Daan Westra

Stuck in the middle? A perspective on ongoing pro-competitive reforms in Dutch mental health care

Pro-competitive reforms have been implemented in many Western healthcare systems, of which the Netherlands is a prominent example. While the pro-competitive reforms in the Dutch specialized care sector have drawn considerable academic attention, mental health care is often excluded. However, in line with other segments of specialized care, pro-competitive legislation has formed the core of mental health care reforms, albeit with several notable differences. Ever since mental health services were included in the Health Insurance Act in 2008, the Dutch mental healthcare sector has been in an ongoing state of reform. Numerous major and minor adaptations have continuously altered the services covered by the basic insurance package, the actors responsible for providing and contracting care, and definitions and measurements of quality. Most notably, insurers and municipalities, which are responsible for selectively contracting those providers that offer high value-for-money, seem insensitive to quality aspects. The question whether the Dutch mental health sector has inherited the best or the worst of a competitive and non-competitive system lingers and international policy makers contemplating reforming their mental health sector should take note.

Understanding specialist sharing: A mixed-method exploration in an increasingly price-competitive hospital market

INTRODUCTION Medical specialists seem to increasingly work in- and be affiliated to- multiple organizations. We define this phenomenon as specialist sharing. This form of inter-organizational cooperation has received scant scholarly attention. We investigate the extent of- and motives behind- specialist sharing, in the price-competitive hospital market of the Netherlands. METHODS A mixed-method was adopted. Social network analysis was used to quantitatively examine the extent of the phenomenon. The affiliations of more than 15,000 medical specialists to any Dutch hospital were transformed into 27 inter-hospital networks, one for each medical specialty, in 2013 and in 2015. Between February 2014 and February 2016, 24 semi-structured interviews with 20 specialists from 13 medical specialties and four hospital executives were conducted to provide in-depth qualitative insights regarding the personal and organizational motives behind the phenomenon. RESULTS Roughly, 20% of all medical specialists are affiliated to multiple hospitals. The phenomenon occurs in all medical specialties and all Dutch hospitals share medical specialists. Rates of specialist sharing have increased significantly between 2013 and 2015 in 14 of the 27 specialties. Personal motives predominantly include learning, efficiency, and financial benefits. Increased workload and discontinuity of care are perceived as potential drawbacks. Hospitals possess the final authority to decide whether and which specialists are shared. Adhering to volume norms and strategic considerations are seen as their main drivers to share specialists. DISCUSSION We conclude that specialist sharing should be interpreted as a form of inter-organizational cooperation between healthcare organizations, facilitating knowledge flow between them. Although quality improvement is an important perceived factor underpinning specialist sharing, evidence of enhanced quality of care is anecdotal. Additionally, the widespread occurrence of the phenomenon and the underlying strategic considerations could pose an antitrust infringement.

Understanding competition between healthcare providers: Introducing an intermediary inter-organizational perspective

Pro-competitive policy reforms have been introduced in several countries, attempting to contain increasing healthcare costs. Yet, research proves ambiguous when it comes to the effect of competition in healthcare, with a number of studies highlighting unintended and unwanted effects. We argue that current empirical work overlooks the role of inter-organizational relations as well as the interplay between policy at macro level, inter-organizational networks at meso level, and outcomes at micro level. To bridge this gap and stimulate a more detailed understanding of the effect of competition in health care, this article introduces a cross-level conceptual framework which emphasizes the intermediary role of cooperative inter-organizational relations at meso level. We discuss how patient transfers, specialist affiliations, and interlocking directorates constitute three forms of inter-organizational relations in health care which can be used within this framework. The paper concludes by deriving several propositions from the framework which can guide future research.

Pharmaceutical companies and healthcare providers: Going beyond the gift – An explorative review

Introduction Interactions between pharmaceutical companies and healthcare providers are increasingly scrutinized by academics, professionals, media, and politicians. Most empirical studies and professional guidelines focus on unilateral donor-recipient types of interaction and overlook, or fail to distinguish between, more reciprocal types of interaction. However, the degree of goal alignment and potential for value creation differs in these two types of interactions. Failing to differentiate between these two forms of interaction between pharmaceutical companies and healthcare providers could thus lead to biased conclusions regarding their desirability. This study reviews the empirical literature regarding the effects of bilateral forms of interactions between pharmaceutical companies and healthcare providers in order to explore their effects. Material and methods We searched two medical databases (i.e. PubMed and Cochrane Library) and one business database (i.e. EBSCO) for empirical, peer-reviewed articles concerning any type of bilateral interaction between pharmaceutical companies and healthcare providers. We included quantitative articles which were written in English and published between January 1st, 2000 and October 31st, 2016, and where the title or abstract included a combination of synonyms of the following keywords: pharmaceutical companies, healthcare providers, interaction, and effects. Results Our search results yielded 10 studies which were included in our analysis. These studies focused on either research-oriented interaction or on education-oriented interaction. The included studies reported various outcomes of interaction such as prescribing behavior, ethical dilemmas, and research output. Regardless of the type of interaction, the studies either reported no significant effects or ambivalent outcomes such as affected clinical practice or ethical issues. Discussion and conclusion The effects of bilateral interactions reported in the literature are similar to those reported in studies concerning unilateral interactions. The theoretical notion that bilateral interactions between pharmaceutical companies and healthcare providers have different effects given their increased level of goal alignment thus does not seem to hold. However, most of the empirical studies focus on intermediary, provider-level, outcomes such as altered prescribing behavior. Outcomes at the health system level such as overall costs and quality of care are overlooked. Further research is necessary in order to disentangle various forms of value created by different types of interactions between pharmaceutical companies and healthcare providers.

If you say so: Perceived and measured effects of hospital mergers on quality of care (WITHDRAWN)

Hospital markets are becoming increasingly consolidated despite mixed evidence regarding the desirability of hospital mergers. This study seeks to advance the understanding of hospital mergers by studying both their perceived and measured effects on quality of care. We used a mixed-methods approach to study hospital mergers in the Netherlands. In the quantitative stage we tested the effect of hospital mergers (approved between 2008 and 2014) on 82 quality indicators (11 at hospital level, 28 at department level, and 43 at disease level) using a difference-in-difference approach. Qualitatively, three case studies were conducted to study how hospital executives, hospital managers, and healthcare professionals perceive a merger to have impacted quality of care. Fifteen quality indicators proved significantly worse in merged hospitals (three after applying Bonferroni correction) and two quality indicators proved significantly better in merged hospitals (none after applying Bonferroni correction). The majority...

Perspectives on Enabling Integration of Primary and Secondary Care

Context : Rising expenditures threaten the sustainability of many healthcare systems. In the Netherlands for example, health spending is predicted to rise from 13% of GDP in 2010, to 22% in 2040 [1], straining the affordability of the system [2]. In response, some governments have reformed their nation’s healthcare sector [3]. However, integrating the delivery of healthcare services could provide a more practical solution to curbing rising expenditures [4]. Substitution of care is therefore high on the (political) agenda in the Netherlands [5]. In unison, the government defined nine pioneer sites (i.e. ‘Proeftuinen’) in which stakeholders experiment with the restructuring of service delivery based on the population management (PM) concept. Although a widely accepted definition is lacking [6], PM initiatives generally address a population’s health needs at all points along the health and well-being continuum through integration. Regional stakeholders are thus expected to establish partnerships with each other, aimed at improving Triple Aim outcomes [7]. In the majority of the pioneer sites, stakeholders have focused their efforts on integrating primary and secondary care, resulting in so-called Primary Care Plus (PC+) initiatives in which medical specialists are placed in primary care settings to treat patients with less complex medical needs. By better integration between primary and secondary care, these initiatives aim to reduce the amount of unnecessary referrals to expensive hospital settings. Instead, patients are treated in less expensive, yet equally adequate, primary care settings. Target participants : This workshop, chaired by Dirk Ruwaard, professor at Maastricht UMC / Maastricht University, presents results of several research projects within the ‘Academic Collaborative Center for Sustainable Health Care’ focused on integrated care. Specifically, the workshop addresses integration of primary and secondary care and it is intended for all who are interested or involved in such initiatives. We will commence by describing which decisions shaped the creation of PC+ centers, to what extent interests and ideals of stakeholders conflicted, and how these conflicts were resolved. Next, we illustrate how the Dutch antitrust regulations influence the prosperity of initiatives attempting to integrated primary and secondary care. Having overcome these legislative hurdles, the workshop will illustrate how the patients experience care in PC+ centers. Is the care truly patient centered for example? Similarly, the workshop will highlight the perspective of health professionals. Based on a novel sustainable employability framework, we discuss to what extent working in PC+ creates new and exciting opportunities, or places a strenuous burden on medical specialists and GPs. Subsequently, the topic of rising health expenditures is addressed. To what extend do PC+ initiatives succeed in their attempt to curb the trend of rising healthcare costs? Has care been substituted towards primary care settings or do PC+ centers serve as an extra ‘layer’ in an already complex and expensive system? Lastly, the workshop provides sufficient opportunity for the attendees to critically assess these initiatives, share their own thoughts and experiences, and engage in a discussion led by Dirk Ruwaard. References : 1- van Ewijk C, van der Horst A, Besseling P. Toekomst voor de zorg. Den Haag: CPB, 2013. 2- Ministry of Health Welfare and Sports (MHWS). Naar beter betaalbare zorg. Rapport Taskforce Beheersing Zorguitgaven. Den Haag: MHWS, 2012. 3- Cutler DM. Equality, efficiency, and market fundamentals: the dynamics of international medical-care reform. Journal of Economic Literature 2002; 40:881-906. 4- Hildebrandt H, Schulte T, Stunder B. Triple Aim in Kingzigtal, Germany: Improving population health, integrating health care and reducing costs of care - lessons for the UK. Journal of Integrated Care 2012; 20:205-22. 5- Ministerie van Volksgezondheid WeS. Bestuurlijk hoofdlijnenakkoord 2012-2015. Den Haag: Ministry of Health Welfare and Sports (MHWS), 2011. 6- Struijs JN, Drewes HW, Heijink R, Baan CA. How to evaluate population management? Transforming the Care Continuum Alliance population health guide toward a broadly applicable analytical framework. Health Policy 2014. 7- Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs 2008; 27:759-69.

Does Price Competition Drive Cooperation in Health Care? A Stochastic Actor Oriented Model Analysis

Pro-competitive reforms have been enacted throughout Western healthcare systems despite mixed evidence of their effect. Although healthcare organizations competing under non-price competition have been shown to cooperate using patient transfers, little is known about cooperative strategies of healthcare organizations in price-competitive healthcare markets. This paper investigates a novel and understudied form of inter-hospital cooperation described as potentially hazardous to well-functioning healthcare markets, namely the act of sharing medical specialists between hospitals. In particular, it investigates the influence of price-competition on cooperative hospital strategies. We use a stochastic actor-oriented model to analyze the cooperative dynamics amongst 94 general and academic hospitals in the Netherlands between 2010 and 2015. Our results show that, in a price-competitive healthcare sector, hospitals predominantly cooperate with their direct competitors. However, the ratio of price-competitive to ...

Individual and Organizational Characteristics of Inter-Organizational Cooperation in Health Care

Although market-based reforms have introduced incentives for healthcare organizations to compete in many countries, cooperative inter-organizational arrangements remain salient to the delivery of h...