Shifting care from hospitals to general practice from the health insurers’ perspective: an interview study

TL;DR

This study explores how health insurers in the Netherlands view barriers and facilitators to shifting care from hospitals to general practice.

Contribution

It provides new insights from insurers on how to facilitate care substitution through policy and collaboration adjustments.

Findings

Facilitators include long-term contracts and strong general practice structures.

Barriers include legal uncertainties and inadequate compensation models.

Adjustments to risk equalization and promoting collaboration are suggested for improvement.

Abstract

Policymakers have embraced substitution of hospital care to more affordable primary care as a means to contain rising healthcare costs and provide care closer to home. Health insurers play an important role in the extent to which substitution of care takes place. This study explores the perspective of Dutch health insurers on barriers and facilitators to facilitate a shift from hospitals to general practice in the current healthcare system.

Semi-structured group interviews were conducted with healthcare purchasers from various health insurers, involving fifteen participants from seven insurers representing 76.5% of the market. Thematic analysis was used to identify perceived facilitators and barriers for effective substitution of care.

Long-term contracts that enable strategic planning and collaboration between general practices and hospitals, as well as strong organizational structures in general practice and long waiting times in hospitals are reported to facilitate substitution. Uncertainties around collaboration under the Competition Act, inadequate compensation through the risk equalization model, complex billing codes for innovative initiatives, a rigid national budgetary framework and strong bargaining power of hospitals as opposed to insurers and general practices are stated to hinder the shift towards general practice.

Key areas for improvement to facilitate substitution, as reported by healthcare purchasers, include clear guidelines on insurer collaboration, adjustments to the risk equalization model, strengthening the bargaining power of general practices, and promoting long-term contracts. This study provides insights into the perceived barriers and facilitators for care substitution from the payer’s perspective. Addressing these barriers is essential for facilitating the shift from hospital to general practice care. Also, potential discrepancies between perceptions and current regulations highlight areas where enhanced dialogue and collaboration between policy makers and health insurers could improve mutual understanding and regulatory compliance.

The online version contains supplementary material available at 10.1186/s12913-025-13650-4.