Barriers and Strategies for Inclusion of Value‐Based Healthcare in Contract Negotiations in the Netherlands: Study Among Hospital and Insurer Executives

ABSTRACT

Background

This paper analyses why, despite its recognized importance, value‐based healthcare (VBHC) has not gained more prominence in negotiations between health insurers and hospitals in the Netherlands.

Methods

Data collected by interviews used a standardized questionnaire with closed‐ and open‐ended questions. Respondents included hospital and insurer executives, and experts on VBHC in the Netherlands.

Results

Hospital and insurer executives addressed issues of cost containment, volume management, and care availability. Despite recognising the potential of VBHC to enhance patient outcomes and experiences, reluctance persists due to uncertainties about cost‐savings, its complexity, lack of data, and competing priorities. Hospital executives advocated experiments with VBHC, trust‐building, and continuous evaluation, with strategies to standardise measures, enhance information technology (IT) infrastructure, promote data transparency, foster collaboration, and educate stakeholders. Participants also underlined the need for systemic change and governmental action.

Conclusions

Negotiations mostly focus on cost containment and volume management. This reflects a systemic emphasis on immediate financial concerns over long‐term value creation. The hesitancy in transitioning to VBHC underscores the need for collaborative strategies and systemic shifts to prioritise patient‐centric care. External factors such as fee‐for‐service payment systems further complicate VBHC adoption, requiring governmental intervention and cultural transformation to align incentives and promote sustainable healthcare practices.

Summary

• Short‐term contracts impede VBHC implementation in contracts;

• Stakeholder hesitancy is rooted in cultural barriers and lack of trust;

• Measuring VBHC outcomes is complex, requiring robust data infrastructure and transparency;

• Current health system dynamics impede VBHC adoption, requiring governmental action and cultural transformation.

1. Background

Value‐based healthcare (VBHC) has gained significant traction in recent years as a promising approach to shift away from a volume‐based healthcare system [1]. VBHC is a healthcare delivery system that emphasises the value provided to patients over the volume of services rendered, with value defined as health outcomes achieved per unit of cost [2]. This represents a balance between patient benefits and resource utilization. In VBHC, outcomes encompass the actual results of care for patients, such as health status achieved or retained [3]. To be effective, these outcomes should be patient‐centred, measured over the full cycle of care, and risk‐adjusted to account for patient differences [4]. Quality in VBHC is multifaceted, and it incorporates clinical effectiveness and patient experience, going beyond mere adherence to medical guidelines to focus on achieving the best possible outcomes that matter to patients [5].

According to Porter and Lee, adopting VBHC implies, for instance, a movement towards integrated care, measurement of outcomes and costs, and geographic expansion [4]. One other pilar for the transition towards a high‐value health care system is a shift from a fee‐for‐service (FFS) reimbursement model, which stresses quantity over quality, to a value‐based payment (VBP) model, which aims at maximising value for patients [6, 7]. While VBP models are often discussed as part of VBHC, it is important to note that VBHC initiatives can be implemented without a payment reform. For instance, many hospitals have implemented only one or two components of VBHC, mainly focussing on the measurement of outcomes and costs or integrated practice units (IPUs) [3].

The Netherlands is considered a frontrunner in the adoption of VBHC projects. For example, a physician‐led project at Catharina Heart Centre demonstrated significant improvements in patient outcomes [8]. Additionally, Erasmus MC adopted a data‐driven approach to VBHC to enhance shared decision‐making and improve patient‐centred care [9]. Another example is the Santeon hospital group, which has implemented VBHC principles across multiple specialities, leading to measurable improvements such as a shorter stay in hospital [10]. The BUNDLE project has reviewed various VBHC projects and has offered insights and advice on alternative payment models [11]. However, the overall implementation of VBHC in the country remains fragmented and challenging. Many Dutch hospitals have set up multidisciplinary value improvement teams around medical conditions, rather than fully transitioning to IPUs as advocated by Porter [3]. The focus in the Netherlands has primarily been on collecting, using, and transparently reporting outcome data relevant to patients, supported by government initiatives [3]. However, the adoption of VBHC principles in contractual agreements between healthcare providers and health insurers appears limited, with traditional volume‐based contracting methods still being dominant [12]. Additionally, the lack of a centralised electronic health records system poses barriers to enabling an information technology (IT) infrastructure, a key component of VBHC implementation [3]. As highlighted by Gajadien and colleagues (2023), alternative payment models to incentivise VBHC have so far been rarely used and seem to have a lower priority despite national policies explicitly aimed at promoting such models [13]. Hendriks et al. (2024) add that the implementation of these models is hindered by, among others, stakeholder resistance to change and complexity of model design suitable for diverse healthcare contexts [14].

This apparent detachment between the potential benefits of VBHC initiatives and their limited inclusion in contractual agreements creates an intriguing puzzle worthy of examination. Our study aims to identify and analyse the complex elements that shape these contractual negotiations and examine why VBHC, despite its potential advantages, has not received more attention in the contracting between health insurers and hospitals in the Netherlands. By exploring the barriers contributing to the limited focus on VBHC in contracting, as well as investigating what is prioritised instead, we aim to provide insights that can inform future policy decisions and guide the evolution of healthcare practices within the Netherlands. Additionally, we will examine whether there is a need for greater emphasis on VBHC in contracting and potential strategies to enhance its inclusion.

This study contributes to the existing knowledge base by providing a comprehensive analysis of the factors influencing VBHC implementation in contractual agreements, an area that has received limited attention in previous research. By focussing on the broader concept of VBHC, we aim to offer a more nuanced understanding of the challenges and opportunities in transitioning towards a VBHC system. These insights may also be useful outside the Netherlands, to other high‐income countries with a similar healthcare system, with private insurance companies acting as third‐party payers, competing in a regulated market.

2. Methods

2.1. Study Setting

The setting of this study is the Dutch health system. In the Netherlands, in 2024, there are 10 health insurance companies and 69 hospital organizations. The healthcare market operates within a system of regulated competition and universal healthcare coverage [15]. The universal social health insurance system combines market competition with strict public regulation to ensure access, affordability and quality. Dutch health insurers are primarily financed by insurance premiums paid by individuals and employers, which consist of a government‐fixed income‐related premium and a community‐rated premium on which insurers compete [16]. A risk equalisation system balances the risk profiles across insurers to provide an equal playing field and to avoid risk selection, which influences their financial incentives in contract negotiations with hospitals [17]. Health insurers are required to accept all individuals who wish to purchase basic insurance coverage. Within this framework, hospitals are private, not‐for‐profit organizations that vary in size and specialisation. Hospitals negotiate contracts with health insurers to determine reimbursement terms and service scope. These negotiations aim to balance stakeholder interests while ensuring high‐quality, accessible care for patients.

Within a system of regulated competition, it is intended that negotiations between health insurers and hospitals take place on an annual basis and start with document processing in April, during which the insurance companies specify their priorities in contracting with hospitals. The formal deadline for finalising contracts is 20^th November of each year. Negotiations go beyond that, and sometimes, contracts are only closed after the start of the new year. Contracts are usually annual contracts, but recent insights from the NZa (Netherlands Healthcare Authority) indicate an increase in multi‐year contracts [18].

The integrated care agreement (IZA), signed by the Ministry of health, insurance companies, the Dutch Hospital Association (NVZ), the Netherlands Federation of University Medical Centres (NFU), and other stakeholders in September 2022, aimed to address the challenges facing healthcare in the Netherlands, focussing on making healthcare more effective, accessible, and affordable [19, 20]. The agreement, set for 4 years, recognises the need for a shift towards a more holistic approach to healthcare, emphasising health promotion and disease prevention rather than just treatment. One key aspect of the IZA is the emphasis on providing Appropriate Care (AC). AC, as defined in the Dutch context, is: (1) care that works at a reasonable price; (2) care organised as close to the patient as possible; (3) care in which patients decide together with their physicians on the best possible treatment; (4) care that goes beyond merely treating disease by also focussing on overall health and what a patient can achieve. AC aligns with the principles of VBHC by focussing on delivering the right care at the right place and is intended to improve outcomes while managing costs. To achieve this, the IZA promotes regional cooperation among healthcare providers, strengthening primary care services and investing in preventive measures. It provides a framework for contractual negotiations between providers and insurers. Both parties are expected to align their negotiations with the principles outlined in the agreement, such as prioritising AC delivery and promoting regional cooperation.

2.2. Study Design

This study employs a descriptive and explorative design based on data collected through interviews with a standardized questionnaire comprising both closed‐ and open‐ended questions. One of the reasons this mixed‐methods approach is particularly well‐suited to our research objectives is that the population size is relatively small, making a purely quantitative study less feasible [21]. A qualitative approach allows for in‐depth exploration of individual experiences and perceptions, which might be overlooked in a larger‐scale quantitative study. Additionally, the study was constrained by a limited timeline due to academic deadlines and resource availability. Given these limitations, this design enabled an efficient collection and analysis of data. The use of a standardized questionnaire ensures consistency across interviews, and the inclusion of both closed‐ and open‐ended questions allows for a balance between structure and flexibility. Closed‐ended questions facilitated the use of descriptive statistics to capture quantitative patterns in participant responses, and for open‐ended questions, content analysis with narrative description was employed to capture the nuanced and contextual aspects of participants' responses.

2.3. Respondents

The respondents in this study were professionals working in the Dutch healthcare sector, specifically senior executives from health insurers and hospitals, who were involved in contractual negotiations. Executives were chosen due to their strategic decision‐making roles, broad organizational oversight, and direct involvement in contractual negotiations within the Dutch healthcare sector. Their unique positions and experiences provide crucial insights into the challenges and opportunities related to VBHC implementation in the Netherlands. Additionally, this study included experts who, despite not belonging to these two parties, could provide impartial knowledge and insights on the topic.

As we combined open‐ and closed‐ended questions, we focused on describing and understanding the respondents' views regarding contractual negotiation. We aimed to include between 20 and 30 respondents in total. Initially, as we aimed to explore the views of executives in both health insurers and hospitals, our study had two groups. However, we found that there were respondents who, despite not belonging to any of the two parties, had knowledge about the negotiations and the system in which these are held. Therefore, we decided to include a third group of respondents, which we called experts. There was no need to have an equal number of respondents per group, as the size of the three targeted study populations differs.

2.4. Recruitment

Purposive sampling was initially employed, involving the identification and selection of respondents with key healthcare roles and experiences related to the study topic. Specifically, the inclusion criteria for participation were: (1) Individuals holding a senior executive position within health insurance companies or hospitals involved in contractual negotiations; (2) Experts with knowledge and experience relevant to the research focus, even if not directly involved in the contract negotiation process. Subsequently, snowball sampling techniques were applied, where respondents connected the research team with other respondents with similar backgrounds who satisfied the inclusion criteria.

Respondents were contacted via email, inviting them to take part in the study. The email informed them about the topic of the research, as well as the research question. Respondents were also informed in the same email of the reason why they were approached to partake in the interview. One reminder about the invitation was sent to the potential respondents who did not respond to the first email, 2 weeks after it was sent. In case respondents accepted this invitation, a subsequent email was sent regarding the interview planning. In this email, an informed consent form was also included, with information regarding topics such as data collection procedure, duration, risks, confidentiality, and sharing of results.

After the interview was conducted and answers to the open‐ended questions were transcribed, the respondents were given the opportunity to read the transcript of their interview and provide comments (member check).

2.5. Data Collection

Prior to the interviews, two unstructured online pilot interviews were held with hospital contracting experts. The pilot interview started with the open question: ‘Would you please share your personal experience regarding the procedure and topics of the contractual agreements between healthcare providers and health insurers? And how much attention is given to VBHC in these meetings?’. The keywords and key topics that were identified in these pilot interviews were used to clarify the content [22, 23]. These interviews and notes also served as a pre‐test to develop the questionnaire (Supporting Information S1).

The questionnaire was sent to the interviewees prior to the interview to increase their comfort and allow for preparation. This enabled the research team to collect as much data as possible in the allocated time. As executives frequently have a very busy schedule, we decided to limit the time taken for the interview and to use this time as efficiently as possible. In the data collection stage, 30‐min interviews were agreed to be conducted online and in English using Microsoft Teams. One researcher (DLLL), not proficient in the Dutch language, conducted 28 interviews in English, and a second researcher (WG) conducted one interview in Dutch, as per the request of the respondent. Of those 30 interviews, 29 were conducted online, and one was completed by the interviewee filling out the questionnaire and sending it through email. Most interviews, 25, involved a single respondent, and in each of the other five interviews, two respondents joined. The interviews were recorded with the interviewees' consent. Verbal informed consent was obtained and recorded at the start of each session. The recordings of the 29 online interviews were captured using QuickTime Player and later transcribed by DLLL using Microsoft Word Online. All 29 transcriptions were sent back to the interviewees for a member check. Of these, four transcripts were returned without any changes, four were sent back with minor modifications, primarily related to privacy concerns (removing potentially identifying information) and grammatical corrections, and the remaining 21 transcripts received no response from the interviewees.

2.6. Questionnaire

The questionnaire was based on pilot interviewees' and researchers' knowledge, and a previously conducted systematic literature review [24]. It consisted of three parts. In the first part of the questionnaire, respondents were asked to indicate their level of involvement in the contractual negotiations. Afterwards, they were asked what the primary focus during those negotiations was. In the second section of the questionnaire, respondents were presented with five statements. For each of these statements, the respondents were asked to indicate the level of agreement on a one to five scale, as well as to motivate their answer. In the last part of the questionnaire, respondents were asked to mention challenges/barriers and strategies that could respectively hinder and enhance the negotiation and implementation of VBHC in practice‬. The final question asked respondents to add any comments they considered important to the topic at hand and had not been covered in the questionnaire. A definition of VBHC was not provided in the questionnaire, nor prior to or during the interviews because it is a widely used concept with varying interpretations. This includes differing views on whether it includes a payment model, allowing participants to express their perspectives based on their own understanding and experiences.‬‬‬‬‬‬‬‬‬‬

2.7. Data Analysis

The analysis of the data consisted of a descriptive statistical analysis of the answers to the closed‐ended questions and a narrative description of the answers to the open‐ended questions. For the descriptive statistical analysis, the data from the closed‐ended questions were systematically organised and summarised using measures of central tendency (mean, median, mode) and dispersion (standard deviation). Frequency distributions and cross‐tabulations were also employed to identify patterns and differences among respondent groups. These analyses were performed using the software package SPSS, which was used for data cleaning, coding, and visualisation of the quantitative findings. The narrative descriptive analysis was based on a content analysis of the data gathered from the open‐ended questions, focussing on understanding the views of the respondents regarding contractual negotiation and identifying overarching themes across the dataset collected from the interviews [23, 25]. In the narrative descriptive analysis, coding and analysis were carried out using Atlas. ti, a qualitative data analysis software tool, to organise and analyse the data systematically. Each transcript of the answers to the open‐ended questions was analysed, and emergent themes were identified inductively. This thematic analysis consisted of identifying text fragments with relevant information to answer the research question [23, 25]. The best‐fitting codes were identified and subsequently grouped by their common meaning and/or content. This process was repeated for each transcript, and previous transcripts were reconsidered iteratively in light of subsequently emergent themes. Finally, the themes from each transcript were combined. When the final themes were identified, a team meeting was held, in which the results were discussed, and any divergence of opinions was settled.

3. Results

3.1. General Description

A total of 30 interviews were conducted to investigate the complex elements that shape contractual negotiations between health insurers and hospitals in the Netherlands and examine why VBHC has not received more attention in contracting. Five possible interviewees did not accept and 39 did not respond to the invitation. Respondents included hospital executives, health insurer executives, and VBHC experts. Table 1 provides a detailed breakdown of the different groups, divided by their job role, as well as the respondents' involvement in contractual negotiations. Due to the differences in the number of respondents per interview, as well as one interview having two interviewees from different respondent groups, the data description was carried out based on the number of interviews and not the number of respondents.

TABLE 1.

General description of respondents.

Classification category and sub‐categories	N	(%)
Respondent Group and Job Role a
Hospitals executives	19	63%
CEO/CMO/member of board of directors	(10)	(53%)
Head of department/director	(5)	(26%)
Manager/negotiation team member	(3)	(16%)
Researcher/professor	(0)	(0%)
Advisor/consultant	(1)	(5%)
Health insurer executives	6	20%
CEO/CMO/member of board of directors	(0)	(0%)
Head of department/director	(3)	(50%)
Manager/negotiation team member	(2)	(33%)
Researcher/professor	(0)	(0%)
Advisor/consultant	(1)	(17%)
VBHC expert	6	20%
CEO/CMO/member of board of directors	(0)	(0%)
Head of department/director	(1)	(17%)
Manager/negotiation team member	(0)	(0%)
Researcher/professor	(3)	(67%)
Advisor/consultant	(2)	(33%)
Type of involvement in contract negotiations b
Direct	14	47%
Indirect	24	80%
Oversight of negotiations	(12)	(50%)
When escalation needed	(11)	(46%)
Final stage	(2)	(8%)
Quality discussions	(3)	(13%)
Strategy meetings	(9)	(38%)
Advisory	(4)	(17%)
No involvement	3	10%

^a In the case of overlapping job roles of respondents, a choice was made and only one was selected.

^b Sum higher than the total number of interviews (N > 30) because respondents may be involved in more than one sub‐category.

Of the 30 interviews conducted, 19 (63%) were with hospital executives from 18 different organizations. Of these, 10 held positions as chief executive officer, chief medical officer or member of the board of directors. These 18 hospitals represented a diverse set of institutions, including academic, general, and specialised hospitals across different regions, which enhanced the representativeness of the sample. Six interviews (20%) involved executives from four different healthcare insurers, and half of those were with heads of departments or directors. Each of the insurance companies had distinct market strategies and regional focuses, which ensured that insurer heterogeneity was captured. Six interviews involved VBHC experts, representing 20% of the total conducted interviews, and three of those were with either advisors or consultants. It is important to note that the sum of these three categories exceeds the total number of interviews because one interview involved both a hospital executive and a VBHC expert.

In 14 (47%) interviews, respondents stated a direct involvement in negotiations. Indirect involvement was reported by respondents in 24 (80%) interviews, with respondents in half of those interviews stating that they oversaw negotiations and 11 reporting involvement only when escalation was necessary. Respondents could belong to both the direct and indirect involvement categories if, for example, they were directly involved in the negotiations considered most important and indirectly involved in the remaining negotiations. The different roles and levels of involvement of the interviewees further increased the generalisability of the study.

3.2. Focus During Negotiations

After getting to know the type of involvement respondents had in the contractual negotiations, they were asked about what the primary focus was, according to them, during these negotiations (Supporting Information S2).

Hospital and insurer executives both acknowledged a focus on reaching a compromise in negotiations, where providers need to ‘give up’ certain areas if they want to obtain something in other areas. These two groups of respondents also recognized the focus placed on the availability of care in their region. Some respondents from all groups, even if few, mentioned the recently announced national healthcare initiative, AC, as a new focus in the Netherlands. This concept incorporates principles of VBHC, shared decision‐making, and the “right care at the right place” (JZOJP ‐ Juiste Zorg op de Juiste Plek). JZOJP has emerged as a prominent initiative that aligns with VBHC principles by connecting financial incentives to quality‐related outcomes. It aims to strike a balance between cost containment and the delivery of high‐quality, value‐driven care, further reinforcing the shift towards a more integrated and patient‐centred healthcare system in the Netherlands.

Most respondents, regardless of the group they represented, stated that negotiations were primarily focused on price and volume. Some added that quality and outcome goals were generally areas of mutual understanding, and financial terms were the primary source of disagreement and, hence, the central focus of most negotiations. However, several hospital executives mentioned their futile efforts to integrate discussions on quality and outcomes, stating that the focus on financial aspects, particularly cost containment, remained dominant. An insurer executive respondent mentioned the importance of focussing on ‘good practices’, described as initiatives that have been proven to be better than others against lower costs.

In line with the financial focus, several interviewees emphasized a focus on both cost containment and volume management in scenarios where either the healthcare provider or the insurer had a low market share. This focus was more emphatic in short‐term (12 months or less) contracts. When engaging with insurers with a dominant market share and/or negotiating long‐term contracts (more than 12 months), hospital and insurer executives alike pivoted more towards quality, innovation, and new policy strategies.

One hospital executive and one insurer executive mentioned a shift towards the inclusion of outcome‐based measures and bundled payment contracts. Another hospital executive and insurer executive highlighted the focus on the relationship between price and quality. The insurer executive further elucidated discussions structured into three categories of care, with one focussing solely on quality, another on quantity, and a middle segment addressing both quality and price, where VBHC was placed.

3.3. Statement Insights

Table 2 shows the analysis of each statement rating divided per respondent group. There were no noticeable differences between groups or when comparing each group to the whole sample. It should be noted that the groups of insurer executives and VBHC experts were rather small (six respondents in each group). Therefore, we have summarised the insights of each respondent group, per statement, without a link to the rate assigned (Supporting Information S3). Table 3 presents quotes of the answers that were deemed most interesting and important to exemplify each statement's insights.

TABLE 2.

Rating of statements (likert scale, 1 = Strongly disagree to 5 = Strongly agree).

Statement	Respondent group	Mean	Std. Dev	Mode	Median
(1) Value‐based healthcare is a healthcare delivery model that improves patient outcomes and experiences and can be used for cost control.	Total sample	4.03	0.78	4.00	4.00
	Hospital executives	4.17	0.80	4.00	4.00
	Insurer executives	3.67	0.82	3.00	3.50
	VBHC experts	4.17	0.75	4.00	4.00
(2) I Consider value‐based healthcare to be an important topic during the contracting process.‬‬‬‬‬‬‬‬‬‬‬‬‬‬	Total sample	3.32	1.32	4.00	3.75
	Hospital executives	3.31	1.33	4.00	3.75
	Insurer executives	3.33	1.21	4.00	3.50
	VBHC experts	3.67	1.75	5.00	4.50
(3) Value‐based healthcare is not given enough attention in contract negotiations between healthcare providers and insurers.‬	Total sample	4.07	0.91	5.00	4.00
	Hospital executives	3.97	1.01	5.00	4.00
	Insurer executives	4.58	0.49	5.00	4.75
	VBHC experts	4.20	0.84	5.00	4.00
(4) Parties involved in contractual agreements are knowledgeable about value‐based healthcare and its elements.‬‬‬‬‬‬‬‬‬	Total sample	2.97	1.00	4.00	3.00
	Hospital executives	2.86	1.04	3.00	3.00
	Insurer executives	2.58	1.28	4.00	2.50
	VBHC experts	3.20	0.84	3.00	3.00
(5) Other priorities often take precedence over value‐based healthcare in the negotiations about health care contracting.‬	Total sample	4.38	0.91	5.00	5.00
	Hospital executives	4.17	1.06	5.00	4.00
	Insurer executives	4.17	1.60	5.00	5.00
	VBHC experts	4.60	0.55	5.00	5.00

Note: Bold indicate the values in the same row as the total sample, for each of the five statements.

TABLE 3.

Quotes of Respondents' answers explaining the statement rating.

Statement given in the questionnaire	Quotes from the respondents' answers to the open‐ended questions related to the statements
(1) Value‐based healthcare is a healthcare delivery model that improves patient outcomes and experiences and can be used for cost control.	I: “The cost control part… I think it's a bit more difficult. And that's mainly because in value‐based healthcare, the target is the patient unit and the patient pathway. And what you see is that, if you want to go to cost control, it's not about the individual patient pathways, but it's about the collective. And I think that's the difficulty. How does all the individual patient pathways count up to the collective?” H: “Because the value‐based healthcare originally described by porter, cost is always… in relation to cost, I don't think that the cost is lowering always, but we get less for it. Because my people, when I change all these protocols to deliver any value to patients, I'll change protocols, patients are often more at home or less in my hospital, but I'll get less money. However, the people who deliver the care or the cure or the costs of that are as high as they were.” H: “There's a risk that it will be used as an economic tool.” E: “… and my observation is that insurance companies have not much interest in in making that open.” I: “… but it was more difficult to get transparency on healthcare outcomes…”
(2) I Consider value‐based healthcare to be an important topic during the contracting process.‬‬‬‬‬‬‬‬‬‬‬‬‬‬	H: “And hospital full of nurses and physicians that want to give quality makes it hard to explain every year… that insurers are only interested in price.” E: “There's not a lot of transparency on the real costs of … treating a condition, for example. So, there is also a big win, I should say, getting more transparency on costs and outcomes.” I: “I actually have to disagree. Personally, I would agree. But what I see from our company, I can't agree with this because it's not a topic… a real topic in the contracting.” H: “… both hospitals and healthcare insurers don't have the manpower to implement those types of models on a… on a general level.” H: “It says to implement value‐based healthcare effectively, support is required from both parties, but also for all parties, and for the 10 or 12 health insurers. You cannot make an agreement about value‐based healthcare and the money, which is spent with it, but only one.”
(3) Value‐based healthcare is not given enough attention in contract negotiations between healthcare providers and insurers.	H: “… focus is mainly on budgets and on money.” I: “… ultimately condenses into a price discussion.” H: “Creating value across entire healthcare chain is possible if the entire healthcare chain is jointly committed to this and is organised…” H: “And that's because we only want to talk about it as a cost model, as a lowering of the cost model… and I don't believe in that.” I: “And one of my tasks is to help providers to make that step from budget contracting to more relational contracting from a long‐term mutual perspective, but it takes times in general.”
(4) Parties involved in contractual agreements are knowledgeable about value‐based healthcare and its elements.‬‬‬‬‬‬‬‬‬‬‬	H: “I think the health insurer sees this as a cost pressure instrument …” H: “… especially the patient outcomes, we have it for an individual treatment, but also to have that information available, so that you can really do the equation. That's also difficult. Our information sessions are not geared to deliver this, at this moment.” H: “Yeah. So, I think the parties are not aware of…enough about what value‐based healthcare really is, so I disagree.” H: So yeah, is that a lack of knowledge or is it misunderstanding? I Think it's a combination. This made it makes it even worse, I think. H: “I think hospitals have a bit more knowledge because for health insurers it's very abstract, and that's also to blame on us.”
(5) Other priorities often take precedence over value‐based healthcare in the negotiations about health care contracting.‬	H: “The financial yeah… issue, then of course it's much easier to steer on cost than to steer on outcome in relation to cost.” H: “In the end, it's all about money.” H: “… at the end of the day, it's all about the financial deal you make. So, that value‐based healthcare elements are… addendums, and the main focus is the big deal, with the price and the volume included in it.” H: “… it's the financial driven, budget driven… and so the EUROS, yeah… are the most important.” E: “And, and maybe if you want to apply the principles of value‐based healthcare right way, then you maybe should work more on the relationship part … the negotiations…”

Abbreviations: H: Hospital Executives, I: Insurer Executives, E; VBHC Experts.

Statement 1

Value‐based healthcare is a healthcare delivery model that improves patient outcomes and experiences and can be used for cost control.

When posed with a definition of VBHC, respondents from all groups mentioned that VBHC brings all elements together and leads to more cost efficiency. VBHC experts emphasised that this delivery model considers the full cycle of care and requires an integrated payment element. Hospital executives mentioned the high complexity of the delivery model, its small scale, lack of focus on the individual perspective, and the time needed for implementation, making it hard to put into practice. To add to this difficulty, they also mentioned a lack of knowledge about the subject and a lack of available data. In general, hospital executives agreed on improvements in outcomes and experiences but were uncertain about cost reductions, criticising insurers for focussing on costs, short‐term contracts, and reluctance to include VBHC in contracts.

Insurer executives also acknowledged the complexity of VBHC and expressed uncertainty about cost savings. They highlighted the lack of shared outcome data as a significant barrier. Insurers noted that while VBHC could potentially improve efficiency, translating outcomes into financial terms remains challenging. They emphasised their own constraints, such as limited data from providers and the need to focus on immediate financial priorities.

Statement 2

I consider value‐based healthcare to be an important topic during the contracting process.

Respondents from all groups highlighted a difference between their belief in the importance of VBHC and its actual inclusion in negotiations. Hospital executives pointed to insurers' hesitancy and lack of knowledge about VBHC and its composing elements (e.g. quality aspects), preferring lower‐risk topics, such as cost reduction. They noted that VBHC had more emphasis with insurers holding higher market shares in their hospital. VBHC experts pointed out a significant gap between insurers' high interest in VBHC as portrayed in their marketing efforts and their low commitment to implementing it in practice. Insurer executives explained that their focus on other priorities, such as accessibility, is often driven by time constraints and immediate operational demands.

Hospital executives further mentioned that VBHC is not yet integrated into their strategic plans. They cited challenges such as insufficient manpower, cost‐centred discussions, time limitations, the complexity of VBHC, and its limited scope. Additionally, they highlighted a lack of trust and the need for cultural change both between insurers and providers, and among providers themselves. Hospital executives also pointed out a misalignment between current payment systems, focused on price and volume, and the principles of VBHC, as well as differing priorities, with insurers emphasising cost control and providers focussing on quality.

Statement 3

Value‐based healthcare is not given enough attention in contract negotiations between healthcare providers and insurers.

All three groups of respondents acknowledged an overwhelming focus on cost reduction. Both hospital and insurer executives mentioned each other's hesitancy in its implementation, as well as their own hesitancy. Hospital executives added that VBHC is not high on insurers' agendas, as they only focus on a minimum quality threshold, and that they prefer short‐term contracts. Insurers were also criticised for wanting to keep silos in hospitals (i.e. different departments or units that do not communicate with each other) to prevent any kind of collaboration. That way, in contractual negotiations each silo is discussed separately, therefore maximising contracting freedom.

Insurer executives acknowledged difficulties in managing diverse contracts with varying focuses. They stressed that VBHC is not a short‐term solution and requires intrinsic motivation from all parties involved. Insurers cited time pressures and insufficient data from providers as reasons for the limited focus on VBHC.

Hospital executives added the difficulty in translating cost improvement into a business model (e.g. defining which costs to include, hospital or social), as well as translating outcome measures into financial terms. They also mentioned that the volume‐focused system is not well aligned with the principles of VBHC. Likewise, hospital executives underlined the small financial margins they had to experiment with ‘riskier’ contracts. They also mentioned VBHC was more important when contracting with insurers with a higher market share.

Statement 4

Parties involved in contractual agreements are knowledgeable about value‐based healthcare and its elements.

All three groups highlighted a disparity in knowledge about VBHC and its elements, not only between insurers and hospital executives but also within each other. Specifically, hospital and insurer respondents recognized a knowledge gap within the same insurer. According to them, insurers with a higher market share at a specific hospital send bigger and more knowledgeable teams, with more freedom to conduct negotiations.

Hospital executives mentioned a lack of knowledge on VBHC by insurers and providers, both conceptually and practically, including a lack of information about outcomes. The existence of barriers between divisions was also stated to lead to a lack of communication (e.g. between quality and the finance teams), and hence result in a lack of knowledge. There were also hospital executives who mentioned some VBHC knowledge but a lack of awareness of its possibilities. Additionally, several others mentioned a high degree of knowledge by parties, with VBHC as part of the strategy in their organization, and the existence of trainings and the IZA in the Netherlands, which helped with the overall understanding of VBHC.

Insurer executives mentioned they had a high level of knowledge regarding VBHC, while others acknowledged a lack of it. The reasons given for the scarcity of knowledge on the topic were other priorities taking precedence, such as personnel shortage and cost reduction. Additionally, insurers mentioned that VBHC had been replaced by AC, similar to what all groups of respondents answered when asked about the focus of contractual negotiations, in the second question of the questionnaire.

Statement 5

Other priorities often take precedence over value‐based healthcare in the negotiations about health care contracting.

Most respondents agreed that there were several other topics that take precedence over VBHC. Only one respondent in the insurer group stated that VBHC was prioritised and was part of their strategy.

Across all groups, a prioritisation of costs was the most mentioned topic. Hospital executives also mentioned contextual factors to explain the lack of focus on VBHC, such as the emergence of differences in the system's operations and rules governing it (e.g. creating a need to make a new pricing system).

Additionally, hospital executives mentioned that the current system, attached to an FFS core, was misaligned with the VBHC elements. These respondents also referred to the complexity of VBHC and did not consider it a short‐term solution. This was echoed by VBHC experts, who also mentioned provider hesitancy, as well as the competitive mindset of both insurers and hospitals and the lack of trust between them. Insurer executives added the lack of motivation from all parties, and lack of time as other reasons for the lack of prioritisation of VBHC in contracting.

3.4. Barriers

In the last part of the questionnaire, we asked respondents to list barriers hindering the negotiation and implementation of VBHC in practice (Supplementary Material 2).

Respondents mentioned an overall hesitancy by parties in making the transition and implementing VBHC. The administrative burden (e.g. transaction costs) behind such a transition was an issue for many respondents. Insurer executives stated that a lot of work was needed for only marginal benefits, as the scale was too small, and the investment was high. However, hospital executives also mentioned that insurers were anxious about larger‐scale VBHC contracts and criticised them for wanting to keep contracts short‐term and not investing in prevention and lifestyle care. Hospital executives claimed they wanted long‐term contracts, as they could facilitate the adoption of VBHC (no fear of losing income). Some insurers recognized the riskiness and unpredictability of including VBHC in contracts. Hospital executives added that this overall hesitancy increased with existing examples of hospitals that were unsuccessful in implementing VBHC.

Data were also a topic frequently mentioned as a barrier. According to hospital executives and VBHC experts, it appeared hard to measure value. Taking the necessary information out of the monitoring systems, steering and connecting it with outcomes, and translating costs were mentioned as being hard to achieve with the sometimes‐flawed IT systems. One insurer executive added that it was hard to recognise true net savings from hospitals, as the hospital may show savings in terms of reference groups, but their capacity remains unchanged. Both hospital executives and VBHC experts also mentioned a lack of time and funding to fix issues regarding data collection and analysis. Insurer executives took a different approach when mentioning data as a barrier in the VBHC negotiation and implementation. This group referred to the complexity of defining, measuring, and evaluating outcome measures, but most mentioned the lack of information stemming from providers not sharing outcome measures' data. This lack of transparency was echoed by hospital executives, with both parties stating an overall lack of trust between them.

Hospital executives and VBHC experts mentioned barriers of disparity in knowledge about VBHC, value, and outcomes. Some of them mentioned low purchasing maturity. Insurers were criticised for marketing VBHC in their strategy but not making it a reality. Additionally, insurers were criticised as wanting to keep silos to maximise their benefits and having an overall competitive mindset (to ‘win the exchange’).

Hospital executives mentioned other priorities as an additional barrier (e.g. mergers) for the lack of attention given to VBHC. They also mentioned that, by the time they negotiated with insurers, they did not have time to discuss long‐term topics and instead focused on budget cost reduction. This sentiment was reiterated by VBHC expert respondents.

Outside the realm of the negotiation table, hospital executives mentioned a lack of governmental action and a national push to focus on VBHC. A VBHC expert mentioned the ‘government is not leading nor controlling’. Several respondents from all groups also mentioned the misalignment of the system for VBHC implementation, with a focus on FFS, rewarding higher volume and not being prepared to reward for doing less. Insurer executives specifically mentioned that hospitals still pay providers based on volume, and it is hard to change that system and culture. Additionally, privacy laws and regulations to prevent collusion, such as limitations on sharing data, were also mentioned to hinder VBHC implementation and negotiation. Finally, respondents also mentioned a problem with society, which expects too much care to be available at any time.

3.5. Strategies

When asked about strategies to enhance the negotiation and implementation of VBHC in practice, respondents across all groups emphasised several key themes (Supplementary Material 2).

A prominent strategy was the need for collaborative experimentation between providers and insurers. Hospital executives suggested creating “Blue Zones”. These are specialised areas where organizations can collaborate in a trust‐based, non‐competitive environment. This approach was justified as acknowledging that implementing VBHC is a learning process that requires the courage to begin, even without perfect conditions. While hospital executives and VBHC experts advocated for starting on a small scale, others, particularly insurers, emphasised the importance of hospital‐wide projects with value‐driven contracts to make the effort worthwhile.

Data management emerged as a critical focus. Respondents across all groups stressed the importance of defining and standardising outcome measures, balancing comprehensive patient health representation with avoiding administrative burden. The need for adequate IT systems and monitoring instruments to streamline data collection, analysis, and connectivity was also highlighted.

Respondents emphasised the importance of building trust and prioritising patient care over organizational finances. Insurer executives highlighted the need for transparency in outcome data sharing. Cooperation and collaboration were seen as essential for aligning strategies, with longer‐term contracts suggested to facilitate transformation. Hospital executives stressed the need for internal alignment within insurers and involving stakeholders like nurses and medical specialists in VBHC implementation. Regular engagement with insurers and meetings to monitor outcomes were also recommended.

Education and training on VBHC concepts, implementation, and negotiation were proposed to address knowledge gaps. Hospital executives also emphasised the need to understand that such a transition would require time and financial investment. They also suggested showing insurers ‘easy‐to‐understand examples’ where VBHC worked to increase interest.

Several respondents proposed the introduction of different types of VBP models, such as pay‐for‐value, population‐based, and bundled payment, stating that they would remove the volume incentive of the current system. This suggestion was made with a desire for action despite the challenges previously discussed.

Outside the negotiation table, respondents emphasised the need for a broader mindset shift towards VBHC, recognising the unsustainability of the current healthcare system. This shift involves changing cost incentive structures and aligning hospital budgeting practices with VBHC principles. Insurer executives supported this by advocating for hospitals to adapt their internal budgeting to promote this alignment, highlighting the importance of creating financial incentives that prioritise patient outcomes over service volume. Hospital executives also pointed out the necessity of educating society to move away from a ‘consumer’ mindset. Additionally, some respondents suggested that a nationwide movement towards VBHC implementation, potentially supported by government intervention, could help overcome hesitations in making this transition.

4. Discussion

Despite the general belief of the potential benefits of VBHC, its integration into contractual negotiations between health insurers and hospitals in the Netherlands appears to be limited. Results from our sample found that VBHC is not a primary focus in most contractual negotiations. This is due to challenges both inside and outside the negotiation table.

Inside the negotiation table, there seems to be an emphasis on price and volume as a topic of discussion during the negotiations, linked with a preference for short‐term contracts. Insurer executives believe in the need for large‐scale implementation, but hospital executives, besides being hesitant themselves in implementing VBHC, criticise insurers' short‐term focus. Hospital executives mention a need to negotiate and experiment with long‐term contracts with a focus on value. Additionally, all respondent groups believe that more communication, trust, transparency, and overall collaboration between parties may enhance the implementation of VBHC in negotiations. Improving the recognized flawed IT system and improving the knowledge of VBHC were also strategies mentioned by insurer and hospital executives. Outside the negotiation table, it was found that the broader health system also presents intimidating barriers to the adoption of VBHC in contractual negotiations. Respondents from all groups mentioned a misalignment between the current payment system of the hospitals and the payment system that VBHC requires. Additionally, societal expectations for unlimited, high‐quality care were mentioned as a possible barrier to adopting VBHC in negotiations. Governmental action was suggested to promote VBHC as a possible strategy to improve its implementation in contractual negotiations.

4.1. Inside the Negotiation Table

Since the hospital market was liberalised, healthcare expenditure and utilization have grown substantially. To manage the growth in hospital expenditures, care agreements were introduced in the Netherlands [26]. Strict budget caps as part of the care agreements that the ministry of health closed with health insurers and hospital representatives, combined with the national government's ‘macro control instrument’, were key in containing spending on hospital care. With the COVID‐19 crisis, due to uncertainty and concerns about current and future costs, the emphasis on price and volume increased [13]. This systemic prominence of cost containment within the healthcare ecosystem is confirmed by the results of this study, with several experts across all groups mentioning price and volume in the form of budgets or financial caps as the focus in negotiations [27, 28]. The strong consensus that other priorities frequently take precedence over VBHC further reinforces this, with respondents giving it the highest rating among all statements.

Our study reveals mechanisms perpetuating this focus on price and volume in negotiations, hindering VBHC implementation. Short‐term contracts emphasise immediate financial gains over long‐term value creation, aligning with Porter and Lee's caution against prioritising cost containment over patient outcomes [4]. To address this, contracts should incorporate patient‐centric outcome measures (e.g. quality of life improvements or functional status) and consider longer terms to encourage quality improvement and innovation [29]. While cost control remains crucial, it should not overshadow the primary goal of improving patient outcomes. Balancing financial considerations with patient‐centred care is essential for the success of VBHC [30].

The small scale of VBHC implementation mentioned by insurers in our study reveals complex challenges in healthcare contracting. While long‐term contracts are often proposed as a solution, their direct impact on value‐based improvements remains uncertain. High investment and administrative costs pose significant barriers to widespread adoption [24], with insurers stating that larger‐scale implementation is necessary to offset these expenses. However, there is an apparent contradiction, as healthcare executives criticise insurers for preferring short‐term, cost‐centred agreements that neglect quality, and preventive and/or lifestyle care [13]. Hospital executives further acknowledge their own reluctance to introduce VBHC in negotiations, citing a lack of practical evidence, uncertainty regarding outcomes, and minimal financial margins for experimenting with “innovative contracts”. This discrepancy is particularly evident in the perception that VBHC is not given enough attention in contractual negotiations, with a strong level of agreement among respondents. To explore potential solutions to these challenges, the concept of “Blue Zones” is suggested as a tentative experimental approach, which could allow both insurers and hospitals to test VBHC initiatives on a small scale with limited financial risk. A scoping review concluded that a practical framework or set of recommendations for implementing VBHC is still lacking and remains largely conceptual [31]. Among all the executive insurers interviewed, only one stated that their company explicitly positioned VBHC as a core strategic priority, underscoring the ongoing challenges in translating this concept into practical implementation. In comparison, healthcare professionals in hospitals view the implementation of VBHC, through outcome measurements and value improvement, as central to their identity and responsibility.

Hospital executives expressed concerns about insurers' siloed approach to hospital contracting (separate negotiations for each hospital division), which they believe hinders integrated care across different settings (e.g. outpatient services and post‐acute care). Furthermore, scaling up VBHC is particularly challenging since it requires contractual agreements at the level of medical conditions, and given that hospitals typically manage many distinct conditions, this may significantly increase the complexity of negotiations [9]. The siloed structure contradicts Porter and Lee's advocacy for IPUs centred around medical conditions [4]. This practice is seen as a strategy by insurers to maximise financial gains, although insurers did not directly confirm this perspective. If insurers typically negotiate siloed contracts for individual divisions, it raises concerns regarding communication and coordination across different hospital units. This finding reveals an unexplored structural barrier to VBHC implementation that extends beyond the traditional focus on price and volume, highlighting an important area for future research in healthcare negotiation strategies. Hospital executives also noted a discrepancy between insurers' proclaimed interest in VBHC and its actual implementation in contracting, suggesting a mutual lack of trust.

The healthcare industry's resistance to change is evident in the hesitancy observed among hospital and insurer executives regarding VBHC inclusion in contracts. In the Netherlands, VBHC initiatives typically start bottom‐up, aligning with the hospital culture and leveraging clinicians' and patients' insights [32, 33]. Successful VBHC implementation requires a radical shift in healthcare delivery, reimbursement, and evaluation, with a culture of collaboration, trust, and continuous improvement supported by common IT platforms or IPUs [4]. This approach should incorporate an individual patient perspective and focus on patient value. Promoting transparency and data sharing can build trust and facilitate informed decision‐making, with VBHC also including cooperation among primary care providers [34].

The hesitancy to develop VBHC may also stem from knowledge disparities between parties, as found in studies conducted in the Netherlands [3, 32]. These have argued that the concept of VBHC is rather vague, leaving it open to interpretation [3, 35, 36]. The perception that stakeholders lack sufficient knowledge, as indicated by the lowest mean rating among all statements in the questionnaire, seems to contribute further to this resistance. To address this, education and training programs can equip stakeholders with the necessary knowledge and skills, with Teisberg and colleagues advocating for VBHC inclusion in educational curricula worldwide [37]. Several Dutch healthcare initiatives have successfully implemented VBHC principles. Meetbaar Beter pioneered VBHC in cardiovascular care, later evolving into the Netherlands Heart Registration [38, 39]. The Santeon group, inspired by Meetbaar Beter's methodology, has achieved significant improvements, including a 30% reduction in unnecessary inpatient stays for breast cancer patients [10, 40]. Additionally, Diabeter, a clinic network specialising in type 1 diabetes care, also implemented VBHC principles, resulting in better patient care and lower hospitalisation rates [41]. Highlighting these successful cases is crucial to enhance stakeholders' interest in incorporating VBHC concepts into contractual negotiations.

Respondents mentioned complexities associated with measuring and evaluating value‐based outcomes, and their translation into costs. This underlines the importance of robust data infrastructure and interoperability. Respondents stated that current IT systems often lack the capability to capture and analyse relevant data across the care continuum, limiting the ability to demonstrate value and integrate outcome measures into negotiations. This is compounded by a lack of trust and transparency in sharing outcome data between insurers and hospital executives, which both parties lament, and is also recognized in the literature [12, 13]. One study suggests the lack of information available on quality indicators as an important factor for the increased reluctancy in its use in contractual agreements [42]. This mutual criticism from both parties hinders collaboration and perpetuates a cycle of mistrust and resistance to change. Including regular conversations between parties on daily practices and outcomes can enhance data accuracy, transparency, and interoperability [43]. Together with an adequate system and measures, this enables stakeholders to effectively collect data and monitor and evaluate the impact of VBHC initiatives.

4.2. Outside the Negotiation Table

Experts in this study highlighted that the current FFS payment system in Dutch hospitals undermines VBHC principles, incentivising volume over value. This aligns with findings from the literature [13]. Respondents emphasised that governmental inaction exacerbates this misalignment, with limited efforts to incentivise outcomes‐based care or address regulatory barriers. Moreover, the regulated competition model in Dutch healthcare presents unique challenges for implementing VBHC. This model aims to balance competition with principles of solidarity and universal access, creating a complex environment where reconciling market dynamics with public interests becomes a key consideration [44]. This complexity may potentially complicate efforts to fully align the system with VBHC's central goal of improving patient value. This suggests a need for fundamental reforms in payment structures and regulatory policies to promote value maximisation for patients. This was also mentioned as a strategy for countries outside the Netherlands [45].

Despite initiatives from the Dutch government, like the investment of 70€ million in the “Outcome‐oriented Care Programme” [13], respondents noted their limited impact in fostering VBHC adoption. Insurer executives in our study highlighted entrenched cultural norms within hospitals, where volume‐based payment persists despite their interest in transitioning towards VBHC. While such governmental actions aim to improve efficiency, the regulated competition model of the Dutch healthcare system may paradoxically create challenges for collaboration and potentially restrict the development of integrated care approaches necessary for successful VBHC implementation [46]. Furthermore, respondents suggested that a national roll‐out to promote VBHC, along with clear guidance and regulations, could facilitate this transition. Existing literature similarly suggests the need for governmental action to set the right conditions, such as more guidance and/or regulations (e.g. clarity in anti‐trust and patient choice regulations) to improve contracting maturity, long‐term relationships, collaboration, and trust between insurers and providers [12, 13, 47]. However, as this study focused on the negotiation table, experts were not specific about which regulations would be most impactful. This underscores the need for further research to evaluate how current regulations affect long‐term contracting and their potential role in accelerating the inclusion of VBHC in contractual negotiations.

Although respondents suggested VBP models as a potential solution, it is important to note that systemic implementation of such models in the Netherlands has faced significant challenges [13]. While there are notable examples of successful implementation of VBHC principles, such as the NHN and Diabeter, these do not represent widespread adoption. Additionally, these initiatives did not primarily rely on VBP models but rather focused on other aspects of VBHC, such as outcome measurement and integrated care. Our study reveals why broader efforts to implement VBP models might have struggled, identifying barriers such as lack of robust data infrastructure, limited interoperability between systems, and difficulties in measuring value‐based outcomes. These findings align with challenges identified by Lefers (2023) in implementing value‐based procurement in Dutch hospitals, particularly regarding the lack of trust and short‐term focus of stakeholders. The short‐term focus prevalent in the competitive Dutch healthcare system can conflict with the long‐term perspective required for VBHC implementation [12].

Moreover, societal expectations of unlimited, high‐quality care exacerbate the challenge of including VBHC in contracting. According to respondents, VBHC in contracting goes against the public demands for more hospital beds, which is a politically sensitive issue. This ‘wicked problem’ is transversal beyond countries, and it has been found that actions taken to implement VBP models have unintended consequences that arise elsewhere in the system [48]. This systemic inertia perpetuates a cycle where VBHC struggles to gain traction.

A critical aspect of overcoming this inertia may be the role of AC, which is emphasised in the IZA. Interestingly, results indicate that both insurer and hospital respondents have mentioned VBHC being replaced by AC in contractual negotiations. This shift, rather than hindering VBHC implementation, may contribute to its progress as AC aligns closely with VBHC principles (patient‐centred and value‐driven care delivery). By framing negotiations around AC, stakeholders may be more readily adopting VBHC concepts without the potential resistance associated with the VBHC label. However, it should also be acknowledged that AC remains a relatively vague concept that could potentially lead to implementations that appear progressive but lack substance. This lack of specificity might introduce ambiguities in its practical applications and allow for the adoption of AC principles without meaningful changes to practices or real improvements in patient care quality.

Furthermore, the success of VBHC is contingent on a balance in market power between health insurers and hospitals. Our study assumes a degree of mutual advocacy, but in contexts where, for instance, a dominant insurer dictates the terms or where a hospital has monopoly power in a region, VBHC's core principles can be compromised [12]. When powerful parties impose VBHC models, irrespective of provider or patient needs, concerns may arise about whether genuine value‐based care can be achieved, or efficiency can be improved. This can lead to a superficial adoption without meaningful improvements, as the priorities of the part with substantial market power may overshadow the collaborative spirit essential for VBHC. Further research should explore the impact of imbalanced market power on the authenticity and effectiveness of VBHC initiatives.

4.3. Implications for Research, Policy and Practices

Several important implications for research, policy, and practice emerge. For research, there is a pressing need to investigate the impact of contract duration on VBHC implementation. Understanding how long‐term contracts may facilitate successful VBHC initiatives could provide valuable insights for stakeholders. Additionally, there is a need for studies that examine the impact of existing regulations on long‐term contracting, as well as research into how the concept of AC may align with and support VBHC implementation in the Dutch context. Evaluating the effectiveness of “Blue Zones” may also be crucial in determining their role in overcoming implementation barriers and their potential for broader application. Another area that could be further explored is the effects of siloed hospital structures on VBHC implementation. Research should focus on how these departmental divisions hinder integrated care delivery.

From a policy perspective, there is a need for policymakers to develop frameworks that support VBHC adoption (e.g. creating guidelines that facilitate data sharing, long‐term contracting). Incentivising the adoption of VBHC practices within hospitals and insurers should be a priority, alongside promoting transparency and standardisation in healthcare data sharing. Addressing cultural barriers within healthcare institutions will also be crucial, and policies should support shifts in physician compensation models to align with value‐based principles. Moreover, government initiatives must be aligned with VBHC principles to ensure that national healthcare programs effectively support this transition. Facilitating cross‐sector collaboration among healthcare providers, insurers, and other stakeholders will be vital in implementing successful VBHC initiatives.

Regarding practices, hospitals should consider implementing IPUs that reorganise care around medical conditions rather than traditional departmental silos. Investing in robust IT infrastructure is essential for capturing and analysing value‐based outcomes effectively. Additionally, both hospitals and insurers must engage in trust‐building initiatives that promote transparency and collaboration to overcome existing mutual distrust. Practitioners should also be encouraged to pilot VBHC initiatives through small‐scale “Blue Zones” to test concepts and build evidence for larger‐scale adoption. Fostering a culture of continuous improvement will be critical. Establishing processes for ongoing evaluation and refinement of VBHC initiatives based on measured outcomes can help sustain momentum. Incorporating patient perspectives into VBHC implementation efforts will ensure that care delivery remains centred around patient needs and outcomes. Finally, leveraging the framework of AC may serve as a bridge to implement VBHC principles more seamlessly within existing healthcare structures.

By addressing these implications across research, policy, and practice domains, stakeholders can work collaboratively to overcome barriers to VBHC implementation in contractual negotiations and healthcare delivery in the Netherlands. This concerted effort has the potential to lead to improved patient outcomes and a more efficient use of healthcare resources overall.

4.4. Limitations

This study, while employing a rigorous methodology, has limitations to consider. First, even though the study included a wide variety of respondents from different groups, the selection was based on availability and willingness to participate, which may limit the generalisability of the findings to the broader population of healthcare professionals involved in contractual negotiations. To address this, both hospital and insurer heterogeneity were carefully considered. The sample included hospital executives from a range of institutions and regions, as well as executives from insurance companies with distinct market strategies and regional focuses. Secondly, while the structured interview approach provided consistency across respondents, the use of a predetermined questionnaire, especially when sent to participants in advance, may have constrained the depth and breadth of the uncovered perspectives. Additionally, the relatively short duration of interviews (30 min) might have limited the opportunity for in‐depth probing of complex issues. Future research could benefit from employing a mix of structured and semi‐structured techniques to capture a more comprehensive range of insights on this topic. Howard et al. (2024) conducted longer interviews on alternative payment models. However, their findings are mainly in line with the findings from this study, with some different emphasis such as a focus on learning instead of costs [49]. Their approach underscores the value of extended interviews for deeper insights, highlighting a potential direction for future research. Thirdly, subjective interpretation in data analysis may influence the identification of themes. To mitigate this, multiple research team members have conducted and cross‐checked this analysis. Additionally, the study's scope may not capture all relevant factors influencing healthcare negotiations, such as regulatory frameworks or financial incentives. Therefore, this study should be interpreted considering the parties included in contractual negotiations. It is also important to consider respondents' opinions and past experiences. Some respondents may have experienced contractual negotiations on both the hospital and insurers' side, while others may have experienced it only on one of the sides of the negotiation table. Furthermore, there was an imbalance in representation between hospital executives and insurer executives, with more hospital representatives participating in the study. This may have led to an overrepresentation of hospital perspectives in our results. While efforts were made to balance these views in the analysis, this disparity should be considered when interpreting the findings. Finally, self‐reporting bias may affect the accuracy of data, where respondents may provide answers that they believe are expected or desirable. By ensuring confidentiality in respondents' responses and using neutral language in the questionnaire, the research team has tried to minimise this limitation.

5. Conclusion

The findings of this study suggest that both insurers and hospital executives have knowledge of what VBHC is, and some elements of it are reported to be applied in hospitals. However, it becomes clear that the implementation of VBHC in contracting is a complex matter. Our study sheds light on the multifaceted challenges hindering the integration of VBHC into contractual negotiations between health insurers and hospitals in the Netherlands. The predominant focus on short‐term financial gains, coupled with organizational resistance to change and deficiencies in data infrastructure, presents a complex set of obstacles to realizing the potential benefits of VBHC. However, by prioritising long‐term contracts that incentivise value‐driven outcomes, where providers are rewarded for achieving specific health improvements rather than merely the quantity of services delivered, stakeholders can build a pathway towards a more sustainable and efficient health system. Additionally, fostering a culture of collaboration and trust, investing in advanced IT solutions, and addressing external factors such as alignment of the payment system and governmental action will further support this goal. By embracing these insights, policymakers, insurers, and healthcare providers can collectively work towards promoting the adoption of VBHC, ultimately enhancing the quality of care, improving patient outcomes, and ensuring the long‐term viability of value‐based practices in the Netherlands. The findings from this study can also be useful in other countries, especially the ones with a similar, multi‐payer system, in which healthcare coverage is offered by multiple competing insurance companies.

Author Contributions

All authors conceived and designed the study and developed the questionnaire. D.L.L.L., D.V.V. and W.G. contacted the respondents. L.A.M.M. provided additional contacts. D.L.L.L. and W.G. collected the data. D.L.L.L., D.V.V., W.G. and M.P. discussed ways of analysing the data. DLLL analysed the data. The synthesis of results was carried out by DLLL, with input from L.M., D.V.V., W.G. and M.P. The drafts and final version of the manuscript were written by D.L.L.L. D.V.V., W.G. and M.P. were involved in every version of the manuscript and read and approved the final version.

Ethics Statement

The research methodology received approval from the Faculty Niet‐WMO Verplicht Research Ethics Committee to ensure compliance with ethical standards. Approval number: FHML‐REC/2023/132. An informed consent form was sent to all interviewees, and consent was verbally asked for at the beginning of each interview. Confidentiality and anonymity were strictly maintained by coding respondents' names and by storing all data securely in the primary investigator's laptop.

Consent

The publication of research results was explained prior to the informed consent obtained from all individual respondents included in the study.

Consent to Participate

Informed consent was obtained from all individual respondents included in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting Information S1

Data Availability Statement

The anonymized transcripts of the interviews conducted, in which the structured questionnaire was used, are available from the corresponding author upon reasonable request.