196 Chapter 7 quality of care. Stakeholders in maternity care agree that a different payment model is needed.32 The maternity care sector in the Netherlands has recently experimented with bundled payment, also named integrated financing, for collaboration in integrated maternity care organizations (in Dutch: integrale geboortezorgorganisaties, IGOs). In these IGOs, maternity care is organized in such a way that all involved providers, such as obstetricians, midwives, and postpartum care providers, can coordinate and cooperate more effectively with the aim to improve the quality of care. The IGO negotiates a bundled fee with the health insurers that covers the full range of maternity care services during the antenatal, intrapartum, and postpartum period. The IGO then distributes the money to the different care providers according to the amount and type of care they provide. This model creates a more flexible reimbursement structure compared to the traditional fee-for-service model in which maternity care providers are paid individually by the health insurers based on specific, predefined care activities.33 However, this experiment has not yet led to the expected improvements in care.33 About 90% of all healthcare professionals do not use it, which means that the results of current evaluations are inconclusive and cannot be generalized to the wider maternity care sector.34 More than 110,000 pregnant women, mothers, and professionals have signed a petition against this form of financing because they were concerned about the impact on women’s freedom of choice in healthcare providers.35 This has created a significant dichotomy between regular financing and the experiment of integrated financing, where it should have brought parties together. Furthermore, after five years of integrated financing (2017-2021), small differences in maternity care utilization and slower spending growth in IGOs were found, and no changes in health outcomes.33 The advantages experienced by IGOs can perhaps also be achieved without integrated financing through good collaboration between different organizations of care.36 Furthermore, there is a reluctance to shift financial accountability from health insurance companies to health care providers, which is one of the elements of integrated financing.37 Healthcare providers are reluctant to take on more financial responsibility. Primary care organizations are concerned that they are too small and have too few financial reserves to take on these financial risks and that they will be held accountable for outcomes over which they have no control. There are concerns that the secondary care budget will not follow the substitution of care towards primary care sufficiently, while more time and, therefore, budget will be needed to take on additional tasks in primary care.38 Insurance companies are reluctant to promise additional structural income to primary care as long as secondary care reimbursements are not reduced. Another barrier is a lack of trust between primary care providers and hospitals, as attempts to implement shared savings programs have failed because of disagreements over how to spend the potential savings.37 The deteriorating reputation of insurance companies and a lack of funding and leadership also hinder further reform.37
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