AIM: To gain insights into what business model-building and model-changing aspects make physiotherapy primary healthcare organisations (PTPHOs) attain and sustain superior performance in a changing environment, according to their managers. BACKGROUND: Since 2006, the transition towards managed competition in the Dutch healthcare market has been intended to improve the performance of primary healthcare organisations like PTPHOs. In such a market, competition on efficiency with reimbursement system has been introduced. Consequently, performance entails achieving and sustaining quality, efficiency, and financial outcomes. Superior performance requires that PTPHOs continuously align their external environment and internal organisation. The business model literature suggests that business model-building and model-changing support this alignment process. METHODS: This qualitative study had an explorative design. A pre-defined interview guide based on business model theory was applied. Semi-structured interviews were conducted with physiotherapy primary healthcare organisation managers and transcribed verbally. The transcripts were analysed using directed content analysis. FINDINGS: The study results show, both verbally and graphically, that PTPHOs generate superior performance in a changing environment through business model-building and model-changing. Participating managers (n = 25) confirmed extant findings that business model-building consists of strategy and business model configuration. In addition, business model-building entails establishing interfaces to exploit external environment and internal organisation information. Also, these interfaces are evaluative techniques and tools, action, and process - make sense of knowledge and information. To sustain superior performance, it is essential to change the business model. This can be achieved through three change cycles: business model change, short-term change, and long-term change. CONCLUSION: Managers of both superior and lower performance organisations ...