The healthcare purchaser as a care chain orchestrator:Healthcare system limitations and opportunities

The healthcare purchaser as a care chain orchestratorHealthcare purchasing, as carried out by health insurers and governmental organisations, contributes to ensuring qualitative, accessible and affordable care. Financial incentives, outcome monitoring and collaboration with care providers are known ways for purchasing organisations to drive better collaboration and task division between care providers. However, purchasers appear to struggle to adopt what we label an orchestrator’s role. To date, there is still limited understanding of how purchaser’s strategies and actions develop in practice, and whether they can be explained by differences between healthcare systems. Comparing England, Sweden and the Netherlands, this thesis shows that purchaser competition, internal governance and patient choice have a particularly strong impact on the role that purchaser’s adopt. These three characteristics determine the extent to which purchasers focus on costs as against health, have a short or long-term vision, support care providers and are able to influence care providers.We saw that, with the support of a Dutch health insurance company, the implementation of out-of-hospital coaching for patients with Chronic Obstructive Pulmonary Disease (COPD) can be both feasible and effective. However, sustainable implementation requires the government to provide the right macro-level incentives and policy context. Further, we found, in a longitudinal case study, that three stakeholder groups strongly influence the strategies adopted by the health insurer: governments, care providers and insurance policyholders. Given the sometimes conflicting medical, financial, relational and public interests of these stakeholders, the health insurer was inclined to fall back on its traditional bookkeeping strategy, despite initial attempts to adopt an orchestrating role