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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.

Innovation is widely recognized as an important means of tackling challenges that face healthcare systems. But innovation can only succeed in this role if financial conditions allow innovations with high societal value to be developed and implemented. This study is an in-depth examination of the role of payment mechanisms throughout the innovation process, from the perspective of innovators. We conducted a comparative case study of four innovation projects, two involving medical devices and two involving health information technologies, all of which originated from academic settings. Although financial factors were found to have impeded the progress of innovative products at every step in the innovation process, this effect appears to have been strongest during the implementation phase. The perceived commercial value of an innovative product was a key factor in obtaining sufficient payment. Innovative products with potentially significant societal value but limited commercial value are unlikely to become structurally embedded in practice, or to be scaled up beyond the local level. The study reveals four additional factors that affect progress through the healthcare innovation process: compatibility of the innovation with existing practice, and commitment, competences, and social capital of the innovator. We identify a number of lessons for policy and practice that we believe would increase the likelihood of innovations with potentially significant societal value to achieve widespread implementation. These lessons reflect three key issues identified in our research: 1) shift the focus from commercial value towards societal value; 2) support dissemination of innovations beyond the local level; 3) help innovators to convey their valuable ideas.

Bismarckian health systems are mainly governed by social health insurers, but their role, status, and power vary across countries and over time. We compare the role of health insurers in three distinct social health insurance systems in improving health systems' efficiency. In France, insurers work together as a single payer within a highly regulated context. Although this gives insurers substantial bargaining power, collective negotiations with providers are highly political and do not provide appropriate incentives for efficiency. Both Germany and the Netherlands have introduced competition among insurers to foster efficiency. However, the rationale of insurer competition in Germany is unclear because contracts are mostly concluded at a collective level and individual insurers have little power to influence health system efficiency. In the Netherlands, insurer competition is substantially more effective, but primarily focused on price and cost containment. In all three countries, the role of insurers has been transforming slowly to respond to common challenges of assuring care quality and continuity for an ageing population. To assure sustainability, they need to ensure that care providers cooperate with the same quality and efficiency objectives, but their capacity to do so has been limited by insufficient support to enforce public information on provider quality.