Objectives Withdrawal of reimbursement for low-value care through a policy change, i.e., active disinvestment (AD), is considered a potentially effective strategy to de-implement low-value care. However, previous studies have shown conflicting results and the mechanism through which active disinvestment may influence clinical decision-making is unclear. This study explored how an active disinvestment initiative of one of the four largest healthcare insurers regarding subacromial decompression (SAD) surgery for subacromial pain syndrome (SAPS) in the Netherlands influenced clinical decision-making around surgery, from the perspectives of orthopedic surgeons and hospital sales managers as the key stakeholders in this process.

Setting From January 2020 onwards, a Dutch healthcare insurer decided to actively disinvest in SAD-surgery for SAPS patients by partially withdrawing reimbursement (i.e. contracting 30% SAD-surgeries than the preceding year in each hospital). The latter was based on (inter)national clinical practices guidelines for SAPS.

Design We conducted 20 semi-structured interviews from November-2020 to October-2021 with ten hospital sales managers and ten orthopedic surgeons from twelve hospitals (including teaching hospitals, non-teaching hospitals and independent treatment centers) across the Netherlands as relevant stakeholders in the active disinvestment process. Hospitals sales managers form the liaison between the healthcare insurer and orthopeadic surgeons as the healthcare insurer informed hospital sales managers about this specific active disinvestment by email and during the annual healthcare contract negotiations. The interviews were video-recorded and transcribed verbatim. Inductive thematic analysis was used to analyse interview transcripts independently by two authors and discrepancies were resolved through discussion.

Results Two overarching themes were identified that negatively influenced the effect of the active disinvestment initiative. 1)’Too small piece of the pie’: Hospital sales managers indicated the AD had little financial consequences as it was merely used in negotiations, required a disproportionate amount of effort from hospital staff given the small saving-potential, and was not clearly defined nor enforced in overall healthcare insurer agreements. 2)’They [healthcare insurer] got it wrong’. Orthopedic surgeons highlighted that the healthcare insurer interpreted the evidence and guidelines incorrectly, the AD was at odds with clinician experiences and beliefs, and perceived the AD as a reduction in their professional autonomy. In addition, several contextual factors were identified that influenced the effectiveness of the AD, such as a lack of communication between relevant stakeholders, patient preferences, fear of losing revenues and simultaneous other interventions that rewarded rather than penalized hospitals for not performing specific procedures.

Conclusions The two overarching themes and their underlying factors highlight the mechanism and complexity for active disinvestment initiatives to produce its effect and influence clinical decision-making. Future active disinvestment initiatives should engage all relevant stakeholders at an early stage to gain support, ensure correct interpretation of the evidence and clear definition of the targeted procedures and should target those low-value procedures that have sufficient saving-potential to increase the possibility of success.