Table 5.

Financial and regulative conditions that stimulate Population Health Management: expectations, intended PHM strategies and prior experiences, as reported by stakeholders

Stakeholder groups’*expectation (short (5-), middle (10-), long (20 years) term)		Stakeholder groups’ intended strategies (short (5-), middle (10-), long (20 years) term)
Short	B, HCI, M, PCG, PM, PRO: No changes in the finance system, certainly no payment models for the total population as originally planned. First TA results will be achieved on intervention level. Business cases based on the TA model. B, M, PCG, PRO. First TA results on intervention level. Shared savings as incentives on an increasing number of projects; first experiences with regional budgets. PM, PCG, HCI, H: The purchasing procedures will change. H, HCI, PCG, PM: Regulations restricting the data-sharing will not be changed shortly.	H, HCI, PCG: Organize multi-year contracts. H, HCI: Invest in business cases based on value-based health care. Integral payment model for mental health care, frail elderly and birth care, HCI, PCG, PM, PRO: Invest in incentives such as shared savings and use revenues for investments in the PHM initiative. PCG, PM: Determine the purchasing process together with the health care insurers and providers and pay more attention to prevention: HCI, M, PCG: Pull funds together for specific interventions for specific populations in light of positive health in specific neighborhoods.
Middle	B, M, PCG, PM, PRO: Bundling of budgets across sectors-TA outcomes for the whole regional population. Regulations are changed for closer collaboration, combining budgets, payment model for the total population. H: Payment of complete pathways instead of payment of separate parts of the pathway. B, H, HCI, M, PCG, PM, PRO: Rules are changed for data sharing	HCI: Experiment with subscription fees that are in line with the practices’ population, combined with a bonus on outcomes that are of joint interest to the entire population. H, HCI, PCG, PM, PRO: Keep experimenting with data optimization. HCI, PCG, PM, PRO: Engage politicians.
Long	B, H, M, PCG, PM, PRO: Citizens’ coordination of regional health’ financial arrangements. B, H, HCI, M, PCG, PM, PRO: Regional health policy is based on big data with matching financial arrangements.	–
Prior strategies and outcomes		contextual factors-mechanisms
HCI: Investments in multi-year contracts with hospitals to reduce volume and costs of care. Shared savings incentives for specific projects. Resistance to outcome funding and new payment models and shared savings agreements based on the total population of the PHM initiative. B, H, HCI, M, PCG, PM, PRO: Improve efficiency and quality motivated by financial incentives. Business cases that are positive from a societal perspective but negative from an organizational perspective are a problem. PHCI, M, PCG: Exchange of data to develop business cases for PHM development. This has challenged the purchasing procedures. Exchange of data sensitive to competition between healthcare insurers is prohibited.		HCI: Hospitals received budget guarantees via multi-year contracts to adjust the company for substitution of care to primary care groups. Contracts could be brokered if the quality of care was reduced and requirements were included within contracts, e.g. to cooperate in data-infrastructure development. Furthermore, no savings incentives for the total population were made due to lack of upfront financial investments, lack of data and knowledge to measure total population’ effects, and insurers did nor prefer interference of an integrator needed to divide the savings. Limited experience with alternative ways of payment. Insurers did not prefer outcome payment due to the danger of patient selection. No preference for region wide population payment due to fear of a shift in responsibility to an integrator. Insurers feared that shifting accountability to providers would increase the information asymmetry in favor of providers, and would lead to loss of control over providers, and weaken their purchasing power. B, H, HCI, M, PCG, PM, PRO: Leadership and trust are preconditions for financial experiments. Fragmented financing and market forces inhibit structural change. H, HCI, PM, PCG: Current policy and purchasing process cannot guarantee efficiency and affordability, accessibility of care and support. The NZa** sets the payment infrastructure, however rational business cases sometimes do not fit into the system, then the NZa should redefine payment structures. Also, the market in which providers have to compete does not fit their need to collaborate for PHM. PCG, PM: Budgets allocated to specific compartments such as hospital care within the budgetary framework of the government, hinder substitution of secondary care to primary care. B, HCI, PCG, PM, PRO: The Competition Act (ACM ***rules) has rules on data exchange between stakeholders in light of maintaining a level playground. Market competition and payments must be based on health gains. However, the privacy legislation is about privacy protection but not about care optimization. The question is whether it is not the other way around: is it not against the law to not use possibilities that exist for optimization of care, as the law on the medical treatment contract (WBGO) says that professional should present the best treatment to patients. Rigorous changes are necessary in the payment system, legislation and regulations for true transitions in health care. Professionals have experienced that confidence and experimental space and an upfront guarantee that their actions are in line with the legal frameworks or are permitted by supervising organization(s), is necessary.

*B = Businesses; H = Hospital; HCI = Health care insurer; M = Municipality; PM = Program manager; PCG = Physician care group; PRO = Patient representative organization

**NZa: The NZa establishes descriptions of the treatments (performance, e.g. maximum rates), and supervises healthcare providers and healthcare insurers

***ACM: The Dutch Authority for Consumers and Markets is a Dutch independent public regulator charged with the supervision of competition, telecommunication and consumer law