Table 4.

Description of the level of integration expected to result from the proposed payment model.

Domain (Level)	Explanation
Target population (2)	The currently used payment model only focusses on people with either DM2, COPD, or CVRM. The alternative payment model includes care for all three chronic diseases in one bundle and additional disease-transcending care. The alternative payment model focuses on a much wider population; therefore, the level of integration moves from 1 to 2.
Time (3)	In the currently used payment model, agreements about the budget are made for one year. We recommend making agreements for multiple years. The collaboration becomes stronger and the mutual trust between primary care cooperative and health insurer increases. Agreements for a longer time span also create more possibilities to innovate and investigate the potentials of the alternative payment model; therefore, the level of integration moves from 2 to 3.
Sectors (2.5)	The currently used payment model focusses on primary care. Secondary care is incorporated, but is rather limited and only includes a single consultation by a specialist for a small proportion of the target population. The aim of the alternative payment model is to finance care from all sectors (primary, secondary, tertiary care, and the social domain). The primary care cooperative is a coordinating organ, so also non-financial agreements could be made with, for instance, the municipality about the social care domain. Both the SDMP and the PC-IC programme include preventive interventions like smoking cessation support and lifestyle interventions, but so far these have not been covered by the bundled payment for SDMP. Therefore, the level of integration moves from 1.5 to 2.5.
Provider coverage (2.5)	The providers covered by the currently used payment model are the practical nurse, the GP, the dietician, the foot therapist, the physiotherapist, and a consultation with a medical specialist. In the alternative bundled payment, we propose to expand the scope to include all services that are part of the personal care plan (Figure 3). All other healthcare utilization is included in the virtual budget (Figure 2); therefore, the level of integration moves from 1.5 to 2.5.
Financial pooling/sharing (2)	In the currently used payment model, the primary care cooperative and health insurer do not usually have agreements about sharing savings or losses. These savings or losses are estimated by comparing a virtual budget (i.e., the expected expenditures) to the real expenditures. We advise to start with a one-sided shared savings model, and therefore, the level of integration moves from 1 to 2.
Income (1)	The alternative payment model for PC-IC will not drastically change the income of the individual health care provider. The budget for chronic care of the GP practice increases as the target population increases, but at the same time less care will be financed through FFS. The net result depends on the details of the contract.
Multiple diseases/needs focus (2.5)	The currently used payment model finances disease-specific care. The alternative payment model includes all services that are part of the personal care plan (Figure 3). At the start, the model will pertain to people with DM2, CVRM, and/or COPD, but once a patient is incorporated into the PC-IC programme, the patient will be fully assessed on six domains (Figure 1). Therefore, the level of integration moves from 1 to 2.5.
Quality measurement (2.5)	In the currently used SDMP, the quality of care is assessed by InEeN, which delivers an annual report about the quality of chronic care. The quality indicators are determined by the Dutch GP society (NHG) and mostly include process indicators (e.g., if the smoking status is registered). The currently used bundled payment is not related to performance on these indicators. In the alternative payment model, we aim to measure quality of care on outcome indicators (e.g., health-related quality of life) and patient satisfaction. The ratio that is used to share savings between the health insurer and the primary care cooperative will depend on the delivered quality of care. Therefore, the level of integration moves from 1 to 2.5.