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Background: Despite a lack of supporting evidence, hospitals continue to merge in pursuit of quality improvements. Purpose: We seek to develop amore thorough understanding of the quality effects of hospitalmergers 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. [ABSTRACT FROM AUTHOR]

Social participation may improve the health and well-being of older adults, and may increase the social and human capacity of their communities. This study investigates the level and forms of social participation among older adults (aged 55 years or older) in the region of South Limburg, the Netherlands, and their association with socio-demographic and health-related characteristics. The study provides evidence that can be used by policy makers to enhance social participation in the region. We use cross-sectional data collected in a survey in 2012 among a sample of older adults (aged 55 years or older) representative for the region of South Limburg. The results indicate that 56% ( N = 16,291/weighted sample N = 213,332) of the older adults in the region participate in social activities. Specifically, 25.5% perform paid labour, 20% give informal care and 25% participate in volunteer work. Older adults with a higher education ( OR = 2.49 for the highest education group) or higher income ( OR = 1.70 for the highest income group) are significantly more likely to participate in social activities compared with the respective reference categories. Increased age ( OR = 0.23 for the oldest age group), female gender ( OR = 0.83), loneliness ( OR = 0.75 for severe loneliness) and restrictions ( OR = 0.78 for restrictions on the OECD scale, OR = 0.68 for restrictions on the HDL scale, OR = 0.52 for transportation restrictions) significantly hinder social participation. The lower social participation rate among older adults that we observe compared with the national statistics can be explained by the relatively higher proportion of people with low or average socioeconomic status in South Limburg. And as South Limburg is the unhealthiest region of the Netherlands, this also contributes to the low social participation. Prevention of poor physical and mental health, and provision of care services are important to encourage social participation among the older adults in South Limburg. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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) 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. [ABSTRACT FROM AUTHOR]

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, 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. [ABSTRACT FROM AUTHOR]

Introduction: Literature is ambiguous towards the effect of price competition in healthcare. The year 2006 marked the introduction of several pro-competitive healthcare policy reforms in the Netherlands, in order to improve the price-quality ratios of delivered care. Currently, price is negotiable for 70% of hospital services. Although several new players have entered the market since 2006, it remains unclear to what extent healthcare providers actually compete or cooperate (i.e. integrate) in order to deliver the best and most efficient care. Methods: To investigate the behaviour of healthcare providers, we examined specialist networks. A cooperative relation between providers is established when a specialist simultaneously works for two or more providers. We consider such collaborative structures as forms of integration between providers. Using longitudinal social network analysis, we analyse horizontal integration behaviour of 5 medical specialties (dermatology, cardiology, neurology, internal medicine, and orthopaedics) between 2005 and 2013. Results and Conclusions: Preliminary evidence indicates that specialists' affiliation to multiple organizations has become increasingly widespread after the introduction of price-competitive policies. The resulting inter-organizational networks present significant variation across specialties and over time. The findings highlight that price-competitive regulation has triggered more cooperation between healthcare organizations through specialist sharing, which can have important implications for policymakers, practitioners, and the level of integrated care. [ABSTRACT FROM AUTHOR]