Understanding competition between healthcare providers: Introducing an intermediary inter-organizational perspective

•The effectiveness of pro-competitive policy reforms in health care remains ambiguous.•Empirical studies regarding competition in health care overlook inter-organizational relations and networks.•Patient transfers, professionals' affiliations, and interlocking directorates constitute such relations.•Such inter-organizational relations mediate the effect of macro-level policy on micro-level outcomes.•The proposed macro-meso-micro level conceptual framework and propositions could guide future research.

Pro-competitive policy reforms have been introduced in several countries, attempting to contain increasing healthcare costs. Yet, research proves ambiguous when it comes to the effect of competition in healthcare, with a number of studies highlighting unintended and unwanted effects. We argue that current empirical work overlooks the role of inter-organizational relations as well as the interplay between policy at macro level, inter-organizational networks at meso level, and outcomes at micro level. To bridge this gap and stimulate a more detailed understanding of the effect of competition in health care, this article introduces a cross-level conceptual framework which emphasizes the intermediary role of cooperative inter-organizational relations at meso level. We discuss how patient transfers, specialist affiliations, and interlocking directorates constitute three forms of inter-organizational relations in health care which can be used within this framework. The paper concludes by deriving several propositions from the framework which can guide future research.