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Like in most Western countries, regional health inequalities are also present in the Netherlands. Explaining these inequalities is necessary for policymakers to target interventions to reduce them. Regional health inequalities are usually attributed to demographic and socio-economic factors, while lifestyle and psychosocial factors are increasingly shown to impact individuals’ health. Therefore, this study analyses the role of lifestyle, loneliness, and self-mastery in explaining regional inequalities, in addition to demographic factors and SES, for self-rated health, presence of chronic diseases, and psychological distress. Analyses are performed in the linked dataset from the Dutch Public Health Services, Statistics Netherlands, and the National Institute for Public Health and the Environment for the year 2016 (n = 334,721). The results show that lifestyle, loneliness and self-mastery contribute to the regional health inequalities in self-rated health and presence of chronic diseases. For psychological distress, both loneliness and self-mastery contribute to the regional health inequalities. Addressing lifestyle and psychosocial factors can offer policymakers additional pathways to bridge regional health inequalities. In this study, the region of Zuid-Limburg represents the reference region. Use compare regions for health and healthcare costs (Regiovergelijker gezondheid en zorgkosten [1]) in order to select all other Dutch regions as reference region.

UNLABELLED: Healthcare costs in the Netherlands are rising and vary considerably among regions. Explaining regional differences in healthcare costs can help policymakers in targeting appropriate interventions in order to restrain costs. Factors usually taken into account when analyzing regional differences in healthcare costs are demographic structure and socioeconomic status (SES). However, health, lifestyle, loneliness and mastery have also been linked to healthcare costs. Therefore, this study analyzes the contribution of health, lifestyle factors (BMI, alcohol consumption, smoking and physical activity), loneliness, and mastery to regional differences in healthcare costs. Analyses are performed in a linked dataset (n = 334,721) from the Dutch Public Health Services, Statistics Netherlands, the National Institute for Public Health and the Environment (year 2016), and the healthcare claims database Vektis (year 2017) with Poisson and zero-inflated binomial regressions. Regional differences in general practitioner consult costs remain significant even after taking into account health, lifestyle, loneliness, and mastery. Regional differences in costs for mental, pharmaceutical, and specialized care are less pronounced and can be explained to a large extent. For total healthcare costs, regional differences are mostly explained through the factors included in this study. Hence, addressing lifestyle factors, loneliness and mastery can help policymakers in restraining healthcare costs. In this study, the region of Zuid-Limburg represents the reference region. Use compare regions for health and healthcare costs (Regiovergelijker gezondheid en zorgkosten) in order to select all other Dutch regions as reference region.SUPPLEMENTARY INFORMATION: The online version of this article (10.1007/s12508-022-00369-4) contains supplementary material, which is available to authorized users.

Health care's grand challenges, such as continuously increasing costs, challenge the sustainability of health systems. Purpose-oriented networks are considered a favorable mode of organization to address these grand challenges. Therefore, it is crucial that they are effective. While network effectiveness is a heavily theorized, multi-dimensional concept that is often measured as a perception of actors, little is known about how network actors perceive effectiveness in practice and how this influences their behavior. In this study, we explored how network actors perceive network effectiveness using 32 interviews with representatives from network member organizations and regulatory agencies actor, 28 h of network meeting observations, and 1.272 pages of documents such as meeting minutes and media outlets. Our results show that actors primarily see hard outcomes (e.g. changes in cost or quality of care) as effectiveness but given the temporal nature of these goals and difficulties quantifying them, they resort to the collaborative process as a proxy to assess effectiveness. Actors engage in networks to solve grand challenges. However, conforming to expectations and environmental pressures also play a substantial role for actors to (continue to) participate in networks. In the absence of hard outcomes, actors legitimize their continued participation in networks using the collaborative process of networks. Actors therefore take purpose-oriented networks for granted as a legitimate way of organizing. Besides attempting to solve grand challenges, networks thus also seem to be adopted because of powerful institutional rules that function as rationalized myths, to gain legitimacy. Future research should be aware of and further unravel the institutional pressures in networks.

SamenvattingNederland kent gezondheidsverschillen tussen regio’s. Het verklaren van deze verschillen kan beleidsmakers helpen om gericht te interveniëren en deze verschillen te verkleinen. Bij het verklaren van deze regionale gezondheidsverschillen wordt veelal gekeken naar de bijdrage van verschillen in demografische opbouw en sociaaleconomische status (SES). Tegelijkertijd worden leefstijl en psychosociale factoren ook in verband gebracht met de gezondheid van het individu. Daarom analyseert dit onderzoek, naast demografie en SES, de bijdrage van leefstijl, eenzaamheid en zelfregie aan de verklaring van regionale verschillen in zelfervaren gezondheid, aanwezigheid van chronische ziekten en het risico op het ontwikkelen van een angststoornis of depressie. We gebruiken daarvoor een gekoppelde dataset van de GGD, het CBS en het RIVM voor het jaar 2016 (n = 334.721). Uit de resultaten blijkt dat leefstijl, eenzaamheid en zelfregie ook bijdragen aan het verklaren van regionale verschillen in zelfervaren gezondheid (prevalentieratio’s (PR) variërend van 0,72–0,93 tot 0,83–0,95) en chronische ziekten (PR’s van 0,81–0,95 tot 0,85–0,96). Voor het risico op een angststoornis of depressie blijken vooral eenzaamheid en zelfregie bij te dragen aan de verklaring van regionale gezondheidsverschillen (oddsratio’s van 0,65–1,27 tot 0,76–1,22). Leefstijl- en psychosociale factoren kunnen dan ook beleidsmatige aanknopingspunten bieden voor de aanpak van regionale gezondheidsverschillen. In dit artikel is de regio Zuid-Limburg de referentieregio. Met de Regiovergelijker gezondheid en zorgkosten kunnen alle regio’s als referentieregio worden gekozen.

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.

Networked forms of organizing in health care are increasingly viewed as an effective means of addressing "wicked", multifaceted health and societal challenges. This is because networks attempt to address these challenges via collaborative approaches in which diverse stakeholders together define the problem(s) and implement solutions. Consequently, there has been a sharp increase in the number and types of networks used in health care. Despite this growth, our understanding of how these networks are governed has not kept pace. The purpose of this chapter is to chart a research agenda for scholars who are interested in studying health care network governance (i.e., the systems of rules and decision-making within networks), which is of particular importance in deliberate networks between organizations. We do so based on our knowledge of the literature and interviews with subject matter experts, both of which are used to identify core network governance concepts that represent gaps in our current knowledge. Our analysis identified various conceptualizations of networks and of their governance, as well as four primary knowledge gaps: "bread and butter" studies of network governance in health care, the role of single organizations in managing health care networks, governance through the life-cycle stages of health care networks, and governing across the multiple levels of health care networks. We first seek to provide some conceptual clarity around networks and network governance. Subsequently, we describe some of the challenges that researchers may confront while addressing the associated knowledge gaps and potential ways to overcome these challenges.

While purpose-oriented networks are widely recognized as organizational forms to address wicked problems in health care such as increasing demands and expenditure, the associated literature is fragmented. We therefore reviewed empirical studies to identify the determinants of the effectiveness of these networks. Our search yielded 3,657 unique articles, of which 19 met our eligibility criteria. After backward snowballing and expert consultation, 33 articles were included. Results reveal no less than 283 determinants of effective health care networks. The majority of these determinants are processual and involving professionals from the operational level is particularly salient. In addition, most studies relate determinants to process outcomes (e.g., improved collaboration or sustainability of the network) and only a few to members’ perception of whether the network attains its goals. We urge future research to adopt configurational approaches to identify which sets of determinants are associated with networks’ ability to attain their goal of addressing wicked problems.

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.

Background: Despite a lack of supporting evidence, hospitals continue to merge in pursuit of quality improvements. Purpose: We seek to develop a more thorough understanding of the quality effects of hospital mergers by integrating various theoretical perspectives using a mixed-methods design. Methodology: Quantitatively, we tested the quality effect of all consummated hospital mergers in the Netherlands between 2008 and 2014 on 15 quality indicators (with 82 measurements at hospital, department, and disease levels) using a difference-in-difference approach with Bonferroni correction. Qualitatively, we conducted three comparative case studies to examine how hospital executives, managers, and medical professionals perceive the quality impact of hospital mergers. Results: Our quantitative results reveal few significant effects of hospital mergers on quality of care at all levels. After applying Bonferroni correction, two quality indicators are negatively associated with hospital mergers. However, the qualitative results indicate that hospital staff have positive perceptions of the mergers’ quality implications, resulting from scale and shock effects. Conclusion: The perceptions of hospital staff regarding mergers diametrically oppose their measurable effects. However, the operationalization of quality by hospital staff members differs considerably from the way it is quantitatively measured. The positive perceptions of hospital staff toward mergers could further contribute to the institutionalization of mergers as a quality improvement strategy. Practice Implications: Hospital managers seeking measurable quality improvements should be wary of merging, despite potential positive perceptions toward it within the organization. In case they do decide to merge, mitigating difficulties in the postmerger integration processes seem most pertinent to achieve measurable effects

Loneliness is a growing public health issue. It is more common in disadvantaged groups and has been associated with a range of poor health outcomes. Loneliness may also form an independent pathway between socio-economic disadvantage and poor health. Therefore, the aim of this study was to explore the contribution of loneliness to socio-economic health inequalities. These contributions were studied in a Dutch national sample (n = 445,748 adults (≥19 y.o.)) in Poisson and logistic regression models, controlling for age, gender, marital status, migration background, BMI, alcohol consumption, smoking, and physical activity. Loneliness explained 21% of socioeconomic health inequalities between the lowest and highest socio-economic groups in self-reported chronic disease prevalence, 27% in poorer self-rated health, and 51% in psychological distress. Subgroup analyses revealed that for young adults, loneliness had a larger contribution to socioeconomic gaps in self-rated health (37%) than in 80+-year-olds (16%). Our findings suggest that loneliness may be a social determinant of health, contributing to the socioeconomic health gap independently of well-documented factors such as lifestyles and demographics, in particular for young adults. Public health policies targeting socioeconomic health inequalities could benefit from integrating loneliness into their policies, especially for young adults.

Maintaining hospital workers’ psychological health is essential for hospitals’ capacities to sustain organizational functioning during the COVID-19 pandemic. Workers’ personal resilience can be an important factor in preserving psychological health, but how this exactly works in high stakes situations, such as the COVID-19 pandemic, requires further exploration. Similarly, the role of team social climate as contributor to individual psychological health seems obvious, but how it exactly prevents workers from developing depressive complaints in prolonged crises remains under investigated. The present paper therefore applies conservation of resources theory to study the relationships between resilience, team social climate, and depressive complaints, specifically focusing on worries about infections as an important explanatory mechanism. Based on questionnaire data of 1126 workers from five hospitals in the Netherlands during the second peak of the pandemic, this paper estimates a moderated-mediation model. This model shows that personal resilience negatively relates to depressive complaints (β = −0.99, p &lt, 0.001, 95%CI = −1.45–−0.53), partially as personal resilience is negatively associated with worries about infections (β = −0.42, p &lt, 0.001, 95%CI = −0.50–−0.33) which in turn are positively related to depressive complaints (β = 0.75, p &lt, 0.001, 95% CI = 0.31–1.19). Additionally, team social climate is associated with a lower effect of worries about being infected and infecting others on depressive complaints (β = −0.88, p = 0.03, 95% CI = −1.68–−0.09). These findings suggest that resilience can be an important individual level resource in preventing depressive complaints. Moreover, the findings imply that hospitals have an important responsibility to maintain a good team social climate to shield workers from infection related worries building up to depressive complaints.

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

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.

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.

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: 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...

Sinds de invoering van de Jeugdwet in 2015 zijn Nederlandse gemeenten bestuurlijk en financieel verantwoordelijk voor de gezondheidszorg voor de jeugd. De Jeugdwet vervangt niet alleen de wet op de jeugdzorg, maar ook de verschillende andere onderdelen van de jeugdzorg die onder de Zorgverzekeringswet (geestelijke gezondheidszorg voor jongeren) en de Algemene Wet Bijzondere Ziektekosten (zorg voor licht verstandelijk beperkte jeugd) vielen. Ook de jeugdbescherming en jeugdreclassering maken onderdeel uit van de wet. Het doel van Jeugdwet is het verbeteren van eigen kracht van jeugdigen en hun ouders, meer ambulante zorg inzetten in plaats van dure specialistische hulp, het versterken van het opvoedkundig klimaat en gezinnen ondersteunen via een geïntegreerde aanpak. De jeugdzorg bestaat voor een deel uit curatieve geestelijke gezondheidszorg voor kinderen en jongeren onder de 18 jaar; de zogenoemde jeugd-GGZ. Dit rapport beschrijft een onderzoek naar het gebruik van de jeugd-GGZ (in Zuid-Limburg). De jeugd-GGZ werd tot 2014 onderverdeeld in eerstelijns en tweedelijns GGZ en sinds 2014 in generalistische basis GGZ en gespecialiseerde GGZ. Sinds de introductie van de Jeugdwet zoeken gemeenten naar manieren om de jeugd-GGZ goed en efficiënt te organiseren. Veel gemeenten besteden daarbij aandacht aan het verbeteren van de samenhang tussen de jeugd-GGZ en het sociale domein om zo vroeg mogelijk de juiste hulp op maat te kunnen bieden. Hoewel uit verschillende studies blijkt dat het gebruik van jeugdzorg in Zuid-Limburg hoger is dan in andere delen van Nederland, zijn er weinig verklarende studies uitgevoerd, voornamelijk met betrekking tot de jeugd-GGZ. De 18 gemeenten in Zuid-Limburg hebben de Universiteit van Maastricht gevraagd om het gebruik van jeugd-GGZ in de regio Zuid-Limburg te onderzoeken.