Modelo bidimensional pseudohomogéneo

The GynOncNet strategists presented the finalized business plan to the new insurance company representatives (which had been replaced after the insurance company’s merger) in January 2012 (see Figure 3.4 for a timeline of this year’s developments). The insurance company made no decision regarding the network’s financial support at the time. Although they found GynOncNet’s proposed regional organization an “attractive alternative” to the strong centralization model, the insurance company representatives decided to wait for a decision from the National Association of Healthcare Insurance Companies (NAHIC)15 _{regarding the reimbursement of joint surgeries (one of the two key}

operational practices proposed by the network) for ovarian cancer tumours (artefact #255; email; 10-02-2012). Despite the lack of resolution, the GynOncNet strategists were optimistic: the insurance company had seemed interested in the soft centralization model they were proposing, and the academic hospital’s Executive Board had also approved the network’s request for temporary funding. Robert communicated these new developments to the general hospitals through an official letter – distributed via email in February 2012 – and GynOncNet effectively began to implement its operational plans (artefact #255; email; 10- 02-2012).

NAHIC’s decision regarding the reimbursement of joint surgeries for ovarian cancer tumours came out in June 2012. It stated that the joint surgery costs should be settled between the collaborating hospitals – initially without suggesting a particular fee, and later explicitly indicating one (artefact #261; official letter; 29-06-2012). Based on the indicated fee, the GynOncNet care managers became aware – in July 2012 – that joint surgeries would not be enough to financially sustain the network (since the network also proposed joint surgeries for other tumour types, joint consultations, and tumour board 15 Zorgverzekeraars Nederland in Dutch.

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discussions) (artefact #263; slide deck; 9-07-2012). In this new context, either the insurance company would fully finance the network, or all the gynaecological cancer cases would need to be centralized in the academic hospital, making it impossible to improve the quality of cancer care in the region.

GynOncNet next met with the insurance company delegation in August 2012. During this meeting, they once again discussed the network’s proposal, and also addressed NAHIC’s recent decision – which the insurance company representatives had not been aware of. Once again, no decision was made. However, the GynOncNet strategists did ask for and receive concrete indications as to what information the insurance company needed in order to make this decision (artefact #256; email; 9-08-2012). At this point in time, the insurance company asked for another presentation on GynOncNet’s proposed model, which would address its potential qualitative benefits. This was because the medical advisor who had been the insurance company’s main contact person with regard to GynOncNet issues had also been replaced in the meantime, and needed to be properly briefed (artefact #281; memo; 23-10-2012). The insurance company also asked that the GynOncNet strategists make explicit the exact financial agreements that the hospitals would be making with regard to joint surgeries, expressed in terms of insurance reimbursement models.

This third and final presentation of the year would take place in October 2012. In the meantime, the GynOncNet care managers began to synthesize information on the financial implications of GynOncNet’s operations, as expressed in terms recognizable to the insurance company (artefact #285; email; 13-11-2012). Doing so further proved to the GynOncNet strategists that the network could not be sustained solely through the hospitals’ financial contributions (artefact #255; email; 10-02-2012). If GynOncNet could not secure the additional funding it needed through one of three options – the insurance company’s agreement, convincing the hospitals to increase their contributions, or convincing the academic hospital to extend its “transitional” financial support by a year – the network would have to (at least partially) cease operations. Should GynOncNet not secure sufficient funding, a great deal – if not all – of the region’s gynaecological cancer care would have to be centralized in the academic hospital. This would be an unsatisfactory outcome for two reasons. First, because the academic hospital would likely not be able to accommodate the region’s full patient inflow. Second, because forwarding all patient cases to the academic hospital would lead to a loss of medical expertise in the other general hospitals, “leading to a great deal of anger and disappointment in the region”. The academic hospital’s gynaecology division manager communicated these scenarios and consequences to its Executive Board on behalf of GynOncNet, through a last memo in October 2012 (artefact #281; memo; 23-10-2012). In this memo, he also asked for the opportunity to discuss these issues – and the future organization of gynaecological cancer care in the region – with the Executive Board. In the meantime, the care managers finalised their reframed financial proposal and forwarded it to the hospitals’ purchasers of medical services, asking that it be discussed by the Executive Boards and insurance company in their individual meetings. However, by then, their hopes of a positive decision from the insurance company were low (artefact #285; email; 13-11-2012).

In the end, in April 2013, the GynOncNet strategizing actors received word that their last proposal had not been discussed in the meetings between the insurance company and each of the partner hospitals (artefact #310; email; 24-04-2013). This indicated that neither the insurance company nor the hospitals’ Executive Boards supported the network’s proposal. When the GynOncNet gynaecologists next came together, in June 2013, they knew that their strategizing efforts – although outlining a good centralization model which improved the quality of care in the region – had failed to secure the necessary

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funding. The actors were left to find another way to organize gynaecological cancer care in the region, and their inter-organizational strategizing efforts – at least regarding the network’s initial form – came to an unsuccessful end (observation notes and artefact #305; meeting agenda; 6-06-2012).