Substitution of care through the eyes of Dutch health insurers: a qualitative study

Abstract

Abstract Objectives The objective of health policy measures in the Netherlands is to promote the substitution of care from hospitals to general practitioners (GPs), with reimbursement facilitating this shift. Given that health insurers are tasked with healthcare reimbursement in the Netherlands, understanding their experiences regarding care substitution is crucial. Methods First, informal interviews were held with employees from the Dutch Ministry of Health, Welfare and Sports, the National Health Care Institute and the Netherlands Institute of Health Services Research to construct the topic list. Then, we conducted semi-structured interviews with 15 employees from 7 health insurers, including healthcare purchasers, strategists, client relations executives, and business analysts, between February and April 2024. Transcripts were analyzed in MAXQDA by two researchers, after member checking. Results Insurers navigating substitution face a complex interplay of competition and collaboration, lacking a comprehensive framework. Long-term agreements with hospitals and GPs are seen as potential solutions, contingent on building trust. Diverse views on insurers’ roles emerge, from passive reimbursement to active infrastructure support. Budgetary constraints vary, with some insurers feeling constrained by national budgets for GPs and hospitals while others perceive more flexibility. Risks equalization and deductibles are identified as hindrances to substitution efforts, necessitating changes in financial incentives. Conclusions Overall, addressing these complexities requires aligning incentives and balancing collaboration and competition to optimize resource allocation to effectively meet evolving healthcare needs. A comprehensive framework to balance collaboration and competition might be helpful. Key messages • Understanding insurers’ views on care substitution is vital for healthcare policy in the Netherlands. • A comprehensive framework is needed to balance collaboration and competition, aligning incentives effectively.