzled by libel laws, and People and E.T.—both sheltered within larger media companies—towed the publicists’s line. There were few widely circulated outlets through which unauthorised voices could gain traction. Old-School Stars and New Media Technologies: The Case of Tom CruiseYet with the relentless arrival of various news media technologies beginning in the 1980s and continuing through the present, maintaining tight celebrity image control began to require the services of a phalanx of publicists and handlers. Here, the example of Tom Cruise is instructive: for nearly twenty years, Cruise’s publicity was managed by Pat Kingsley, who exercised exacting control over the star’s image. With the help of seemingly diverse yet essentially similar starring roles, Cruise solidified his image as the cocky, charismatic boy-next-door.The unified Cruise image was made possible by shutting down competing discourses through the relentless, comprehensive efforts of his management company; Kingsley's staff fine-tuned Cruise’s acts of disclosure while simultaneously eliminating the potential for unplanned intrusions, neutralising any potential scandal at its source. Kingsley and her aides performed for Cruise all the functions of a studio publicity department from Hollywood’s Golden Age. Most importantly, Cruise was kept silent on the topic of his controversial religion, Scientology, lest it incite domestic and international backlash.  In interviews and off-the-cuff soundbites, Cruise was ostensibly disclosing his true self, and that self remained the dominant reading of what, and who, Cruise “was.” Yet in 2004, Cruise fired Kingsley, replaced her with his own sister (and fellow Scientologist), who had no prior experience in public relations. In essence, he exchanged a handler who understood how to shape star disclosure for one who did not. The events that followed have been widely rehearsed: Cruise avidly pursued Katie Holmes; Cruise jumped for joy on Oprah’s couch; Cruise denounced psychology during a heated debate with Matt Lauer on The Today Show. His attempt at disclosing this new, un-publicist-mediated self became scandalous in and of itself.   Cruise’s dismissal of Kingsley, his unpopular (but not necessarily unwelcome) disclosures, and his own massively unchecked ego all played crucial roles in the fall of the Cruise image. While these stumbles might have caused some minor career turmoil in the past, the hyper-echoic, spastically recombinatory logic of the technoculture brought the speed and stakes of these missteps to a new level; one of the hallmarks of the postmodern condition has been not merely an increasing textual self-reflexivity, but a qualitative new leap forward in inter-textual reflexivity, as well (Lyotard; Baudrillard). Indeed, the swift dismantling of Cruise’s long-established image is directly linked to the immediacy and speed of the Internet, digital photography, and the gossip blog, as the reflexivity of new media rendered the safe division between disclosure and intrusion untenable. His couchjumping was turned into a dance remix and circulated on YouTube; Mission Impossible 3 boycotts were organised through a number of different Web forums; gossip bloggers speculated that Cruise had impregnated Holmes using the frozen sperm of Scientology founder L. Ron Hubbard. In the past, Cruise simply filed defamation suits against print publications that would deign to sully his image. Yet the sheer number of sites and voices reproducing this new set of rumors made such a strategy untenable.  Ultimately, intrusions into Cruise’s personal life, including the leak of videos intended solely for Scientology recruitment use, had far more traction than any sanctioned Cruise soundbite. Cruise’s image emerged as a hollowed husk of its former self; the sheer amount of material circulating rendered all attempts at P.R., including a Vanity Fair cover story and “reveal” of daughter Suri, ridiculous. His image was fragmented and re-collected into an altered, almost uncanny new iteration. Following the lackluster performance of Mission Impossible 3 and public condemnation by Paramount head Sumner Redstone, Cruise seemed almost pitiable.  The New Logic of Celebrity Image ManagementCruise’s travails are expressive of a deeper development which has occurred over the course of the last decade, as the massively proliferating new forms of celebrity discourse (e.g., paparazzi photos, mug shots, cell phone video have further decentered any shiny, polished version of a star. With older forms of media increasingly reorganising themselves according to the aesthetics and logic of new media forms (e.g., CNN featuring regular segments in which it focuses its network cameras upon a computer screen displaying the CNN website), we are only more prone to appreciate “low media” forms of star discourse—reports from fans on discussion boards, photos taken on cell phones—as valid components of the celebrity image. People and E.T. still attract millions, but they are rapidly ceding control of the celebrity industry to their ugly, offensive stepbrothers: TMZ, Us Weekly, and dozens of gossip blogs.  Importantly, a publicist may be able to induce a blogger to cover their client, but they cannot convince him to drop a story: if TMZ doesn’t post it, then Perez Hilton certainly will. With TMZ unabashedly offering pay-outs to informants—including those in law enforcement and health care, despite recently passed legislation—a star is never safe. If he or she misbehaves, someone, professional or amateur, will provide coverage. Scandal becomes normalised, and, in so doing, can no longer really function as scandal as such; in an age of around-the-clock news cycles and celebrity-fixated journalism, the only truly scandalising event would be the complete absence of any scandalous reports. Or, as aesthetic theorist Jacques Ranciere puts it; “The complaint is then no longer that images conceal secrets which are no longer such to anyone, but, on the contrary, that they no longer hide anything” (22).These seemingly paradoxical involutions of post-modern celebrity epistemologies are at the core of the current crisis of celebrity, and, subsequently, of celebrities’s attempts to “take back their own paparazzi.” As one might expect, contemporary celebrities have attempted to counter these new logics and strategies of intrusion through a heightened commitment to disclosure, principally through the social networking capabilities of Twitter. Yet, as we will see, not only have the epistemological reorderings of postmodernist technoculture affected the logic of scandal/intrusion, but so too have they radically altered the workings of intrusion’s dialectical counterpart, disclosure.In the 1930s, when written letters were still the primary medium for intimate communication, stars would send lengthy “hand-written” letters to members of their fan club. Of course, such letters were generally not written by the stars themselves, but handwriting—and a star’s signature—signified authenticity. This ritualised process conferred an “aura” of authenticity upon the object of exchange precisely because of its static, recurring nature—exchange of fan mail was conventionally understood to be the primary medium for personal encounters with a celebrity. Within the overall political economy of the studio system, the medium of the hand-written letter functioned to unleash the productive power of authenticity, offering an illusion of communion which, in fact, served to underscore the gulf between the celebrity’s extraordinary nature and the ordinary lives of those who wrote to them.  Yet the criterion and conventions through which celebrity personae were maintained were subject to change over time, as new communications technologies, new modes of Hollywood's industrial organization, and the changing realities of commercial media structures all combined to create a constantly moving ground upon which the celebrity tried to affix. The celebrity’s changing conditions are not unique to them alone; rather, they are a highly visible bellwether of changes which are more fundamentally occurring at all levels of culture and subjectivity. Indeed, more than seventy years ago, Walter Benjamin observed that when hand-made expressions of individuality were superseded by mechanical methods of production, aesthetic criteria (among other things) also underwent change, rendering notions of authenticity increasingly indeterminate.Such is the case that in today’s world, hand-written letters seem more contrived or disingenuous than Danny DeVito’s inaugural post to his Twitter account: “I just joined Twitter! I don't really get this site or how it works. My nuts are on fire.” The performative gesture in DeVito’s tweet is eminently clear, just as the semantic value is patently false: clearly DeVito understands “this site,” as he has successfully used it to extend his irreverent funny-little-man persona to the new medium. While the truth claims of his Tweet may be false, its functional purpose—both effacing and reifying the extraordinary/ordinary distinction of celebrity and maintaining DeVito’s celebrity personality as one with which people might identify—is nevertheless seemingly intact, and thus mirrors the instrumen tal value of celebrity disclosure as performed in older media forms. Twitter and Contemporary TechnocultureFor these reasons and more, considered within the larger context of contemporary popular culture, celebrity tweeting has been equated with the assertion of the authentic celebrity voice; celebrity tweets are regularly cited in newspaper articles and blogs as “official” statements from the celebrity him/herself. With so many mediated voices attempting to “speak” the meaning of the star, the Twitter account emerges as the privileged channel to the star him/herself. Yet the seemingly easy discursive associations of Twitter and authenticity are in fact ideological acts par excellence, as fixations on the indexical truth-value of Twitter are not merely missing the point, but actively distracting from the real issues surrounding the unsteady discursive construction of contemporary celebrity and the “celebretification” of contemporary subjectivity writ large. In other words, while it is taken as axiomatic that the “message” of celebrity Twittering is, as Henry Jenkins suggests, “Here I Am,” this outward epistemological certainty veils the deeply unstable nature of celebrity—and by extension, subjectivity itself—in our networked society.If we understand the relationship between publicity and technoculture to work as Zizek-inspired cultural theorist Jodi Dean suggests, then technologies “believe for us, accessing information even if we cannot” (40), such that technology itself is enlisted to serve the function of ideology, the process by which a culture naturalises itself and attempts to render the notion of totality coherent. For Dean, the psycho-ideological reality of contemporary culture is predicated upon the notion of an ever-elusive “secret,” which promises to reveal us all as part of a unitary public. The reality—that there is no such cohesive collective body—is obscured in the secret’s mystifying function which renders as “a contingent gap what is really the fact of the fundamental split, antagonism, and rupture of politics” (40).  Under the ascendancy of the technoculture—Dean's term for the technologically mediated landscape of contemporary communicative capitalism—subjectivity becomes interpellated along an axis blind to the secret of this fundamental rupture. The two interwoven poles of this axis are not unlike structuralist film critics' dialectically intertwined accounts of the scopophilia and scopophobia of viewing relations, simply enlarged from the limited realm of the gaze to encompass the entire range of subjectivity.  As such, the conspiratorial mindset is that mode of desire, of lack, which attempts to attain the “secret,” while the celebrity subject is that element of excess without which desire is unthinkable. As one might expect, the paparazzi and gossip sites’s strategies of intrusion have historically operated primarily through the conspiratorial mindset, with endless conjecture about what is “really happening” behind the scenes. Under the intrusive/conspiratorial paradigm, the authentic celebrity subject is always just out of reach—a chance sighting only serves to reinscribe the need for the next encounter where, it is believed, all will become known. Under such conditions, the conspiratorial mindset of the paparazzi is put into overdrive: because the star can never be “fully” known, there can never be enough information about a star, therefore, more information is always needed. Against this relentless intrusion, the celebrity—whose discursive stability, given the constant imperative for newness in commercial culture, is always in danger—risks a semiotic liquidation that will totally displace his celebrity status as such. Disclosure, e.g. Tweeting, emerges as a possible corrective to the endlessly associative logic of the paparazzi’s conspiratorial indset. In other words, through Twitter, the celebrity seeks to arrest meaning—fixing it in place around their own seemingly coherent narrativisation.  The publicist’s new task, then, is to convincingly counter such unsanctioned, intrusive, surveillance-based discourse. Stars continue to give interviews, of course, and many regularly pose as “authors” of their own homepages and blogs. Yet as posited above, Twitter has emerged as the most salient means of generating “authentic” celebrity disclosure, simultaneously countering the efforts of the papparazzi, fan mags, and gossip blogs to complicate or rewrite the meaning of the star. The star uses the account—verified, by Twitter, as the “real” star—both as a means to disclose their true interior state of being and to counter erastz narratives circulating about them. Twitter’s appeal for both celebrities and their followers comes from the ostensible spontaneity of the tweets, as the seemingly unrehearsed quality of the communiqués lends the form an immediacy and casualness unmatched by blogs or official websites; the semantic informality typically employed in the medium obscures their larger professional significance for celebrity tweeters.  While Twitter’s air of extemporary intimacy is also offered by other social networking platforms, such as MySpace or Facebook, the latter’s opportunities for public feedback (via wall-posts and the like) works counter to the tight image control offered by Twitter’s broadcast-esque model. Additionally, because of the uncertain nature of the tweet release cycle—has Ashton Kutcher sent a new tweet yet?—the voyeuristic nature of the tweet disclosure (with its real-time nature offering a level of synchronic intimacy that letters never could have matched), and the semantically displaced nature of the medium, it is a form of disclosure perfectly attuned to the conspiratorial mindset of the technoculture.  As mentioned above, however, the conspiratorial mindset is an unstable subjectivity, insofar as it only exists through a constant oscillation with its twin, the celebrity subjectivity. While we can understand that, for the celebrities, Twitter functions by allowing them a mode for disclosive/celebrity subjectivisation, we have not yet seen how the celebrity itself is rendered conspiratorial through Twitter. Similarly, only the conspiratorial mode of the follower’s subjectivity has thus far been enumerated; the moment of the follower's celebrtification has so far gone unmentioned. Since we have seen that the celebrity function of Twitter is not really about discourse per se, we should instead understand that the ideological value of Twitter comes from the act of tweeting itself, of finding pleasure in being engaged in a techno-social system in which one's participation is recognised.  Recognition and participation should be qualified, though, as it is not the fully active type of participation one might expect in say, the electoral politics of a representative democracy. Instead, it is a participation in a sort of epistemological viewing relations, or, as Jodi Dean describes it, “that we understand ourselves as known is what makes us think there is that there is a public that knows us” (122). The fans’ recognition by the celebrity—the way in which they understood themselves as known by the star was once the receipt of a hand-signed letter (and a latent expectation that the celebrity had read the fan’s initial letter); such an exchange conferred to the fan a momentary sense of participation in the celebrity's extraordinary aura. Under Twitter, however, such an exchange does not occur, as that feeling of one-to-one interaction is absent; simply by looking elsewhere on the screen, one can confirm that a celebrity's tweet was received by two million other individuals.  The closest a fan can come to that older modality of recognition is by sending a message to the celebrity that the celebrity then “re-tweets” to his broader following. Beyond the obvious levels of technological estrangement involved in such recognition is the fact that the identity of the re-tweeted fan will not be known by the celebrity’s other two million followers. That sense of sharing in the celebrity’s extraordinary aura is altered by an awareness that the very act of recognition largely entails performing one’s relative anonymity in front of the other wholly anonymous followers.  As the associative, conspiratorial mindset of the star endlessly searches for fodder through which to maintain its image, fans allow what was previously a personal moment of recognition to be transformed into a public one. That is, the conditions through which one realises one’s personal subjectivity are, in fact, themselves becoming remade according to the logic of celebrity, in which priority is given to the simple fact of visibility over that of the actual object made visible. Against such an opaque cultural transformation, the recent rise of reactionary libertarianism and anti-collectivist sentiment is hardly surprising.  ReferencesBaudrillard, Jean. Simulacra and Simulation. Ann Arbor: Michigan UP, 1994.Benjamin, Walter. Illuminations. New York: Harcourt, Brace and World, 1968.  Dean, Jodi. Publicity’s Secret: How Technoculture Capitalizes on Democracy. Ithaca: Cornell UP, 2003.  DeCordova, Richard. Picture Personalities: The Emergence of the Star System in America. Urbana: University of Illinois Press, 1990. Jenkins, Henry. “The Message of Twitter: ‘Here It Is’ and ‘Here I Am.’” Confessions of an Aca-Fan. 23 Aug. 2009. 15 Sep. 2009 〈 http://henryjenkins.org/2009/08/the_message_of_twitter.html 〉 .Lyotard, Jean-Francois. The Postmodern Condition: A Report on Knowledge.  Minneapolis: Minnesota UP, 1984.Ranciere, Jacques. The Future of the Image. New York: Verso, 2007.