Orchestration versus bookkeeping: How stakeholder pressures drive a healthcare purchaser’s institutional logics

Bart A C Noort, Taco van der Vaart and Kees Ahaus

PLOS ONE, 2021, vol. 16, issue 10, 1-24

Abstract: Background: Healthcare purchasers such as health insurers and governmental bodies are expected to strategically manage chronic care chains. In doing so, purchasers can contribute to the goal of improving task division and collaboration between chronic care providers as has been recommended by numerous studies. However, healthcare purchasing research indicates that, in most countries, purchasers still struggle to fulfil a proactive, strategic approach. Consequently, a typical pattern occurs in which care improvement initiatives are instigated, but not transformed into regular care. By acknowledging that healthcare purchasers are embedded in a care chain of stakeholders who have different, sometimes conflicting, interests and, by taking an institutional logics lens, we seek to explain why achieving strategic purchasing and sustainable improvement is so elusive. Method and findings: We present a longitudinal case study in which we follow a health insurer and care providers aiming to improve the care of patients with Chronic Obstructive Pulmonary Disease (COPD) in a region of the Netherlands. Taking a theoretical lens of institutional logics, our aim was to answer ‘how stakeholder pressures influence a purchaser’s use of institutional logics when pursuing the right care at the right place’. The insurer by default predominantly expressed a bookkeeper’s logic, reflecting a focus on controlling short-term care costs by managing individual providers. Over time, a contrasting orchestrator’s logic emerged in an attempt to achieve chain-wide improvement, striving for better health outcomes and lower long-term costs. We established five types of stakeholder pressure to explain the shift in logic adoption: relationship pressures, cost pressures, medical demands, public health demands and uncertainty. Linking the changes in logic over time with stakeholder pressures showed that, firstly, the different pressures interact in influencing the purchaser. Secondly, we saw that the lack of intra-organisational alignment affects how the purchaser deals with the different stakeholder pressures. Conclusions: By highlighting the purchaser’s difficult position in the care chain and the consequences of their own internal responses, we now better understand why the intended orchestrator’s logic and thereby a strategic approach to purchasing chronic care proves unsustainable within the Dutch healthcare system of managed competition.

Date: 2021
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (1)

Downloads: (external link)
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258337 (text/html)
https://journals.plos.org/plosone/article/file?id= ... 58337&type=printable (application/pdf)

Related works:
This item may be available elsewhere in EconPapers: Search for items with the same title.

Export reference: BibTeX RIS (EndNote, ProCite, RefMan) HTML/Text

Persistent link: https://EconPapers.repec.org/RePEc:plo:pone00:0258337

DOI: 10.1371/journal.pone.0258337

Access Statistics for this article

More articles in PLOS ONE from Public Library of Science
Bibliographic data for series maintained by plosone ().