Exploring facilitators and barriers in the financial model of hospitals: a qualitative case study on prehabilitation from the Netherlands

Abstract

Objectives

To explore facilitators and barriers in the financial model of hospitals when a change in a care pathway is implemented.

Design

A qualitative research reported according to the Consolidated Criteria for Reporting Qualitative Research.

Setting

Five hospitals in the Netherlands, between February and September 2023.

Participants

28 interviewees with 7 different stakeholders: (director of) healthcare procurement, contracting manager, financial, business or project manager, physical therapist, board of Medical Consultant Group and surgeon.

Results

The absence of permanent funding in the hospital reimbursement model and the allocation of available resources in the internal hospital distribution model are the two most important barriers when implementing prehabilitation for patients with colorectal cancer. The main facilitator was found to be the internal provision of spare budget. Lump sum agreements are the preferred contract type because they may facilitate internal substitution of budgets according to need. Bundling primary and hospital care funding is recommended to overcome barriers in the financial model. Activity-based budgeting is the preferred budgeting method because budgets can be adjusted over time according to costs. Cost reduction can only be achieved when prehabilitation is offered to more patients. In addition to an appropriate financial model, preconditions like the involvement of a medical specialist and sense of urgency in the organisation should also be arranged.

Conclusions

The financial model of hospitals may affect the implementation of changes in care pathways. Despite barriers in both the reimbursement and the distribution model, it is possible to facilitate this transformation.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The qualitative approach with semistructured interviews is well suited for a broad exploration of a relatively new topic in the literature: the intersection of the reimbursement and distribution model in hospitals.

• To ensure the trustworthiness of the analysis, all interviews were conducted by one researcher trained in qualitative methods, transcribed verbatim and coded by two researchers based on an inductive approach.

• Although it can be seen as a limitation that only three interviews took place with health insurers, the large market share of these insurers ensures that this perspective is adequately covered.

Background

Globally, healthcare costs are rising.¹ Hospital care is the largest cost component and accounts for approximately 40% of total healthcare spending in 2021.² Accessibility of hospital care is under pressure.³ Knowledge about how the complex financial models of hospitals are used in the real world is scarce. This research aims to explore facilitators and barriers in the financial model of hospitals when implementing changes in care pathways.

The financial model of hospitals consists of two parts: (1) a reimbursement model that funds their operations and (2) a distribution model that allocates how these funds are spent.⁴ Reimbursement mechanisms for hospitals vary worldwide.^{5 6} In addition, the internal distribution of budgets in hospitals differs at least as much and typically also deviates sharply from the reimbursement mechanism. Research shows that the correlation between reimbursement and distribution of budgets in hospitals is limited, leading to a difficult-to-comprehend web of cross-subsidies.⁴

To meet the challenges of increasing staff shortages and financial pressure, more efficiency in care processes is necessary.⁶ For this purpose, a variety of innovations has been studied and implemented. For example, the use of medical devices, health information technologies or changing care pathways.^{7 8} When implementing these initiatives, permanent reimbursement is often not (yet) available for hospitals. Temporary resources, for instance, research funds, may be an option for initiatives conducted in a research setting.

Everyone who lives or works in the Netherlands is entitled to basic health insurance.⁹ Physical therapy can be offered in primary care and in a hospital setting.¹⁰ Insurance for physical therapy is limited to specified chronic diseases, with the first 20 treatments being at the patients’ own expense.^{11 12} It is possible to purchase supplementary insurance for physical therapy.¹³ To qualify for reimbursement, care must meet the ‘state of science and practice’. This requirement means that there is sufficient evidence, preferably from (worldwide) scientific research and that care for this condition, disease or diagnosis is safe and effective in the long term.⁹ As a result, obtaining a claim title within the basic health insurance is a multiyear process. This lengthy process contributes to appropriate considerations for insured care in the Netherlands. But it is difficult to find a good balance between sufficient evidence and duration of implementation. Changes in care pathways that contribute to more efficient care by reducing staffing and/or financial resources do not necessarily qualify for a claim title based on the specified conditions. In the long run, this should not be a problem, given the expectation that the requirements will be met. However, in the short term, costs often precede benefits. Nevertheless, innovations have been implemented successfully in hospitals. In our study, we aim to gain knowledge about facilitators and barriers within the financial model of hospitals to implement changes in care pathways when permanent reimbursement is not (yet) available.

We intend to examine practical experiences by using a case that entails a change in the care pathway for which (a) there is no claim title available (yet), (b) which has been implemented in practice in multiple hospitals in the Netherlands, (c) where patient outcomes are expected to at least not worsen (ideally improve), (d) where more efficient use of capacity, staff and finances is expected and (e) which affects the various components in the financial model of hospitals, that is, it affects both the reimbursement and distribution model.

Prehabilitation for patients with colorectal cancer in the Dutch context was identified as an appropriate case for this study because it is a multimodal treatment of patients before surgery, with the aim to improve postoperative outcomes.^{14 15} Efforts to improve functional capacity prior to surgery are referred to as a tertiary preventive strategy.^{16 17} In prehabilitation, the programme involves exercise training under the supervision of a physical therapist, nutritional intervention, smoking cessation and psychological support.^{18 19} Colorectal cancer is a common type of cancer, with a high complication rate after surgery.¹⁸ Prehabilitation for patients with colorectal cancer may result in reduced length of stay, fewer days in Intensive Care Unit (ICU) and a decrease in the number of patients with complications.²⁰ This might allow a reduction in the use of scarce hospital personnel, as well as in hospital costs. Prehabilitation for patients with colorectal cancer is a relatively new treatment; therefore, evidence for better outcomes is inconclusive.1420,22 But there is already considerable evidence on the positive effects of lifestyle interventions prior to surgical procedures. Therefore, prehabilitation is expected to at least not worsen the health status of patients with colorectal cancer. Despite increasing evidence that prehabilitation for patients with colorectal cancer may reduce hospital costs and staffing, it is in the Netherlands not reimbursed within regular hospital funding.²³ Nevertheless, there are several hospitals in the Netherlands where this treatment is offered to patients.

By implementing prehabilitation, all aspects of the financial model of hospitals may be affected; both the revenues in the reimbursement model may change when length of stay is reduced, and costs may shift from postoperative clinical care to preoperative (primary) physical therapy. Therefore, experiences in hospitals where prehabilitation for patients with colorectal cancer is implemented may provide valuable insight into facilitators and barriers of the financial model of hospitals. In addition, the Dutch context provides for a broad variation of contract types between insurers and providers, as well as different budgeting methods in hospitals. In the Netherlands, hospital care is financed by DTCs (Diagnosis Treatment Combinations, translated from Dutch: Diagnose-BehandelCombinatie), a DRG-based hospital payment system.^{24 25} Agreements are made between health insurers and hospitals regarding the prices of the DTCs. The most frequently used contract types are lump sum agreements wherein revenues are received regardless of the amount of care provided, and price*volume agreements in which more treatments result in more revenue (often with a cap or adjusted prices above the cap).²⁶ Different models are also used for the distribution of budgets in hospitals. The most common models are activity-based budgeting (ABB) with budgets based on actual calculated costs and expected production, direct budget distribution: direct allocation of budget for specific (one-time) expenses and incremental budgeting (IB) based on historical budgets.⁴

There are several DTCs that can be claimed for the treatment of a patient with colorectal cancer. Due to inconclusive evidence for better outcomes, reimbursement within these DTCs does not include prehabilitation costs. As a result, facilitators and barriers of different reimbursement and distribution models may be identified.

Although it is assumed that changing care pathways contributes to efficiency in hospital care, implementation is often complex. Knowledge on how financial models come into play is limited. Based on the successful implementation of an innovation that is not (yet) reimbursed, the aim of this study is to gain insight into facilitators and barriers in the financial model of hospitals. The results might help effectuate and achieve cost reduction in hospitals. Furthermore, these insights may contribute to future efforts to implement new treatment options and care pathways, with the purpose of improving efficiency in hospital care.

Methods

Design

We developed a conceptual framework based on the financial model for Dutch hospitals. The financial model of hospitals consists of three components: (1) the reimbursement model which refers to contract agreements with health insurers, (2) the internal distribution model, concerning the annual budget allocation (to departments) and (3) the external distribution model (towards self-employed physicians).⁴ The external distribution model is a specific characteristic of some Dutch hospitals. In teaching hospitals and general hospitals, 65% of the medical specialists are self-employed and united in associations, so-called Medical Consultant Groups (MCGs).²⁷ Financial output of the hospitals is considered to be the product of both the reimbursement and the distribution model.⁴

The conceptual framework, as shown in figure 1, contains the three components of the financial model for hospitals. This framework was used as an outline for the semistructured topic guide. This study was reported according to the Consolidated Criteria for Reporting Qualitative Research.²⁸ The completed checklist can be found as online supplemental file 1.

Figure 1. Conceptual framework for facilitators and barriers in hospitals.

Considering other constraints in the system, factors not directly related to the financial model and recommendations were included as a topic in the topic guide. Online supplemental file 2 presents the topic guide for the interviews.

Participants and procedures

A purposive sampling method was used to select five hospitals representing the different types in the Netherlands. Prerequisite was that prehabilitation was offered to patients with colorectal cancer. One out of 7 academic hospitals, 2 out of 27 teaching hospitals and 2 out of 29 general hospitals were recruited.29,31 It has been determined that these hospital types typically use different combinations of reimbursement and distribution models.⁴

To gain an in-depth insight into perceived facilitators and barriers of the financial model, we focused on a diverse set of stakeholders, each with their own vantage point on the financial model of hospitals, in the five hospitals. Three major health insurance companies, representing 74.3% of the insured citizens, were selected.³² Due to the specific selection of interviewees, some of them were part of the researcher’s network. A qualitative approach with semistructured interviews was chosen, as this enables a broad exploration of perspectives and experiences of these individuals and their context.³³

In figure 1, the red blocks represent the position in the financial model of hospitals of the preferred study participants. The (director of) healthcare procurement has an external view to the hospital from the reimbursement model. Conversely, the contracting manager’s perspective is from the hospital to the reimbursement model. In the internal distribution model, the financial has an internal provider focused view, where the business or project manager has a more narrow view on the financials of their own business unit. The perspective of the physical therapists on the financial model is complementary given their positioning in primary care and in the hospital setting. Finally, the board of MCG members and the surgeons’ perspectives are from the external distribution model, as this is their main source of income. In addition, the surgeons’ perspective, also when employed by the hospital, is the medical content. The latter perspective is more distanced from the financial model.

Five pilot interviews with different stakeholders were held in one hospital. This confirmed that interviewees had adequate knowledge about the topics. We expanded the topic guide to gain insight into the potential to create substantial impact. Furthermore, we decided against providing the conceptual framework in advance. In some pilot interviews, sharing this framework led to general statements about hospital financing in the Dutch healthcare system rather than an explanation of the interviewees’ experience in the implementation of prehabilitation for patients with colorectal cancer.

Data collection and analysis

Potential interviewees were invited via email which included an explanation of the purpose of the interview. The interviews took place from February to September 2023 and were conducted in person at the interviewee’s workplace, except for two online interviews. All interviews were conducted by one female researcher trained in qualitative methods (LVLvL). The interviews were recorded with permission of the interviewees and lasted 33 min on average (17–48 min).

The interview recordings were transcribed verbatim by a third party and overseen by LVLvL. In Atlas.ti V.23 and Atlas.ti Web, the interviews were coded based on a coding list derived from the topic guide (online supplemental file 2). Within this coding, which represents the main components of the financial model of hospitals, the various facilitators and barriers mentioned were analysed based on an inductive approach. To avoid bias, coding was performed individually by two researchers (VAV and LVLvL). Discussions of the data further refined the definitions of the coding list.

Patient and public involvement

Patients and or public were not involved in the conduct of this study.

Results

A total of 32 potential participants were approached through the research group’s network and by referrals from the interviewees in hospitals. Of these, one indicated not to participate due to lack of time. With two potential participants, scheduling issues arose. Ultimately, 29 interviews took place, after which complete saturation was achieved. Of the 29 interviews, one was not included in further analysis because the role and responsibilities of the interviewee were not comparable to other participants. During analysis, this interview was found to have no added value for this study. As a result, 28 interviews were included with various stakeholders (table 1).

Table 1. Participants.

Organisation	Stakeholders’ position	Description	Number of interviews	Referred to as
Hospital	Contracting manager	Bears responsibility for the negotiations and contract arrangements with health insurers	5	CM
Hospital	Financial	Responsible for technical processing of budget distribution in the hospital	5	Financial
Hospital	Business or project manager	Business or project manager with financial responsibility for a business unit or project	5	BPM
Hospital	Surgeon	Medical specialist who performs the surgery, responsible for quality of care and outcomes	4	Surgeon
Hospital	Physical therapist	Involved in design and delivery of physical therapy care in and/or outside the hospital	4	PT
Hospital	Board of MCG member	Responsible for financial arrangements between hospital and MCG	2	MCG
Health insurer	(Director of) healthcare procurement	Bears responsibility for contract arrangements with hospitals	3	HP
Total			28

MCG, Medical Consultant Group.

Based on coded data from these 28 interviews, the different components of the financial model (green in figure 1) were analysed. Successively, results will be presented regarding (1) the reimbursement models, (2) the distribution models and (3) financing of physical therapy care. Finally, (4) results on other factors not directly related to the financial model will be addressed.

Reimbursement models

The conceptual framework in figure 1 shows that hospitals may use different contract types in their reimbursement model. Because prehabilitation for patients with colorectal cancer is not part of basic health insurance, separate funding must have been made available in all hospitals. Table 2 shows the dominant contract type used as well as the main reimbursement source for prehabilitation per included hospital in this study.

Table 2. Contract types, budgeting methods and funding for prehabilitation.

Hospital	1	2	3	4	5
Dominant contract type	Lump sum	P*Q agreement with a maximum cap	P*Q agreement with a maximum cap	P*Q agreement with adjusted prices above a maximum cap	Lump sum and P*Q agreement with a maximum cap
Reimbursement for prehabilitation	Internal budget and grants	Policy rule* under cap and grants	Policy rule* above cap and internal budget	Affiliation agreement on the policy rule† under cap, grants, and internal budget	Internal budget
Reimbursement facilitators (F) and barriers (B)	F: substituted within lump sum budgetB: incentive for hospital to lean back	F: treatment costs are reimbursedB: temporary, not all insurers and upscaling	F: treatment costs are reimbursedB: temporary, not all insurers and upscaling	F: treatment costs are reimbursedB: temporary, not all insurers and upscaling	F: treatment costs are reimbursedB: temporary, not all insurers and upscaling
Dominant budgeting method	Incremental budgeting (IB)	Activity-based budgeting (ABB)	IB	ABB	IB
Internal distribution for prehabilitation	Budgets passed between RVEs, funding within existing budget.	Policy rule not reflected in budget. Funding within existing budget. After several years, the budget was adjusted by methodology. Additional authorised budget overrun‡.	Funding within existing budget and separately available internal policy resources budget for incidental start-up costs.	Affiliation agreement budget is available. Temporarily supplemented with internal innovation fund and authorised budget overrun‡. After several years budget was adjusted by methodology.	Budgets passed between departments. Restricted internal innovation budget available for start-up costs.
Distribution facilitators (F) and barriers (B)	F: relatively uncomplicated internal budget availableB: internal budget is limited and temporary, no structural adjustment in budget, no incentive to organise efficiently	F: budget adjustmentB: delay in the budget method	F: relatively uncomplicated budget availableB: internal budget is limited and temporary, no structural adjustment in budget, no incentive to organise efficiently	F: relatively uncomplicated internal budget available, budget adjustmentB: delay in the budget method	F: relatively uncomplicated internal budget availableB: internal budget is limited and temporary, no structural adjustment in budget, no incentive to organise efficiently
Paramedical care	Internal (hospital) and external network (primary care)	Internal (hospital) and seven external practices (primary care)	External oncology physical therapists when possible (primary care)	Internal (hospital)	Internal (hospital) intake, external regional network when possible (primary care)
Funding for paramedical care	Internal: charging of costs§ to Surgery department. External: patients own expense up to a maximum amount.	Internal: budget of paramedic department, after several years budget adjusted by methodology. External: service agreement with few practices, declaration to hospital.	Internal: declaration charged to internal policy resources. External: declaration to hospital.	Internal: affiliation agreement budget supplemented with internal innovation fund and authorised budget overrun‡.	Internal: temporary government funding and budget of paramedic department. External: patients own expense.
Paramedical care facilitators (F) and barriers (B)	B: internal temporary and additional administrative work, external complex and patients own expense	F: internal budget adjustmentB: internal delay in the budget method, external complex and additional administrative work	B: internal temporary, external complex and additional administrative work	F: budget adjustmentB: delay in the budget method	B: internal temporary, external patients own expense

^*Policy rule: a government provided regulation with the aim to give healthcare providers and health insurers the opportunity to experiment on a short-term and small scale with innovative healthcare services with the objective of improving the price/quality ratio of care.42

^†Affiliation agreement on the policy rule: an agreement specifying that a healthcare provider is affiliating with a pre-existing policy.42

^‡Authorised budget overrun: an overrun of the available budgets, accepted by the board of directors.

^§Internal charging of costs: interdepartmental settlement of costs.

Despite the variety in funding sources to facilitate prehabilitation for patients with colorectal cancer, all are temporary in nature. This fact and the process of achieving permanent reimbursement are mentioned as a main barrier. As CM_2 mentions: “at the end of the day, that permanent funding is not well managed. (…) And that’s just the problem and that’s unfortunate actually”. To achieve permanent funding, evidence of the effectiveness of the treatment is required which meets the ‘state of science and practice’. Ironically, funding is needed to collect this evidence. Surgeon_2 explains: “so then you continually end up in a cycle (…) of; we have a good idea, pre-habilitation, there is increasing evidence that it works. We want to scale up. If we want to scale up, we want the support of the system, that is, of the Dutch Health Care Institute and health insurers. But they say; then you have to have more evidence. Yes, we say; we do want to get more evidence, (…) but then we need more patients. Yes, but the Dutch Health Care Institute and health insurers are not going to pay for that, because it is not yet part of the basic insurance package”. Insurers are restricted by laws and regulations when financing care. If care is ‘not covered by the basic insurance, we may not reimburse’ (HP_2). However, there are options to gain temporary government funds for research, such as the policy rule used for prehabilitation for patients with colorectal cancer.

In hospitals that are using this (affiliation agreement on the) policy rule, reimbursement of treatment costs is mentioned as a facilitator. However, the process of achieving (an affiliation agreement to) this policy rule ‘took some time’ (BPM_3) and was ‘difficult, because it is very bureaucratic’ (CM_5). The added value is limited in some hospitals because “a payment title is not the same as actually receiving the money” (Financial_3). It is indicated that reimbursement through the policy rule should be ‘paid in addition to the existing agreements’ (Financial_1). Furthermore, there are also patients for whom no external reimbursement is available because their insurer does not comply with such contracts (free-rider problems). In addition, the regulation only applies to prehabilitation for patients with colorectal cancer. As a result, upscaling the initiative to other diagnoses ‘could not take place at all’ (Financial_1).

A possible solution is seen in alternative financing such as population-based funding, CM_4: “instead of focusing on the funding system, just consider what (…) are we spending on it now and what is really the revenue on that um population”, and ‘bundled payments’ (CM_1). In addition, other contract types are also proposed, specifically ‘lump sum agreements’ (MCG_2) or ‘shared savings and multi-year contracts’ (CM_4). In contrast, it is mentioned that lump sum agreements contain a ‘perverse incentive’ for hospitals to ‘lean back’ (HP_2) because revenues are guaranteed, independent of the care provided. Suggested solutions typically imply an increase in the discretionary spending powers of the hospital.

Multiple interviewees recommend that prehabilitation for patients with colorectal cancer should be reimbursed from basic insurance. Within existing contract types, a higher price for patient with colorectal cancer who are treated with prehabilitation can be agreed to, HP_3: “if it can't work with the, the DTC price that was negotiated (…) then you agree on a higher price”. In this regard, hospitals may take a ‘stronger position’ (HP_1) towards health insurers in contract negotiations.

Distribution models

In table 2, an overview is presented of the budgeting methods used for prehabilitation in the five participating hospitals. The availability of a budget is considered important by all interviewees. However, in none of the included hospitals was this the case. As Financial_3 mentions: ‘we did not consciously choose to actually allocate the resources for pre-habilitation’ which caused delay for the start of pre-habilitation.

Hospitals 3, 4 and 5 financed the start-up phase of the project with internal funds. The availability of these funds is cited as ‘a good vehicle’ (Financial_4). Nevertheless, it is also mentioned as a barrier because these funds are ‘temporary’ (Financial_2), ‘but at a certain point it stops’ (Surgeon_3), ‘limited’ (Financial_4) and difficult to obtain. Therefore, permanent financing is lacking.

According to the health insurers, hospitals need to make choices. HP_3: “You have to allocate a margin in your, in your budget. (…) And that requires making a choice”. But in all hospitals, reallocating budgets between different departments is seen as a major barrier. For example, Surgeon_1 mentions: “apparently it is very difficult to transfer budget from the bottom right of the hospital to the bottom left of the hospital”.

Three hospitals apply models of IB. No adjustments are made as a result of implementing prehabilitation for patients with colorectal cancer. A barrier in this budgeting method is that the ‘incentive is also not actually there to really make sure that you um well organize things efficiently’ (Financial_3). Hospital 2 and 4 use some variants that relate to ABB. In these hospitals, an overrun of the obtained budget occurred: ‘the board of directors just said okay, a budget overrun is allowed’ (PT_1). Delay in the budget method is mentioned as a hindering factor of activity-based budgeting, but ‘if it’s used well then it’s a good system’ (Financial_5).

Physical therapy

Paramedic care in prehabilitation for patients with colorectal cancer consists of dietetics and physical therapy. Because dietetics is reimbursed within basic insurance up to a certain threshold, the interviews focused mainly on physical therapy. Physical therapy can be offered both in primary care and in the hospital. Table 2 shows that hospital 4 solely offers in-hospital physical therapy. For patients in the other hospitals, physical therapy in primary care is also available.

The difference in funding between primary and hospital care is perceived as another barrier to implementation. BPM_5 mentions: “because those physical therapy practices, that financing is also quite complicated”. In hospital 1 and 4, patients need to pay for the physical therapy treatment. When they have additional insurance, these costs are reimbursed. Hospitals 2 and 3 allow physical therapy practices to charge the hospital.

In general, it is mentioned that physical therapy should be addressed in primary care. Almost all interviewees indicated prehabilitation should be part of basic insurance. PT_3 states: “the absolute best, of course, would be if just physical therapy in primary care would just be covered in the ba—in basic insurance”. Especially considering ‘fewer and fewer people take out supplementary insurance for physical therapy’ (HP_1). Based on the main assumption that ‘it should be accessible to all patients’ (PT_4).

Two solutions to regulate reimbursement in the current financial system are suggested. The first possibility is for primary physical therapists to claim directly to the health insurance company. Financial_1: “Just classify it as primary physical therapy care. Make sure that there is a connection with the hospital and, and the primary care practices, but let it mainly be provided there, ehm and also be reimbursed that way”. This solution is mentioned mostly by BPM, CM and Financials because it reduces the administrative burden. BPM_5: “Because if you do it all via the hospital again, you have an extra administrative burden, which I think we want to reduce in healthcare”.

The second suggested solution is a bundled financing of primary and hospital care, “if you increasingly want to integrate your primary and hospital care, it is very strange that you don't do that on your financial eh component” (MCG_1). The advantage of this method of funding is that pre-habilitation for colorectal cancer patients is offered as one package, PT_2: “that it’s covered within that scope of what the patient is hospitalized for”. However, this results in additional administrative work, ‘If you have to make service agreements with all of them (…) you get a lot of different declarations that you have to process. Yes, that is administratively impossible’ (CM_5). In addition, ‘you actually shift money from hospital care, academic care to primary physical therapy practices’ (PT_3).

Additional factors

Other factors that affect the implementation and use of prehabilitation were also mentioned. Health insurers indicate “The relationship between say clinical effectiveness and cost-effectiveness, which is really something that we as an insurer look at very critically” (HP_1). However, this proves to be difficult according to several interviewees including Financial_3 “We don't have a status quo in the sense of eh other than that nothing at all happens (…) nothing is exactly the same. Everything is in motion. And we now want to pull out one element to evaluate.” Furthermore, the health insurer was deliberately not involved in some hospitals. Surgeon_4 states in this context: “I am not going to wait for an um, for an external actor, because (…) they have no interest in this at all”.

Among the interviewees, gaining support in the organisation is cited as the main reason for involving many stakeholders. Financial_5 mentions: “in the hospital world is always, everybody is entitled to an opinion on these matters”. Most interviewees mentioned that it helps when the project aligns with the hospital’s vision and strategy wherein clear choices are necessary, “if you have vision then, then, then vision can lead to investment” (Surgeon_1), “and if you make that choice, you also have to facilitate it” (PT_1). The five main other preconditions that were mentioned by the interviewees for facilitation are: (1) a medical specialist as a catalyst, (2) a project leader to coordinate the implementation, (3) culture of the organisation, (4) finance should not be the motivation for change and (5) sense of urgency that capacity is needed. Table 3 supports these preconditions with relevant quotations.

Table 3. Illustrative quotations for main preconditions.

Precondition	Quote
Medical specialist as a catalyst	I think that did, that really did help to get where we are now in terms of pre-habilitation, that’s just an involved healthcare professional. If you don't have that, you don't get there (Financial_1)
Project leader to coordinate the implementation	What helped eh is the eh dedicated positioning of the project leader (BPM_1) A project leader like that is really essential, because they just have the time and the attention (PT_2)
Culture of the organisation	Yes, and then you have to have the political will, some of it, to talk about it and say that you have to reduce your budget (Financial_3) You really should be able to explain why you're not going to do this. And eh it’s-there’s a certain non-commitment, it’s the culture of the organization (CM_1) And then it is also in the discipline, the financial discipline of a hospital to then at some point remediate those costs as well (CM_3)
Finance should not be the motivation for change	The motivation is not that it is financially advantageous, (…) but that your motivation is simply to give the patient the best care (BPM_5) There must be some other motivation, for both doctor and patient than an eh economic to make this eh a success (MCG_2) So if you improve quality, that’s my idea, then you automatically improve all kinds of other outcomes like eh length of stay, eh eh eh fewer complications, so but if you look, for example: I want to save costs by making fewer complications, then the quality gets worse, so my, my vision is do bet on quality, on logical big points, not all little things on the margin, but big--on the full breadth of, from A to Z and then it automatically starts reinforcing each other (Surgeon_4)
Sense of urgency that capacity is needed	So where in theory you could save 200 hospital days on an annual basis, just like that, it means that you can do 100 small other surgeries (…) so to fill those beds again with that (…) we can't deny that we do have more, more, more patients (BPM) In 5 years, it’s going to, it’s not going to work like this anymore (…) we already see eh shortage of staff (Financial_5)

Finally, despite good knowledge about the costs, creating a positive business case turns out to be a challenge. Interviewees agree that an up-front investment is needed to start the project. For example, for the employment of a project leader. Part of these activities are performed by existing employees within current contracts, BPM_3: “those costs are eh I think so mainly in brainpower and the processes, (…) so eventually you see that many people are working on it anyway”. It is also clear that additional costs will be made for paramedical care, mainly physical therapy.

Views on cost reduction possibilities do vary. Some interviewees indicated that costs could not be reduced or that the freed-up capacity will be used for other patients. The majority of interviewees indicated that a cost reduction could be achieved over time or if a larger number of patients were offered prehabilitation. For example, Financial_2 mentions: “So I think scaling up would be almost necessary to make it financially … really translate into less personnel, less material costs or whatever”. They suggest the freed-up capacity should be used to fund pre-habilitation. PT_4 states: “money you don't spend on those inpatient days could also be spent at the start eh on pre-habilitation”. This might be achieved by scaling down clinical capacity. In contrast, health insurers notice that hospitals “put up all kinds of extra things or ‘well that um, we’re doing something additional’, but if it saves something on the other side somewhere, you don't get it back” (HP_3). Finally, several interviewees advise to not wait but just start if an initiative seems promising. “If you want to calculate everything, just like with that, that, that pre-habilitation of um colorectal cancer, that two hundred thousand euros, if you start calculating exactly the pre- and the post costs, it never works out” (HP_3).

Discussion

This study focused on exploring facilitators and barriers in the financial model of hospitals, using prehabilitation for patients with colorectal cancer in the Netherlands as a case. With increasing pressures on affordability of hospital care, it is necessary to organise care more efficiently.^{3 6} By understanding facilitators and barriers in the financial model, changes in hospital care pathways to improve efficiency may be better facilitated. Interviewees acknowledged the importance of the financial model in implementing changes in the care pathway.

Based on 28 interviews with 7 different stakeholders, facilitators and barriers in the financial model of hospitals were identified. Although many similar points of view were revealed in the interviews, there were also notable differences. As to be expected, the (directors of) healthcare procurement and contracting managers have a more clear perception of facilitators and barriers in the reimbursement model than other stakeholders. However, their interests are not aligned and as a result, features of the model were identified as being both facilitators and barriers. Something similar occurred with financials and business or project managers. These stakeholders were able to list the most facilitators and barriers about the distribution model. It is notable that financials generally look at the hospital perspective, whereas business or project managers focus on positive or negative effects in their own unit. Surgeons and physical therapists seem less aware of the financial model. These stakeholders mentioned mainly barriers in the financial model. This may be explained by the fact that the financial model probably only comes into play for them when barriers occur. Because of their practical knowledge and expertise, they had relatively more thoughts on other preconditions for successful implementation.

In the reimbursement model, the absence of permanent funding is mentioned as the most important barrier. Temporary financial resources have been made available in all five included hospitals. Obtaining additional external financial resources proved to be a complex and time-consuming process. According to most interviewees, a lump sum agreement is the most preferable contract type to enable financial resources because it facilitates substitution of budgets. In addition, the (directors of) healthcare procurement pointed out the perverse incentive for hospitals to lean back in case of lump sum contracts. This concern is found in other research where authors argue that lump sum contracts may contribute to underprovision of necessary care, quality skimping and risk selection.³⁴ However, this relates to regular care and is not mentioned as a disincentive for innovation. Nevertheless, the absence of a production/revenue relationship in lump sum contracts may reduce the incentive to obtain permanent funding for changes in care pathways due to the possibility of budget substitution. In contrast, ABB does not facilitate funding for start-up costs for change, which contributes to the incentives to gather evidence but may hinder the progress of implementation.

When financial resources are available, the interviewees mentioned the challenge of properly allocating these budgets through internal distribution models. Previous research indicated a limited interaction between the reimbursement model and the distribution model of hospitals.⁴ Interviewees identified this as a major barrier to the financial model for hospitals. Interviewees in some hospitals mention the availability of a temporary internal investment budget as a facilitator. However, none of the hospitals made sustained adjustments in the budget distribution model. There is limited transparency in the allocation of budgets in hospitals.³⁵ The difficulty in identifying if and how cost reduction will take place complicates an adequate allocation of budgets according to the interviewees. In some hospitals, this caused budget overruns.

Different budgeting methods were used. Both ABB and IB contain barriers to reallocate budgets between departments according to the interviewees. But ABB is preferred. This budgeting method is more flexible than IB because it enables budget changes, though typically only after several years.⁴ Irrespective of the model, the most frequently mentioned facilitator is a separate available budget in the hospital.

The interviewees agreed that physical therapy should preferably occur within the context of primary care. But the reimbursement of physical therapy in primary care is seen as a barrier due to the complex relation of primary care to hospital care. This led most interviewees to the conclusion that population-based funding or bundled funding for primary care and hospital care could be a suitable alternative financing method. They assume this might help to reduce healthcare spending, although studies on the impact of these funding methods on accessibility of care are currently lacking.^{36 37} When physical therapy within primary care is covered by basic insurance, accessibility may increase.³⁸

In addition to the facilitators and barriers in the financial model, the interviews uncovered other preconditions. The culture in the organisation should be open to change with a sense of urgency. Culture is known as a contributing factor to improve productivity and efficiency.³⁹ The medical specialist is an important stakeholder. The medical specialist often fulfils a guiding position within the team.⁴⁰ In accordance with development in the profession, the medical specialist can be a catalyst to drive change. Appropriate facilitation, for instance by a dedicated project leader, is another precondition. The final prerequisite to be met, according to interviewees, is that financial gains should not be the motivation for change. This perception is consistent with the implementation of new technologies, where cost containment is also seen as a separate parallel process not causally related to the formal budget cycle.³⁵

Creating a positive business case is complicated, because revenues are difficult to collect and insight into budget distribution is limited. A Catch-22 situation seems to occur, wherein sufficient evidence is the prerequisite for structural funding and this evidence can only be provided with funding. The five hospitals included in this study have managed to overcome this dilemma. To achieve a rapid implementation, an internal hospital-based approach, without involving external stakeholders such as health insurers, seems to work best. Without involvement of health insurers, hospitals should invest and ensure budget availability for the initiative. According to the majority of interviewees, cost reduction will occur over time or after scaling up to a larger patient group. The financial resources that become available then can be used as investment for a new initiative.

Funding in the Dutch healthcare system does not seem to encourage change in care pathways. Given the urgency to stimulate initiatives that contribute to accessibility and affordability of healthcare, the Dutch government made 2.8 billion euros available over 5 years.⁴¹ This stimulates transformation, but for structural funding, it is still required that change is proven effective and meets the ‘state of science and practice’. Meaning that there is sufficient evidence, preferably from (worldwide) scientific research, that care for this condition, disease or diagnosis is safe and effective in the long term.⁹ This is perceived as a time-consuming and bureaucratic process by interviewees. A change in funding structure may facilitate change and is a complex process.³⁶ The hospitals in this study demonstrated that implementation of a modified care pathway is possible even within the current system and despite barriers in the financial model of hospitals. This starts with recognising the sense of urgency for change. This is driven by multiple reasons, including increasing pressure on accessibility of hospital care due to increasing staff shortage and financial constraints.^{3 6} When a promising idea presents itself and preconditions are in place, hospital administrators should make an investment and dare to take the considered risk. The costs of change are often incurred before benefits can be collected, making it difficult to establish a balanced business case. More efficient utilisation of scarce clinical capacity and staff may not be considered as straightforward financial or cash returns, although given scarcity, this is even more valuable nowadays.

Strengths and limitations

By using a qualitative approach, we were able to identify a wide variety of facilitators and barriers in the financial model of hospitals. We aimed to meet the standards for qualitative research.^{28 33} For example, minimising researcher bias by conducting the data analysis by two researchers. Prehabilitation for patients with colorectal cancer is an interesting case that affects many aspects of the financial model of hospitals, but the preventive nature of the case may limit its relevance for other initiatives that contribute to efficiency and cost reduction. However, the exploration of how the financial model comes into play can be a worthwhile approach for many endeavours.

Conclusions

This study aimed to explore facilitators and barriers in the financial model of hospitals. With this knowledge, changing care pathways to increase efficiency in hospital care may be better facilitated. Both the reimbursement model and the distribution model contain barriers that have complicated the implementation of prehabilitation for patients with colorectal cancer in the Netherlands. Lump sum contracts in the reimbursement model and ABB as a distribution model seem to be the best facilitators. Furthermore, bundling the funding of primary care and hospital care is recommended. Other preconditions for implementation, such as the involvement of a medical specialist and sense of urgency in the organisation, should also be well established. Based on our findings, we suggest that regardless of the financial model that is used, hospitals should make internal budgets available to facilitate initiatives that contribute to more efficient care.

Data availability statement

Data are available on reasonable request.