Abstract
Background: In healthcare systems with a provider-payer split, contracting is key in delivering integrated care. Currently, most provider-payer contracts are transactional in nature, characterized by extensive terms, short durations, and a focus on price over quality. This approach hinders trust and collaboration, thereby impeding integrated care efforts. In contrast, relational contracting, which emphasizes cooperation and mutual dependence, holds significant potential as a foundation for multidisciplinary integrated care. Although relational contracting has demonstrated success in other sectors, it remains underutilized in healthcare settings.
Approach: The study aims to explore stakeholders' perspectives on relational contracting within the Dutch hospital-insurer relationship. We conducted 18 semi-structured interviews with healthcare purchasers from insurance companies, hospital sales representatives, CEOs, policy advisors, and a physician. Additionally, an in-person focus group with 7 representatives from both payer and provider organizations was held to foster open discussions, encouraging diverse viewpoints. All interviews were transcribed and analyzed through open and descriptive coding to identify key themes.
Results:
The results of our study indicate that within the Dutch healthcare system:
1.Respondents described the relationship between health insurers and hospitals as akin to a ""forced marriage."" Insurers are obligated to purchase adequate care for their enrollees, while hospitals rely on insurers for financial viability. This dynamic undermines the intrinsic motivation to establish sustainable, long-term partnerships.
2.Hospitals generally do not adjust quality or accessibility based on the specific insurer with whom a patient is enrolled, which shifts negotiations to financial terms. This financial focus is exacerbated by a competitive insurance market focused on the lowest premiums, making it challenging for hospital and insurer to align on shared goals.
3.Respondents identified tight deadlines, social and political pressures, and heavy workloads due to the multitude of insurers and hospitals involved as factors that complicate the contracting process, particularly in a tight labor market and with a high volume of involved stakeholders.
4.Despite these challenges, most respondents viewed relational contracting as a promising, even necessary, development, especially when insurers and hospitals have substantial mutual interest in terms of patient volume. To facilitate this, greater congruency in the contracts between providers and several insurers is essential.
Implications: We conclude that although the healthcare market is in many ways more complex than other sectors, relational contracting holds significant potential in future-proofing the healthcare landscape and facilitating integrated care. Based on the results, we developed a six-step road map for establishing a relational contract in a multi-payer, competition-based healthcare system:
1.Build trust through transparency regarding interests and expectations, and secure internal support.
2.Collaboratively analyze regional challenges and develop a shared vision with mutual goals.
3.Formulate a long-term partnership agreement that encapsulates the spirit of the partnership.
4.Annually update the contract to reflect recent developments in pricing, innovations, and regulations.
5.As a Provider, ensure congruency with the other payers on payment models and procedures for care delivery.
6.Maintain alignment by robust governance and monitoring of developments in the market.