Understanding specialist sharing: a form of horizontal cooperation stimulating integrated care or an antitrust risk for competitive healthcare markets?

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]