Multi-year contracts between Dutch hospitals and health insurers: Exploring contract function and frame

Formal contracts play a central role in the relationships between healthcare purchasers and providers. While formal contracts enhance clarity and accountability, they can also foster transactional, risk-averse interactions that prioritize self-interest over shared objectives. In the context of formal healthcare contracting, where collaboration is increasingly important, this study examines how contract function (control vs. coordination) and contract frame (prevention vs. promotion) intersect to shape the balance between contractual and relational governance. Despite prior research outside healthcare, little is known about how these dimensions are embedded in healthcare contracts.

Using content analysis of contracts, we examined 663 clauses from 42 multi-year contracts between Dutch hospitals and health insurers initiated in 2017, 2018, and 2019.

The analysis shows that contract clauses cluster into distinct groups. Clauses with a control function and a prevention frame dominate in operational and technical sections of contracts such as financial arrangements, dispute resolution, and monitoring. By contrast, coordination- and promotion-oriented clauses are more prevalent in collaborative sections, including shared objectives and operational coordination. At the contract level, variation is observed across health insurers in how these clauses are combined. Some contracts show a relatively balanced mix of contractual and relational elements, while others rely predominantly on control- and prevention-oriented clauses.

These findings demonstrate that clauses supporting both contractual and relational governance coexist within the same contract, albeit to varying degrees across health insurers, contracts, and contractual domains. The observed variation suggests differences in strategic orientation, contracting capabilities, and market position rather than a single optimal contracting model.