Aligning Ambition and Reality: A Multiple Case Study Into Synergistic Influences of Financial and Other Factors on the Outcomes of Integrated Care Projects.

Introduction: While the benefits of integrated care are widely acknowledged, its implementation has proven difficult. Together with other factors, financial factors are known to influence progress towards care integration, but in-depth insight in their influence on the envisioned outcomes of integrated care projects is limited. Methods: We conducted a multiple case study of four integrated care projects in the Netherlands. The projects were purposely sampled to be representative of integrated care in its different forms. A total of 29 semi-structured interviews were held with project members, both medical and non-medical staff. In addition, 141 documents were analyzed, including scientific publications and minutes of meetings. Based on elaborate project descriptions we deduced the synergistic influences of financial and other factors on the outcomes of the projects. Results: Financial factors have an important influence on integrated care projects, though this influence is neither deterministic nor isolated. This is because the likelihood of realizing a positive outcome is affected by the degree to which four key conditions are fulfilled: 1) willingness to change, 2) alignment of interests and uniformity goal, 3) availability of resources to change, and 4) effectiveness of management of external actors. Conclusion: Financial factors have an impact on the outcomes of integrated care projects and must be viewed in synergy with interrelated other factors. Crucial for realizing success in integrated care, a balance must be struck between the level of ambition set in a project and the reality of the prevailing key conditions.

Preconditions for efficiency and affordability in competitive healthcare markets: Are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland? Ten years later.

From the mid-1990s several countries have introduced elements of the model of regulated competition in healthcare. In 2012 we assessed the extent to which in five countries ten important preconditions for achieving efficiency and affordability in competitive healthcare markets were fulfilled. In this paper we assess to what extent the fulfilment of these preconditions has changed ten years later. In 2022, as in 2012, in none of the five countries all preconditions are completely fulfilled. In the period 2012-2022 on balance there have been some improvements in the fulfillment of the preconditions, although to a different extent in the five countries. The only preconditions that were improved in most countries were 'consumer information and transparency' and 'cross-subsidies without incentives for risk selection'. On balance the Netherlands and Switzerland made most progress in the number of better fulfilled preconditions. For Belgium these preconditions no longer seem relevant because the idea of regulated competition has been completely abandoned. In Germany, Israel and Switzerland, the preconditions 'effective competition policy' and 'contestability of the markets' are not sufficiently fulfilled in 2022, just as in 2012. In Germany and Switzerland this also holds for the precondition 'freedom to contract and integrate'. Overall, the progress towards realizing the preconditions has been limited.

The dynamics of international health system reforms: Evidence of a new wave in response to the 2008 economic crisis and the COVID-19 pandemic?

Global economic and health shocks, such as the 2008 global financial crisis and the COVID-19 pandemic typically impact healthcare financing and delivery. Cutler found that profound societal changes in the 20th century induced three waves of healthcare reform across seven major OECD countries. Our study investigates whether major crises in the 21st century induced similar reform waves. Through thematic analysis, we systematically compared health system changes in response to these shocks, using data from the Observatory on Health Systems and Policies and the OECD. Our analysis reveals similar overarching reform trends across countries in response to the 2008 economic crisis: a tendency toward re-centralization of health system governance to control and leverage the efficient rationalization of public health resources. This, to some extent, countered the effects of the market-based reforms of the previous wave. The reforms induced by the 2008 crisis were mediated by its repercussions on the countries' economies. In contrast, reforms in response to the pandemic aimed primarily to address the direct impact of the shock on the health system. Despite its negative economic impact, the pandemic resulted in a substantial but temporary increase in public health spending. A better understanding reform dynamics and their impact on overarching conflicting health system objectives may prevent unintended consequences and enhance health systems' resilience in response to future shocks.

Financing COVID-19-related health care costs in the Dutch competitive health system during 2020 and 2021: Overall experiences and policy recommendations for improving health system resilience.

The Dutch health system is based on the principles of managed (or regulated) competition, meaning that competing risk bearing insurers and providers negotiate contracts on the price, quantity and quality of care. The COVID-19 pandemic caused a huge external shock to the health system which potentially distorted the conditions required for fair competition. Therefore, an important question is to what extent was the competitive Dutch health system resilient to the financial shock caused by the pandemic? Overall, the Dutch competitive health system proved to be sufficiently flexible and resilient at absorbing the financial shock caused by the COVID-19 pandemic in 2020 and 2021 due to an effective combination of regulatory and self-regulatory measures. However, based on the overall experiences in the Netherlands, from the health policy perspective improvements are needed aimed at (i) refining the catastrophic costs clause included in the Health Insurance Act, (ii) reducing the vulnerability of the Dutch risk equalisation system to distortions due to unforeseen catastrophic health care costs, and (iii) establishing more equal financial risk sharing between health insurers and health care providers. These improvements are also relevant for other countries with a health system based on the principles of managed (or regulated) competition.