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Hospitals operate in increasingly complex and dynamically uncertain environments. To understand how hospital organizationscan cope with such profound uncertainty, this article presents a multiple case study of five hospitals during the COVID-19crisis in a heavily hit region of the Netherlands. We find that hospitals make adaptations in five key categories, namely:reorganization, decision-making, human resources, material resources, and planning. These adaptations offer insights intothe core capabilities needed by hospitals to cope with dynamic uncertainty. Our findings highlight the need for hospitals tobecome more flexible without sacrificing efficiency. Organizations can accomplish this by building in more sensing and seizingcapabilities to be better prepared for and respond to environmental change. Furthermore, transforming capabilities alloworganizations to be more resilient and responsive in the face of ongoing uncertainty. We make recommendations on howhospitals can build these capabilities and address the core challenges they face in this pursuit.

Comparison is a key method in learning about what works in health and healthcare. We discuss the importance of comparability in cross-national health research using health insurance claims data, develop a framework to systematically asses these threats and apply it to the German (DaTraV) and Dutch (Vektis) national-level insurance claims datasets.We propose a framework of threats to the comparability of health insurance claims databases, which includes three domains: (1) representation of populations compared, (2) data sources and data processing and (3) database contents and availability for research purposes. We apply the framework to analyze the comparability of DaTraV and Vektis databases using publicly available information (organization's websites, scientific publications) and our experiences from an interregional project on rare diseases (EMRaDi).Both databases were created for the same purpose (morbidity-based risk adjustment) and use the same underlying sources of data. Differences in population representation and uncertainty about data processing procedures represent potential sources of incomparability. Access for research purposes is feasible in both databases but may be subject to long processing time.We find important threats to the comparability of the Dutch and German national insurance claims databases and by extension to validity of any comparative health studies that rely on them. Standard adjustment techniques, making more information available about data collection and processing procedures and adding more diagnosis-related descriptors offer ways to overcome the identified threats to comparability.Comparison is a key method in learning about what works in health and healthcare. We discuss the importance of comparability in cross-national health research using health insurance claims data, develop a framework to systematically asses these threats and apply it to the German (DaTraV) and Dutch (Vektis) national-level insurance claims datasets.We propose a framework of threats to the comparability of health insurance claims databases, which includes three domains: (1) representation of populations compared, (2) data sources and data processing and (3) database contents and availability for research purposes. We apply the framework to analyze the comparability of DaTraV and Vektis databases using publicly available information (organization’s websites, scientific publications) and our experiences from an interregional project on rare diseases (EMRaDi).Both databases were created for the same purpose (morbidity-based risk adjustment) and use the same underlying sources of data. Differences in population representation and uncertainty about data processing procedures represent potential sources of incomparability. Access for research purposes is feasible in both databases but may be subject to long processing time.We find important threats to the comparability of the Dutch and German national insurance claims databases and by extension to validity of any comparative health studies that rely on them. Standard adjustment techniques, making more information available about data collection and processing procedures and adding more diagnosis-related descriptors offer ways to overcome the identified threats to comparability.

Objectives: Loneliness has been associated with unhealthy behavior, poorer health, and increased morbidity. However, the costs of loneliness are poorly understood.Methods: Multiple sources were combined into a dataset containing a nationally representative sample (n = 341,376) of Dutch adults (18+). The association between loneliness and total, general practitioner (GP), specialized, pharmaceutical, and mental healthcare expenditure was tested using Poisson and Zero-inflated negative binomial models, controlling for numerous potential confounders (i.e., demographic, socioeconomic, lifestyle-related factors, self-perceived health, and psychological distress), for four age groups.Results: Controlling for demographic, socioeconomic, and lifestyle-related factors, loneliness was indirectly (via poorer health) associated with higher expenditure in all categories. In fully adjusted models, it showed a direct association with higher expenditure for GP and mental healthcare (0.5 and 11.1%, respectively). The association with mental healthcare expenditure was stronger in younger than in older adults (for ages 19–40, the contribution of loneliness represented 61.8% of the overall association).Conclusion: Loneliness contributes to health expenditure both directly and indirectly, particularly in younger age groups. This implies a strong financial imperative to address this issue.

Background Loneliness is a growing issue. It has been associated with a range of unhealthy behaviors, poorer health, and increased morbidity. However, the healthcare costs of loneliness are poorly understood as limited existing research on loneliness focused on older age populations, few expenditure categories, and controlled for just a few potential confounders. Our study aims to fill this evidence gap. Methods Multiple sources were combined into a dataset containing a nationally representative sample (n = 341,376) of Dutch adults (>18 y.o.). The association between loneliness and total, general practitioner (GP), specialized, pharmaceutical, and mental healthcare expenditure was tested using Poisson and Zero-inflated negative binomial models, controlling for numerous potential confounders (i.e. demographic, socioeconomic, lifestyle-related factors, self-perceived health, and psychological distress), for multiple age groups. Excess expenditure attributed to loneliness was extrapolated to the entire population. Results Controlling for demographic, socioeconomic, and lifestyle-related factors, loneliness was indirectly (via poorer health) associated with higher expenditure in all categories. In fully adjusted models, it showed a direct association with higher expenditure for GP and mental healthcare (0.5% and 11.1%, respectively). The association with mental healthcare expenditure was stronger in younger than in older adults (for ages 19-40, the contribution of loneliness represented 61.8% of the overall association). Conclusions Loneliness contributes to health expenditure both directly and indirectly, particularly in younger age groups. This implies a strong financial imperative to address this issue. Key messages Loneliness is associated with increased healthcare expenditure independent of demographic and socioeconomic factors. Excess healthcare expenditure related to loneliness are particularly apparent in mental healthcare and in younger age groups.

Cooperative inter-organizational relations are salient to healthcare delivery. However, they do not match with the pro-competitive healthcare reforms implemented in several countries. Healthcare organizations thus need to balance competition and cooperation in a situation of 'coopetition'. In this paper we study the individual and organizational determinants of coopetition versus those of cooperation in the price-competitive specialized care sector of the Netherlands. We use shared medical specialists as a proxy of collaboration between healthcare organizations. Based on a sample of 15,431 medical specialists and 371 specialized care organizations from March 2016, one logistic multi-level model is used to predict medical specialists' likelihood to be shared and another to predict their likelihood to be shared to a competitor. We find that different organizations share different specialists to competitors and non-competitors. Cooperation and coopetition are hence distinct organizational strategies in health care. Cooperation manifests through spin-off formation. Coopetition occurs most among organizations in the price-competitive market segment but in alternative geographical markets. Hence, coopetition in health care does not appear to be particularly anti-competitive. However, healthcare organizations seem reluctant to share their most specialized human resources, limiting the knowledge-sharing effects of this type of relation. Therefore, it remains unclear whether coopetition in health care is beneficial to patients. Keywords: Coopetition, Inter-organizational cooperation, Managed competition, Human resources, The Netherlands

Background: The sustainability of many healthcare systems in Western countries is of serious concern due to rising expenditures. In the Netherlands for example, the expenditures on medical specialist care increased with more than 55% during the past decade to more than 27 billion euros in 2016. Therefore, redesigning healthcare delivery models is high on the Dutch political agenda. In two Dutch pioneer sites, various stakeholders started experimenting with a new healthcare delivery model called Primary Care Plus (PC+). In PC+, various medical specialists perform consultations in the primary care setting in order to achieve substitution of specialised hospital care with less expensive primary care to control for rising costs. Additionally, stakeholders aim to achieve better integration between primary care and specialised hospital care by enhancing collaboration and communication between GPs and medical specialists. This should ultimately prevent unnecessary referrals to (outpatient) hospital care and consequently improve Quadruple aim outcomes. Aims and Objectives: The aim is to present and discuss the evaluation and results of the PC+ interventions in two Dutch pioneer sites measured according to the Quadruple Aim outcomes (experiences of patients and healthcare providers, population health and costs). The results are based on the evaluation, which started in 2013 and will be finished in 2018. At the ICIC 2016 in Barcelona, results of a PC+ pilot and preliminary results of the implementation of the PC+ centres were presented and during this workshop we will present the final results and lessons learned. Format: The workshop, which will be chaired by professor Dirk Ruwaard as leader of the Living Lab on Sustainable Care at Maastricht UMC+/Maastricht University, will be structured according to the Quadruple Aim outcomes in the pioneer sites for PC+ and will end with the lessons learned including recommendations for policy, practice and research. Several researchers of the Living Lab will present their work and there will be ample time to discuss the outcomes and share thoughts and experiences. Speakers: Dirk Ruwaard, Tessa Quanjel, Esther van den Bogaart, Daan Westra, Niels Hameleers and Marielle Kroese. Timing: 65 minutes presentation and 25 minutes discussion Proposed Structure 10 min: Opening: Integrated care through Primary Care Plus by Dirk Ruwaard 45 min: Quadruple aim outcomes: 10 min: Quality of care as experienced by patients by Tessa Quanjel 10 min: Experiences and satisfaction of healthcare providers by Esther van den Bogaart 10 min: Health of the population measured with health related quality of life outcomes by Marielle Kroese 15 min: Effects of PC+ on the healthcare costs by Niels Hameleers 10 min: Lessons learned by Daan Westra 25 min: Discussion (led by Dirk Ruwaard) Target audience: researchers, healthcare providers, healthcare insurers and policy makers Learnings/Take away: We will share our experiences with the audience regarding the evaluation of PC+ on Quadruple Aim outcomes and the do’s and don’ts for all stakeholders on how to start and implement new healthcare delivery models, such as PC+.

The environment of healthcare organizations is becoming increasingly uncertain. Emergent environmental threats such as the recent COVID-19 pandemic pose imminent and real risks to our societies and...

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. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

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.

In response to skyrocketing healthcare expenditures worldwide, policymakers have attempted to introduce market elements in the healthcare sectors of several countries, under the neo-classical assumption that competition will drive innovation, spur efficiency and ultimately contain costs. This chapter providers an overview of competitive forces in healthcare, their theoretical drivers, and empirical outcomes. Starting from the understanding of healthcare system configurations and the varying role of competition in different institutional and regulatory settings, the value-creating potential of competitive elements in the healthcare domain is considered. The structure of competition and its theoretical assumptions are then clarified to subsequently understand competitive outcomes, in terms of influence on entry barriers, innovation and entrepreneurial opportunities. The case of the Dutch healthcare system, the only price-competitive healthcare market in Western Europe, provides an illustrative scenario where to observe competitive dynamics and unexpected consequences of competitive triggers. An interesting entrepreneurial development is exemplified through Dutch independent treatment centers (ITCs), a form of healthcare delivery that has witnessed exponential growth after the introduction of pro-competitive regulation.

Background Emphasizing the gatekeeper role of primary care organizations is a strategy to reduce healthcare costs in several systems. Performance of primary care organizations can consequently be o...

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...

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 ...

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.

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.

Introduction: Mergers, market-entry of independent treatment centers, and new forms of collaboration and competition have surfaced since the introduction of price-competition in the Dutch specialized care sector in 2006. Such phenomena have the potential to modify competitive dynamics in healthcare markets with complex and long-term effects for integrated care, organizational performance, and patient outcomes. Particularly, since the introduction of price-competition an increasing number of hospitals are sharing specialists. Specialist sharing refers to specialists working in multiple health care organizations simultaneously, which is frequently observed in healthcare but uncommon or even prohibited in other domains. Its rise under increased competitive pressure bears the question whether specialist sharing constitutes a form of cooperation between hospitals, stimulating specialization, integrated care, and ultimately benefiting patient outcomes, or whether it is a subtle form of anti-competitive behavior. Despite its relevance, there is little to no knowledge about specialist sharing, its prevalence, the motives behind it, and its effects on patient and organizational outcomes. Our research aims to tackle these gaps by exploring the phenomenon in a price-competitive health care market, namely the Netherlands. Theory and Methods: Under price-competitive circumstances healthcare providers may use specialist sharing to increase their bargaining power, to the extreme of becoming anti-competitive. However, sharing specialists could also facilitate knowledge flow and contribute to innovation, uptake of best practices, cost reductions, and integrated care. Due to this duality, we conducted exploratory, mixed-method, research aiming to unravel the antecedents and outcomes of specialist sharing. We explored the prevalence of the phenomenon by using Social Network Analysis (SNA) 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117087– http://www.ijic.org/ to build countrywide networks of shared specialists based on AGB-codes, which identify specialists in the billing process. Next, we gathered in-depth insights into specialists’ perception towards specialist sharing through 9 qualitative semi-structured interviews with specialists in four different medical specialties (i.e. Ophthalmology, Plastic Surgery, Orthopedics, and Cardiology) in the Maastricht University Medical Center. Results and Conclusion: Our quantitative analysis shows that, although the structure of specialist sharing networks differs across medical specialties, the general prevalence is high. Our qualitative evidence highlights mixed views of specialists towards the phenomenon. They recognize the potential for learning and specialization that working for multiple institutions offers, but practical difficulties such as increased workload, time management, and deprived continuation of care make it difficult to capitalize on this potential. Unanimity does exist about the fact that specialist sharing is a decision taken at organizational level to facilitate specialization and centralization of care and to counteract competitive pressure. Specialist sharing thus strongly emerges as a form of horizontal organizational cooperation. Although payers encourage specialist sharing by providing incentives to centralize care, hospitals reportedly use it to reach new markets, decrease competitive pressure, and increase bargaining power towards the payers. These mechanisms, combined with the ambiguous quality effects, lead us to question whether horizontal cooperation through specialist sharing enhances efficient health care delivery. More research into this phenomenon is needed but meanwhile antitrust authorities should be cautious of it in competitive markets.

Introduction: In late 2013, 9 stakeholders, including the Dutch Federation of University Hospitals (NFU), the Dutch Hospital Federation (NVZ), and Top Clinical Hospitals (STZ), announced their plan to optimize delivery of oncology care in the Netherlands. In order to do so, cooperation among hospitals and between hospitals and primary care practices, in so-called ‘Comprehensive Cancer Networks’ (CCN), is to be intensified. The goal is to offer patient centered, high quality, efficient care, under increasingly cost-sensitive (e.g. competitive) circumstances. These networks should be fully functional by the end of 2015 and the NFU is said to invest an annual 2 million euro’s in their realization. In a practical sense, the CCN’s are advised to organize their care delivery based on existing regional situations. Health care providers are to agree on division of labor, standardization, diagnostics, follow-up, and referrals. However, these existing regional situations, especially in terms of division of labor among organizations and referral patterns, are unclear. Therefore, we seek to contribute to the question how oncology care is currently, informally, organized, by exploring organizational relations through patient referral networks in the Netherlands. Methods: We use over 1.3 million medical claims to build patient referral networks among secondary care providers of roughly 385 thousand oncology patients between 2008 and 2011 in the Netherlands. Using Social Network Analysis techniques, we built networks of referrals within 3, 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117092– http://www.ijic.org/ 6, and 9 months after initial diagnosis. We focus on four different tumor types, namely breast tumors, prostate tumors, colon tumors, and gynecological tumors. We characterize these patient referral networks based on network level characteristics such as the existence or absence of price competition and the types of organizations active in the network, and ode level (i.e. organizational level) measures such as centrality, density, reciprocity, and the number of cliques. Next, we statistically compare these characteristics across and within each tumor type to explore differences, and the development of referral networks over time. Results and Conclusions: We find that structures of the referral networks for oncology care differ between tumor types. Although academic medical centers play a central role across all tumor types, the role of top-clinical hospitals, general hospitals, and independent treatment centers differs depending on the tumor type. For most tumor types referrals predominantly flow towards university hospitals, for others, most notably prostate tumors, referrals are more equally distributed between different organization types. It is noteworthy that referrals can occur up to 9 months after the initial diagnosis and that most referrals are unreciprocated. That is, when a patient is referred to another medical center, they are seldom referred back to the original hospital (for example for post-surgical care). Especially the lack of such reciprocated ties shows potential for improvement through constructing CCN’s. We conclude that the existing care situation does not always match the CCN goals and we therefore advise that these networks should be critically assessed during the formalization of network structures.

Healthcare organizations commonly collaborate by sharing human resources attempting to improve quality of care and/or reduce costs. However, little is known about the effects of working at such int...

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...