Impact of Coopetition between Healthcare
Providers and Insurers on the Quality of Care
Research Paper
By Joost de Vries
S4182316
University of Groningen
Care is a service that everyone uses. The intensity and experience of care is different for everyone. Healthcare has high quality standards and continuous efforts are made to improve these. Coopetition between health insurers and care providers influences the quality of care considerably. Care is one of society's primary basic needs. In general, the quality of care is good but there is potential for a lot of progress, especially in the field of coopetition between healthcare providers and health insurers. Coopetition has been found to influence the quality of care and has a lot of impact on the type of relationships between different organizations. Findings show that coopetition has both positive and negative effects on the quality of care. Case study research has been conducted by interviewing two healthcare organisations focused on the level of coopetition they use and its impact on the quality of care. Based on the
outcomes and results it can be concluded that coopetition in healthcare goes along with a high level of complexity. Although the fact that positive results of such collaboration are known, the actual step towards common cooperation is still a long way off.
Keywords: Coopetition
Healthcare providers
Insurers
Quality
Health Value Chain
Supervisor: M. Fröhlke
INTRODUCTION
In many healthcare systems the right participation between healthcare providers and insurers is required to provide care. The involvement among those is necessary to structure a healthcare system by making agreements on cost coverage, reimbursements, excess, quality requirements and general underlying agreements. To provide patients with the kind of care that the patient needs. In doing so, it is about the desired quality and the price that comes with it, which is a real challenge. Stolper, Boonen, Schut, & Varkevisser, (2019) claim that
insurers are caught between the positive and negative incentives. In general, the people in the top management of the firm steer more on the quality of care, while the purchasers and marketeers are steering on the economic aspects. In addition, the demands and perception of society in the field of quality are constantly changing, for which ever-higher expectations are set every day (Morley & Cashell, 2017). Most of the times a certain level of coopetition is required to realize the desired quality of care (Padula & Dagnino, 2007; Walley, 2015). Coopetition combines paradoxical forces: competition and cooperation (Tréhan & Pourrat, 2016). Walley (2015) claims that it is plausible to assume that the interests of both the companies and the customers they supply will be realised by coopetition.
Dafny and Lee (2016) claim that cooperation and competition improves quality and efficiency, stimulates innovation, and minimizes costs. Health care should be no exception. So far relatively little research has been done between the relationship of coopetition and the quality of care (Angerer, Schmidt, & Brand, 2017), which emphasizes the essence of this study even more. Therefore, additional research on the effects of coopetition between healthcare providers and insurers on the quality of care is relevant and necessary, to create a better understanding. This has led to the following research question:
How does coopetition between healthcare providers and insurers influences the quality of care?
THEORETICAL FRAMEWORK / BACKGROUND
The following section discusses the most important theoretical concepts about coopetition between care providers, insurers, and the quality of healthcare, after which these insights are combined in a conceptual framework.
Coopetition between healthcare providers and insurers
Coopetition refers to a certain relationship, which simultaneously involves both competition and cooperation. Walley (2015) describes this by indicating that the participants have partially convergent interests. Therefore, the notion of coopetition indicates that
cooperation and competition are not mutually exclusive (Padula & Dagnino, 2007).
According to Dagnino (2007) and Peng and Bourne (2009) coopetition in healthcare is still a relatively an under-researched phenomenon in the healthcare sector.
It has been found that coopetition influence the performance, for instance in terms of quality of care. Raza-ullah and Kostis (2020) have found a positive relationship between the level of trust between participants and their performance outcomes. They found that both trust and distrust are the key mechanisms through which coopetition impacts relationship
performance.
Coopetition between insurers and providers is an important aspect in healthcare systems. It influences the performance of care. Because mutual competition between insurers and healthcare providers increased, there is less focus on the quality of care, degree of
innovation, efficiency, cost effectiveness and patient satisfaction (Rosenau & Lako, 2008). Stolper, Boonen, Schut and Varkevisser (2019) and Broek, Boselie and Paauwe (2018) argue that insurers extensively negotiate with providers about the price and quantity of care, but that the quality of care is not or hardly addressed in these negotiations. Stolper, Boonen, Schut and Varkevisser (2019) claim that the reason for not discussing quality of care in these
negotiations is because there is no clear, transparent, and accepted standard definition of quality in healthcare.
providers are necessary. These providers often focus on their own objectives and interests and do not focus towards a common goal.
Quality in Healthcare
Quality can be defined in different ways. In healthcare, a patient-centred definition is often adopted that involves the personal wishes. One individual places high demands on a certain quality aspect while another does not attach any value to it at all (Fibuch & Ahmed, 2017). Therefore, the individual health demands of patients are considered in the measure of quality of care. According to Fibuch and Ahmed (2017) healthcare quality can be defined as the degree to which healthcare increase the likelihood of desired health outcomes.
To further illustrate this, Nadziakiewicz and Mikolajczyk (2019) further specify the following aspects of quality of care: efficiency, security, equality, patient center care, effectiveness and availability, which are defined by (Verboom, Montgomery, & Bennett, 2016). It shows process quality indicators that identify the desired actions and elements of concern. “The process quality indicators are created on the basis of standards, guidelines for good practices in dealing with events, phenomena, activities separated from elements that make up the diagnostic or therapeutic process (Nadziakiewicz & Mikolajczyk, 2019)”.
Status Quo of coopetition between healthcare providers and insurers
In healthcare there is both cooperation and competition. Healthcare providers, insurance companies and other parties involved have to make agreements about the price, quantity and quality of care (Broek et al., 2018). The negotiations about those agreements is not without problems and often leads to a certain tension and conflicts between healthcare providers and insurers (Okma, 2008).
The impact of coopetition on the quality of care
Coopetition between healthcare providers and insurers is assumed to have a major impact on the quality of care. Dafny and Lee (2016) and Lied and Altman (2017) claim that coopetition, and particular competition, is necessary to guarantee the quality of care at the right ratio in terms of price. Griesinger (1990) claims that enterprises and organisations support a slight form of self-interest. This means that someone’s own interests are always put first, which has an adverse impact on the overall interest, the quality of care.
The results of research on the impact of coopetition, on the quality is divided among the authors. Theoretical evidence suggests a positive effect on the quality of care (Beitia, 2003). Empirical evidence is more divided and find both positive (Cooper et al., 2009) and negative (Propper, Burgess, & Gossage, 2008) relationships between competition and quality of care. They see significantly better results, for instance, higher survival rates in heart attack patients.
Health value chain
Vries and Huijsman (2011) emphasize that many healthcare providers realize that a holistic health view is necessary to provide effective and efficient care, which leads to better results for the patient. Burns, Danzon, and Kimberly (2002) claim that a health value chain could be a potential way to focus more on the common interest, the quality of care, which is only possible through voluntary collaborations between the different participants.
The health value chain is derived from the 'value chain' devised by Porter (1991). It focuses on value creation within a single organization. The health value chain is applied to the entire healthcare system, which consists of those directly or indirectly involved in the
provision of care. According to Burns, Danzon and Kimberly (2002), the health value chain can be divided into five main areas in which organizations have similar tasks, where every interface between individual participants can be seen as potential break-up points, which must be avoid for a smooth flow in the ‘health value chain’, see figure 2:
Vries and Huijsman (2011) and Behzad, Moraga, and Chen (2013) claim that the implementation of models such as the 'Health Value Chain' can led to a reduction in the use of resources and improve the quality of care. The health value chain promises an increase in efficiency and effectiveness in the quality of care for each patient. Porter and Teisberg (2006) claim that insurance companies should have a central role in the health value chain. They figure as long-term agents of the patients and can steer the health value chain both
horizontally and vertically. Insurers ensure a continuous exchange of information, through intensive customer contact.
Conceptual Framework
The literature review revealed research gaps about the impact of coopetition between insurers and care providers on the quality of care. Dagnino (2007) and Peng and Bourne (2009) claim that impact of coopetition in the healthcare sector is still not clear. Stolper, Boonen, Schut and Varkevisser (2019) and Broek, Boselie and Paauwe (2018) claim that the quality of care is still not the most important aspect in the coopetition between insurers and healthcare providers. They are both focused on their own interests, while there is a high potential to improve the quality of care through coopetition.
There is no concrete evidence of the extent to which coopetition between healthcare providers and insurers affects the quality of care. There has been too little empirical research into this subject, and quality is a factor that is difficult to measure. Barretta (2008) and Angerer, Brand, and Schmidt (2017) argue that few empirical studies have analysed the coopetition between healthcare providers and insurers. To the best of our knowledge, there is no study focusing on the daily operational interactions between health- and insurance
providers and their influencing factors (Angerer et al., 2017). Knowing this, the primary focus of this study is to close this 'research gap' and to generate new insights on this subject.
Combining all the theoretical insights has led to the following research framework in figure 3:
METHODS Research Design
The nature of this study is a case study design, defined as a form of research in which data is collected and interpreted to get a clearer understanding of this unknown subject (Corbin & Straus, 2014). For this research two in-depth interviews about coopetition between healthcare providers and insurers are conducted.
Another additional advantage of qualitative research is that it focuses on underlying beliefs, connections and motivations and study these in more detail. Instead of analysing large amounts of data from various people, qualitative research uses detailed data from a small amount of people (Patton, 2015). Therefore, a qualitative research suits the formulated research question of this study best.
Research Setting
Two organizations (one hospital and one insurer) have been selected, approached, and reviewed on this subject. The case study takes place in healthcare and focus on the coopetition between healthcare providers and insurers. Therefore, interviews are conducted with
representative of a hospital and an insurer. It is a top clinical hospital, from the Netherlands, that provides highly specialised care. Where development and quality are the main priorities. The insurance company is part of a larger concept and is a big name in the north of the Netherlands. Both interviewees are in management positions and responsible for the contract negotiations with the other side. Distinctive characteristics of the interviewed organizations are displayed in table 1.
Table 1: Overview of selected organizations used for interviews Type of
organization
Top Clinical Hospital Organization 1
Insurer Organization 2 Interviewee Commercial Business
Manager
Business Owner Care
Number of employees 4973 450 Number of admissions 33.061 *
Data Collection
For this study, 2 semi-structured interviews were used to collect data. The interviews are based on the interview guide that was developed by (Clifford et al., 2003). With approval, the interview was recorded and transcribed for further analysis. “A semi-structured interview is a verbal interchange where one person, the interviewer, attempts to elicit information form another person by asking questions (Clifford, Cope, Gillespie, & French, 2003).”
The interview guide addressed three main topics: Coopetition, impact of coopetition between insurers and care providers on the quality of care and the health value chain. As a result of which the interviewee was completely free in his answers. Based on the answers, further specific questions were asked to understand coopetition between hospital and insurance companies and what impact this has on the quality of care. The main concepts of this research have been operationalised through more specific questions, which are displayed in table 2 below.
Operationalisation of the most important concepts Table 2: Operationalisation of the most important concepts
Coopetition 5. What is the reason for cooperation between the care providers and the insurers?
6. How does a relationship between health care providers and health insurers come about?
8. To what extent is there coopetition between health care providers and health insurers?
Impact of coopetition between insurers and care providers on the quality of care
10. How does coopetition between insurers and healthcare providers affect the quality of care?
14. Is the quality of care the most important aspect of your relationship despite the degree of coopetition?
12. In a 'Health Value Chain', all parties in the care chain work together towards a common goal. To what extent would this influence the quality of care?
Data Analysis
The transcribed interviews are analysed by using coding. Coding can be used to identify and categorize the most important concept mentioned in the transcribed interviews (Corbin & Straus, 2014). The code tree is based on the most important aspects of the research. These aspects are all incorporated in the main question, which is central to this research, quality of care, coopetition between healthcare providers and insurers, impact of coopetition and the health value chain. An overview of the code tree can be found in table 3.
Table 3: Code Tree with most important concepts
Theoretical Background Main Code Definition
A. Quality of Care
(Nadziakiewicz & Mikolajczyk, 2019)
A1 Quality Quality of Healthcare while implementing coopetition
A2 Defining How do we define quality in Healthcare
A3 Perception Is there a general perception of care and quality
B. Coopetition between healthcare providers and insurers (Stolper et al., 2019); (Angerer et al., 2017); (Okma, 2008) B1 Insurers / healthcare providers
The role of insurers, and who have benefit from them, in relation to care.
Coopetition between healthcare providers and insurers
B2 Commitment Commitment of insurers towards take initiative B3 Control /
management
Can insurers influence the degree of coopetition
(Angerer et al., 2017); (Vries & Huijsman, 2011)
D. Impact of Coopetition
(Broek et al., 2018)
D1 Information Coopetition and the essence in healthcare
D2 Complexity To what extend have convergent interest impact on the level of coopetition
D3 Resistance Leven of resistance against coopetition
D4 Pros and Cons
Pros and Cons about coopetition for the quality of healthcare D5 Quality
Impact
RESULTS
To display the interview results per organization, the organizations are specified as organization 1 and organization 2.
Table 4: Defining Interviewed Organizations
Hospital Organization 1
Insurer Organization 2
Coopetition between care providers and insurers
From the interviews conducted it became clear that coopetition is a complicated way of working. There are 2 main key elements when it comes to coopetition between healthcare providers and healthcare insurers, which are: fulfil both the common- and the personal interests, which makes coopetition complex and the strong level of interdependency in order to operate. In coopetition between insurers and healthcare organizations the hardest challenge is to find the right balance between different interests of the two individual organisations and create a benefit for them both, while ensuring the quality of care. Organization 2 emphasises that their interest is twofold. “They want satisfied customers who stay and continue to pay premiums, and, on the other hand, they want the hospital to provide good care and be cost-efficient. The balance between health insurers and hospitals, the string you balance on, is very thin”.
A complex set of factors from different organizations that together ultimately represent a single societal interest, provide the patient with the best quality of care and the right
Quality of care
Ensuring quality is the top priority for a hospital and any other organization connected to the hospital. It’s their primary process, as stressed by organization 1, “We mainly strive for the right care, the right quality and in the right place” and stressed by organization 2
“Ultimately, it's all about the right quality of care and be sure that everyone has access to it. Achieving that is a complex process”. In the long term, insurers and healthcare providers want to achieve the same thing, the right price-quality ratio in the field of care, while respecting their own interests. Consensus appears to exist regarding that the quality of care is the most important as described by Organization 1, “It necessary to find the right balance. In which patient satisfaction must be considered” and organization 2, “We actually have to look after our own interests, but don't forget that we represent a social matter and care is the number one priority”.
The impact of coopetition on the quality of care
Coopetition has impact on the quality of care. Both in a positive and a negative sense. Nevertheless, the degree of coopetition between the insurer and care provider is noticeable and the parties believe that the other party can invest more in order to provide a positive stimulus to the quality of care and, on the other hand, make mutual negotiations smoother and, above all, fairer. Both parties agree that coopetition is necessary in this sector, but also see drawbacks. It appears that there are trust issues among the different organizations. Organizations 1 claims that they want to be entirely transparent, but that they are not sure what the health insurer will do with all the information. According to organization 1 there is a big difference between small and large insurance companies, with the largest insurers you usually make a multi-year plan, to really get to the content and discuss themes such as quality. In contrast, small insurance companies are very focused on their own interests and are less focused on the quality of care. “The small insurance companies are a little more competitive. Here you notice that there are more opposites if you compare them with the major insurance companies”. On the other hand, organization 2 claims that there is a level playing field in the negations, in terms of costs, which influences the quality of care. Insurers are obliged to publish their prices annually before a certain date. Hospitals put insurance companies under pressure, hoping that they agree for the lowest price, just before the due date. “The
The coopetition between insurers and healthcare providers improves the quality of care to some extent. Despite the convergent interest some interactive long-term relationships are set up to really look at the future and together improve care. Organization 1 experience this with influential insurers, “Together with the major health insurers we are trying to set up plans, related to value-based healthcare. What do we want to achieve in terms of quality of care, what are we aiming for? You really make such agreements with the largest healthcare providers”. These agreements create a necessary transparency between the provider and insurer, which benefits the mutual process of communication, development and sharing of ideas. Organisation 2 also experiences the potential of long-term agreements, only it is not able to make such long-term agreements with every care provider because not every care provider can give the right certainty about the number of treatments to be carried out in the coming years, which makes it difficult to make agreements on quality-related matters. In the first instance, the focus is on the economic aspect.
In the interviews with the organization 1 it becomes quite clear, the insurer has a management function and should make more use of it. The insurer encounters every care provider and can thus deliberately steer for quality and share positive developments with other organisations. Organization 1 is convinced that with the right approach, the insurer can
positively stimulate the quality of care. Organization 1 expects the following: “We had expected that the cooperation with the health insurer in this area would yield more”. On the other hand, the insurers think that hospitals should be more specific. What do they want to improve and how? It is easy to say that the insurers should steer more on improving the quality of care, because they have a management function in the healthcare network.
According to organization 2 quality can be a lot of things and is different for everyone. “There is, of course, another aspect to quality and that is, how efficiently do I let the process run?". That is also a way of experiencing quality”.
Both organisation 1 and 2 claim that soon, care will be brought closer to home and major quality steps will be taken in the way care is offered, mainly because of coopetition. The degree of efficiency will increase. Organization 2 thinks that “If more and more care is provided indoors or brought back to the first line, you create more efficient and shorter lines. This makes care more pleasant and efficient, which is certainly a form of quality
Health Value Chain
Looking for improvements, there is a lot of potential to improve the quality of care even further. According to organisation 1 and 2, coopetition plays an important role in this, because of interdependency. This not only concerns the way in which care will be offered to patients in the future, but also what kind of potential the 'health value chain' has on the quality of care.
DISCUSSION AND CONCLUSION Interpretation of Results
This research paper aims to answer the research question: How does coopetition between healthcare providers and insurers influences the quality of care?
With regards to the first element of the conceptual model, healthcare providers and insurers were found to have a high interdependency. In which both their own as the
collaborative interest. Because of size and uncertainties, the level over coopetition in relation to the quality of care between insurers and providers differs a lot. Where in some cases quality is one of the main topics of negations, in others it is hardly addressed. Some insurers as care providers are mainly focused on their own interest, money. The collective goal, quality of care is not their first priority. Fulfilling one's own interests makes coopetition regarding the
common interest, quality of care, extremely complex. It causes problems in negotiations and makes both organizations relatively passive in taking actions to maximize the quality of care. The increase in mutual competition as part of the coopetition between insurers and care providers ensures the coopetition focus less on the quality of care (Rosenau & Lako, 2008). This can be defined as the main problem in coopetition between insurers and care providers, which makes it difficult to align and fulfil both organizations interest, while assuring the common interest, the quality of care.
Complexity and how to define / provide quality in healthcare causes problems in the coopetition between insurers and care providers, as shown by the second aspect in the
Insurers and care providers are both convinced of the usefulness of a health value chain. A collective collaboration managed by one chain manager, in this case the insurer, who is in direct contact with the entire chain. This makes it easier to share expertise, experiences, and knowledge, which will ultimately have a positive influence on the quality of care. The cooperation of hospitals, insurers, and the government in the fight against COVID-19 is a clear example that a coopetition does pay off. There is need for collective collaboration. It is just not yet known how this form of coopetition by making use of a ‘health value chain’ can be implemented in practice. This requires new research. So this research has identified how the complexity of cooperation in this field influences the quality of care in general, because it has found that the complexity and different perspectives of insurers and healthcare providers ensures that the self-interest is more important than the common interest.
Hence, on the results of this research it can be claimed that cooperation between insurers and care providers has a major impact on the quality of care. Whether this impact is positive or negative varies considerably and depends on the relationship between insurer and care provider. Coopetition can have a major positive impact on the quality of care in the future, provided that the necessary requirements are realised in the form of a collaboration that does not yet exist.
Implications for Theory
This research increases the available knowledge on the impact of Coopetition between healthcare providers and insurers on the quality of care. In the literature review of this
research, Dagnino (2007) and (Peng & Bourne, 2009) mentioned that coopetition in healthcare is still under-researched and impact is unknown. Stolper, Boonen, Schut and Varkevisser (2019) and Broek, Boselie and Paauwe (2018), Raza-ullah and Kostis (2020) identified that insurers extensively negotiate with providers about the price and quantity of care, but that the quality of care is not or hardly addressed in these negotiations, and that both trust and distrust are the key mechanisms through which coopetition positively impacts relationship performance, that relationship was confirmed in the coopetition between insurers and healthcare providers. Therefore, complexity of the current coopetition and trust issues are identified as barriers to further improve the quality of care through coopetition. Griesinger (1990) claims that enterprises and organisations support a slight form of self-interest, which has an adverse impact on common interests or objectives. This form of self-interest indeed led to negative impact on the coopetition between insurers and healthcare providers and
balance between two organisations with convergent interests, which is exactly the case between the insurers and healthcare providers.
Implications for Practice
Insurers and healthcare providers that are willing to improve the quality of care together by efficient coopetition could make use of this research by identifying how their current way of coopetition together influences the quality of care. Now the value of
coopetition and the influence on the quality is clearer, insurers and healthcare providers can re-design their coopetition process based on this finding, an integrated health value chain. Furthermore, this research provides better insights in the potential causes for negative effects on the quality of care because of coopetition. Insurers and healthcare providers are now better able to identify these.
Critical Reflection
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