Analyzing Professionalism and Privatization in the Dutch Healthcare System
Name: Stefan van der Veen Super visor : Dr. Johan De Deken
Student ID: 6053564 Second reader : Dr. Stephanie Steinmetz
Date: 14 december 2015
In 2006 a new healthcar e system was installed in the Netherlands. The pr evious system was believed to be too costly. The new system aims to har monize cost-management and quality in
car e pr ovision. In order to r ealize this, healthcar e insur ers w er e privatized. Privatized healthcar e insur ers ar e believed to pr ocur e car e fr om car e pr of essionals that is both low-priced
and of pr ofessional quality, because this pr ovides them with a competitive advantage on the insurance-market. I analyze that as a r esult of this pr ofessionalism is af fected. This thesis investigates what the ef fect has been of privatiz ing healthcar e insur ers on the pr ofessionalism
of general practitioners and to what extent the goals of the newly intr oduced system can be expected to r ealize in a healthcar e model with pri vatized insur ers and pr of essional pr ovider-s.Twelve GPs and two healthcar e insur ers wer e inter viewed. This data was cr oss-verified with
car e-contracts. Initially, outside pr essur es ar e adopted by GPs, and they seem to ‘hybridize’ their pr ofessionalism. How ever, insur ers ar e not suppor tive of hybridization, but instead en-for ce extensive contr ol and management in car e pr ovision. As a r esult of this the goals of the
model ar e not likely to be attained.
I INTRODUCTION
Our moder n wester n society is no long er under the reign of plagues, epidemics or infestations. However, never have we lived in an epoch where health and ill-ness are dominating the public ag enda more as they do now. In recent years public expenditure on healthcare has become one of the larg est g over nmental spending items. In 2012 the EU member states 1 publicly 2 spend 6.5% of their
g ross domestic product (GDP) on healthcare (OECD, 2015). T he Netherlands
EU-28 minus Bulgaria, Cyprus, Malta, Romania, and Croatia, for lack of comparable data.
1
Public spending is calculated on the basis of comparable data on social security funds and other govern
-represents one of the big g est spenders in the EU with a public healthcare ex-penditure of 9.6% of their GDP in that same year 3. T he recent economic and
financial crises have weighted heavily on the fiscal position of most countries. T hese crises, combined with a rapidly g rowing health-care demand have rein-forced the need to improve public spending efficiently (OECD, 2010). A key policy challeng e is to improve efficiency in healthcare spending, while simulta-neously improving or maintaining quality in care provision.
T he Dutch g over nment felt pressures to refor m its healthcare system even
prior to the crises of 2008 and 2009. Already in 2006 the Dutch g over nment in -troduced a new Health Insurance Law (Zvw) to curb the rising costs. T his law aimed to protect and ameliorate the quality and cost-ef ficienc y of public health-care, by introducing regulated competition between care providers and insurers of healthcare (Van Kleef et al., 2012). T he implementation of this law has se-verely altered the Dutch healthcare system. As of 2006 the Dutch National Health Ser vice Funds were privatized. From that day forward, private healthcare insurers buy-in care from care providers on behalf of their insured clients. Care providers are believed to be professionals that are motivated to provide qualita-tive g ood care. Providing quality care can be at odds with containing the ever rising costs in the healthcare domain. Hence, regulated competition as a mecha-nism for healthcare allocation and financing was introduced because it is thought that private healthcare insurers stimulate medical professionals to not only provide care that is upheld by a cer tain professional standard of quality, but also provide care cost-efficiently. Because insurers compete with each oth-er, they strive to procure care that is both good and low-priced. Eventually, this will provide them with a competitive advantag e compared to the other insurers. T he stated policy g oals are believed to be attained by privatizing healthcare in-surers.
T his thesis investig ates what the ef fect of privatizing healthcare insurers has
been on the professionalism of care providers by focusing on g eneral practi-tioner care provision within the in 2006 implement model. And related to this, by analyzing this case I examine to what extent the central policy g oals can be expected to be attained in a system with privatized insurers and professional providers. It is hypothesized —based on literature and the research of others— that privatizing healthcare insurers can have one of the following effects on the
To compare: Dutch private expenditure amounts to 1.4% in 2012 (of which 0.6% are private out-of-pocket
3
payments and 0.7% are private insurance payments (other than compulsory insurance contributions)) and EU-28 private expenditure amounts to 2.1% in 2012 (of which 1.6% are private out-of-pocket payments and 0.4% are private insurance payments (other than compulsory insurance contributions)).
professionalism of care providers. (1) T hey can either experience depr ofessional-iz ing tendencies as a consequence of the privatofessional-ized institutional environment in which they have to operate (e.g. Broadbent et al., 2005); (2) they r epr ofessionalize their work to counter outside interference (e.g. Freidson, 2001; Tonkens, 2003); or (3) they can incorporate these outside inf luences into their work practices and their professionalism, consequently care providers hybridize their profes-sionalism (e.g. Noordeg raaf, 2007).
T his thesis shows that privatizing healthcare insurers results in them inf lu
-encing professional care provision (e.g. Pollitt, 1990). When market-considera-tions are incor porated into the professionalism of care providers, they can be said to hybridize. A hybrid g over nance system —which the Dutch healthcare system ultimately is— calls for hybrid professionals. Hybrid professionals pro-vide professional care cost-efficiently. As such, both policy g oals can be ex-pected to be attained. Neither deprofessionalized nor pure professional care provision can be expected to realize both g oals. Deprofessionalized care provi-sion is not provided according to a profesprovi-sional standard for quality. Hence, quality might be endang ered in such a provision system. On the other hand, a pure professional provision system cannot be expected to realize cost-efficiency in care deliver y since this is not a consideration for pure professionals. T he ambition is to have a system that guarantees professional quality and cost-effi-ciency. T his will only be realized if care professionals adapt and hybridize. T herefore, this thesis investig ates whether care providers —focusing on GPs— hybridize as a consequence of the policy measure to privatize healthcare insur-ers. T his research shows and examines: (1) why and how privatized healthcare insurers interfere with professional care provision; (2) that interference affects the professionalism of care providers; (3) that hybridizing professionalism can be a productive response to outside interference; and (4) if GPs in practice dis-play hybrid professionalism —and thus whether the policy g oals can be expect-ed to be realizexpect-ed.
Hybrid professionalism is a rather under-investig ated concept, especially in
the context of the Dutch healthcare model. Scientifically, it is interesting to re-search this under-investig ated concept because it offers insight into profession-al work in neoliberprofession-al times where market incentives are imposed on professionprofession-al work. Evidently, this is not only the case for medical professionals, but for all public professionals. Societally, it is interesting to research this concept be-cause quality and cost-efficiency of care are not the sole concer n of policy makers. Patients and citizens are equally affected by a healthcare model when it
is neither g ood in providing quality nor costefficient. In this thesis a theoreti -cal model of hybrid professionalism is developed using a mechanistic appr oach. T he empirical framework of this thesis exists of twelve semistr uctured inter -views with g eneral practitioners, almost exclusively working in the same region, inter views with the two big g est healthcare insurers in that area, and an inter -view with the Dutch Care Authority (Nederlandse Zor g autoriteit, NZa). T hese in-ter views were triangulated with documentation on care purchasing and the actu-al care contracts of both the inter viewed heactu-althcare insurers.
T his thesis is str uctured as follows. Firstly, in chapter 2 the new model of healthcare allocation in g eneral practitioner care is investig ated. We will see that privatization of care allocation aims to enhance consumer-oriented quality and treatment quality, as well as cost-efficiency in provision. Secondly, in chapter 3, I examine —on the basis of literature— what the consequences of this are for pro-fessional work, and how propro-fessional care provision is affected by the new model. Chapter 4 investig ates the professional responses to affected professionalism in care provision and examines whether productive interactions between professional work and administrative control can, in theor y, be established. T his will result in a theoretical model of hybrid pr ofessionalism, build up by several par ts of a mecha-nism that tog ether are believed to establish g ood and low-priced care provision. Here I utilize the process-tracing methodolog y as proposed by Beach and Peder-sen (2010). Moreover, a set of obser vable implications of each par t of the mecha-nism is for mulated. Finally, in chapter 5 the developed theoretical model is stud-ied in practice by investig ating care purchasing and the consequences of this for care provision by GPs. Evidence is g athered to see whether the obser vable impli-cations of the mechanism actually exist or not. T he aim of this empirical work is to confir m or disconfir m the existence of the hypothesized mechanism linking factors (the par ts of the mechanism) with a proposed outcome (low-priced quali-ty) in the investig ated case. I will show empirically that hybrid professionalism is indeed potentially beneficiar y to the Dutch policy g oals. However, the theoretical model is supplemented with a new dimension: institutional context. T he institutional context in which hybrid professionals operated can enable them to establish hy-brid deliver y, but it can also disable them to do so. If hyhy-brid deliver y is disabled the central g oals of the Dutch healthcare system cannot be expected to be real-ized.
II THE DUTCH HEALTHCARE ALLOCATION MODEL
T he Dutch g over nment feels responsible for, and aims to realize a care system that is affordable and provides qualitative g ood care (Tweede K amer, 2003-2004). Har monizing cost manag ement on the one hand and quality of care on the other, is not an easy task, and one that policy makers have been str ug gling with for the last three decades. Already in the eighties of the twentieth centur y, the costeffi -ciency of the care system was up for debate. Due to technological prog ress and financial pressures, cost containment became an issue. T he system was not be-lieved to be sustainable as a result of rising costs. T his culminated in the enact-ment of the Dutch Health Insurance Law (Zvw, Zor gverzekerings-w et) in 2006. T his law privatized all health insurers, thereby enabling them to compete, set prices, and make profit (VWS, 2007). Prior to the new Health Insurance Law existing ar rang ements for the provision of health care were believed to be inefficient and too costly. To improve this, it was thought necessar y to tur n to manag ement mod-eled after the private sector (Ackroyd, 2013, p. 21). As a consequence of this, the so called New Public Manag ement ideolog y entered the Dutch public policy do-main. Econom y, ef f ectiveness and, ef ficienc y are at the hear t of the NPM movement and were deployed to contain costs in the healthcare domain.
Previous state-centered, professional-driven ar rang ements were replaced by market-oriented models (e.g. Clarke & Newman,1997). However, the Dutch health-care model cannot be said to be solely g over ned by market forces. T he Dutch healthcare model after 2006 is characterized by a hybrid for m of g over nance. Healthcare is neither the exclusive domain of the state, the market, nor profes-sionals. T he Dutch model is defined by a market-orientation on the insurance market, while simultaneously maintaining professionalism in the provision of care. Brock et al. (1999) have argued that the provision of ser vices in the domain of healthcare can be said to be unavoidably professional. In the next chapter I will show that a market-orientation inherently inf luences the professional provision of care and related ser vices. T he remainders of this chapter is used to explain how a privatized healthcare insurance market is believed to help realize the two g oals which are at the hear t of the Dutch healthcare system.
Cost-efficiency of care provision is stimulated in this new model because healthcare insurers are competitive par ties that, on behalf of their clients, pur-chase care from care providers. T he price of insurance policies is a key factor for people deciding upon which policy they opt for. In the Dutch model all citizens
are oblig ed to do this on a yearly basis 4. As a result of this, healthcare insurers
strive to buy-in care that is cost-efficient in provision because this will enable them to offers low-priced healthcare policies.
Besides cost-efficiency in care provision, the new model also encourag es the provision of g ood care. T he procurement of g ood care provides insurers —in a similar fashion as low-priced insurance policies do— with a competitive advantag e on the insurance market. On this market insurers compete with one another for clients’ favor. Good insured care, similar to low-priced care, is key to persuading people to opt for a specific insurance policy. Hence, insurers aim to buy-in care that is of g ood quality. People do not solely have preferences concer ning the qual-ity of treatment. Qualqual-ity preferences also concer n the qualqual-ity of the ser vices pro-vided, i.e., the level of consumer-orientation in care provision. As a result of pri-vatizing healthcare insurers, insurers will tr y to persuade care providers to provide low prices, high treatment quality, shor t waiting times, rapid ser vices, and other wishes their clients have. In the Dutch model healthcare insurers have a private interest to do so. As such, privatization in the healthcare domain is ought to en-sure the realization of both policy aims. For the g oals to be realized, productive relations between insurers and providers have to be established. Insurers stimulate providers to be cost-efficient and provide g ood care. However, care is delivered by providers to patients. T he involvement of insurers into care provision alters the nature of provision by care professionals as I will explain below.
III FORCES AFFECTING PROFESSIONAL WORK
T he enactment of the new model in 2006 brought a ‘third par ty’ into the domain of healthcare provision. Provision by care providers to patient in the new model inevitably also involves the healthcare insurer. T his is because the patient does not pay for the ‘consumed’ care, but care-work is instead reimbursed by insurers directly to the providers of care. As such, in this model, care is consumed by a first par ty consumer (a patient) which is provided by a second par ty producer (e.g. GPs, specialist, physical therapist) and is payed for by a third par ty (the healthcare insurer) (e.g. Gilber t, 2002). Scholars have argued that this chang es the natur e of pr ofessional work in care provision (e.g. Freidson, 2001; Tonkens, 2003; Noorde-g raaf, 2007; 2015a; Knijn & Selter n, 2006; TrappenburNoorde-g, 2006; Duyvendak et al., 2006). Where care provision per viously followed a ‘professional logic’, third par ty involvement brings with it a ‘manag erial logic’ that contrasts to the professional
Every Dutch citizens is obliged by law to insure oneself for (possible) healthcare expenses. Moreover, the
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one, ultimately changing care provision. In this chapter I will investig ate (1) what the professional logic and professional care provision are, (2) how the new model has introduced a contrasting logic into the domain, and (3) how this is believed to affect professional work.
3.1 The professional logic and professional care deliver y
Professionalism is a distinct logic str ucturing work. A logic contains principles that concer n (1) how work is coordinated, (2) how authority is established, and (3) what values are put central. Taken tog ether, they compose a logic that str uctures work practices. T his analytic schema relates to the core dimensions of ordering and str ucturing work in org anizational circumstances (cf. Freidson, 2001; 1994; Adler et al., 2008; Noordeg raaf, 2007; 2015a). As such, a logic can be investig ated by explicating these three underlying principles.
Medical professionals adhere closely to a professional logic (Freisdson, 1970; 2001). T heir work is characterized by complex content, i.e., illness is no mere switch that can be fixed when it is broken. Rather, it is a ‘holistic’ affair that concer ns a rang e of inter related bodily activities and functions. T his calls for the deployment of highly specialized skills and exper t knowledg e in professional work. T hese specialized and exper t knowledg e and skills are derived from a model of technical rationality which is established through extensive professional training. Professional work consists of instr umental problem solving through the cor -rect application of g eneral and scientific knowledg e to specific cases (Schön, 1983). Moreover, the ‘professional method’ is made rig orous through the appro-priation of scientific theor y and techniques (Ibid.). T hus, professional work is co-ordinated through the rig orous and appropriate application of exper t skills and knowledg e. T he appropriate application of this, requires professionals to possess a cer tain deg ree of discretionar y power. Within the complex content they are con-fronted with, medical professionals need to be able to discretionar y apply their exper t skills and knowledg e (Freidson, 2001).
Within the professional logic, authority is established through professional exper tise. T his is realized through the establishment of rig or in professional work and through professional control of professional work. Rig or in professional work is realized by the routinization and institutionalization of professional practices and scientific theories and techniques. Ag ain, this is done by lengthy training of future professionals and through the continuous education of established profes-sionals. Both rig or and (continuous) professional training contribute to the exper t status of care providers. Professional exper tise is fur ther consolidated through
disciplinar y control of practices by the professional body itself (Freidson, 2001; Abbott, 1988). Because of the complexity of content and professional discre-tionar y power, non-professionals are ill equipped to evaluate professional work (Freidson, 1970). Professional exper tise is fur ther solidified by the professional claim to ser ve the public g ood, rather than private interests (Hupe & Van der Krogt, 2013). T he professional ideolog y asser ts that the application of knowledg e and skill follows a transcendental value and that they are not deployed to ser ve individual or economic g ains (Noordeg raaf, 2007). Sennett has characterized med-ical professionals as craftsmen that have institutionalized the basic human impulse to do a job well, solely for the sake of doing the job well (Sennett, 2008). T he professional logic stipulates that proprofessionals establish their authority through exper -tise which they appropriate through professional training, disciplinar y control, and by ser ving the public g ood. Effective authority g rants professionals with a cer tain deg ree of autonomy from outside interference in their work.
T he professional logic values quality of work over any other value. T his log-ic establishes regulator y mechanisms such as ethlog-ical oaths, r ules and codes of conduct, and routines. T he aim of these mechanisms is to train and socialize pro-fessionals to secure quality in their work (Noordeg raaf, 2015a).
Table 3.1 The pr of essional logic str ucturing pr ofessional car e pr ovision 5
Specialized skills and knowledg e, exper tise, and the emphasis on quality reinforce each other. Tog ether they constitute the professional logic and str ucture profes-sional care provision. Table 3.1 depicts the three principles that tog ether pre-scribe what I conceptualize as the ‘pure’ mode of professional care provision. Within this mode, work is coordinated through skills and knowledg e, authority is established by professional exper tise, and quality in care provision is valued over any other merit.
Principles Pure Professionalism
Coordination Skills and knowledge
Authority Expertise
Value Quality
This table is adopted and adapted from Noordegraaf, 2015a.
3.2 A Contrasting Logic: Mana gerialism
T he professional logic as conceptualized above does not accommodate outside in-terference. Instead, pure professionalism demands discretionar y power and auton-omy. However, in the Dutch model care professionals are exposed to outside in-f luences embodied by healthcare insurers. As opposed to care proin-fessionals, healthcare insurers are the third par ty in the care domain and consequently adhere to a manag erial logic. T his logic contrasts to the professional one.
As explained above, privatization entails that healthcare insurers purchase care from providers that is consumed by their clients. T he insurer effectively op-erates as a third par ty in the process of care provision (Schut, 2009). T his third par ty is supposed to adopt the perspective of the consumer. Gilber t raises con-cer n about the allocation of ser vices or products through a third par ty. He notes that third par ties fail to provide “consumer signals that ser ve to regulate cost and quality in the competitive market” (Gilber t, 2002, p. 117). Allocation through a third par ty (healthcare insurer) is problematic because the third par ty buyer does not consume the ser vices acquired, the first par ty consumer (patient) does not pay for the ser vices received, and the second par ty producer (care provider) “stands in the highly advantag eous position of dealing with a buyer who rarely sees what is purchased and a consumer who never bears the expense” (Ibid).
As a result, the relation between insurers and providers of care is character -ized by two central principal-ag ent problems. In buying care, insurers (the princi-pals) are faced with the classic ag ency problem of asymmetric infor mation (Shapiro, 2005). Care providers (ag ents) are better infor med about the treatment and ser vices they provide than insurers (principals). Secondly, the interest of in-surers and care providers are not aligned. Care professionals are believed to value the quality of care, as I argued above. Insurers are too. However, insurers also value cost-efficiency in care deliver y. Cost-efficiency and quality care provision can be at odds with one another. Hence, interest alignment between the two par-ties is not a given.
In the process of procuring care, insurers are at a disadvantag e. T he infor -mation about (the quality and the cost-efficiency of) treatment and ser vices is nested with providers of care. Insurers do not have guaranteed access to this. Ag ency theor y predicts that a disadvantag ed position implies that principals are faced with adverse selection, resulting in sup-optimal outcomes. T he result of this might be that the care they purchase is either not adequate, and, or over-priced. Moreover, insurers have no control over the actual treatments and ser vices
deliv-ered, effectuating the possibility for oppor tunistic behavior and ‘moral hazard’ on the side of the ag ents 6. Principle-ag ent theor y proposes that these objections
might be countered by installing infor mation systems and monitoring practices. T hese will adjust the existing infor mation asymmetr y and enable insurers to pre-vent hidden action, oppor tunistic behavior, and moral hazard. Fur ther more, ag ency theor y stipulates that principles can offer ag ents incentives to align their interests to that of principals (Shapiro, 2005). Insurers can tr y to stimulate care providers to not only value quality in provision but also the cost-efficiency of it.
Noordeg raaf (2015a) has argued that principals will adopt a ‘manag erial logic’ to overcome the two central ag encyproblems. According to this logic, profes -sional work has to be vig orously contr olled to counter the infor mation asymmetr y and managed in order to align the interests of the principal with the professional perfor ming the work. Other scholars have argued in the same vein that principles indeed wish to control, super vise and steer the outcome of ser vice deliver y (Pol-litt, 1990). In order to realize this, insurers can enforce extended accountability practices onto professional practices. Because care is far from a homog enous product, care providers will have to make an extensive effor t to map the relevant infor mation in order to breach the infor mation asymmetr y (Eng elen, 2005). In the ag ency literature, these effor ts are called bonding-costs (e.g. Jensen & Meckling, 1976). Fur ther more, in order to align their interest with that of care providers, manag ement is installed in professional work. Principles will tr y to add manag erial targ ets, incentives, or straight-up commands to the professional environment.
3.3 Controlled care provision
As a consequence of their position as a third par ty in the system insurers adopt a manag erial logic. T his affects the provision of care by professionals. Tokens (2008) has argued that medical professionals experience a g rave rise in manag erial practices in their day to day work because a rang e of manag erial targ ets are added to the professional environment. Trappenburg (2006) has analyzed that increased interference of third par ties with professional work has compelled professionals to abide by manag erial standards. She has obser ved that managing professional work leads to an ‘audit-explosion’ because professional work has to be made veri-fiable (2008).
Manag erialism in care provision can be described as org anized and manag ed action aimed at providing care and related ser vices that satisfy consumer
Hidden actions result in in-efficiency from the perspective of the principle, while the agent is not adversely
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ences (Noordeg raaf, 2015a). In the Dutch model, provision of care is the domain of medical professionals. However, care provision is financed by private health-care insurers. T herefore, private healthhealth-care insurers want to control and manag e the work of professionals. As a result of this, care deliver y by professionals is se-verely controlled and manag ed by insurers. Where the professional logic pre-scribes a pure professional mode of care provision, the manag erial logic which is adopted in a hybrid system by insurers, prescribes a controlled mode of care de-liver y. T his mode is characterized by three distinct principles: hierarchy, account-ability, and cost-containment in professional work.
T he manag erial logic of professional care deliver y stipulates that work is coordinated through hierarchical str uctures. Private insurers are believed to be driven by a profit-motive. As a result, they tr y to establish competitive advantag es in comparison to other insurers, by offering low-price and guaranteeing (con-sumer-oriented) quality. In order to do so, care and ser vices have to be delivered by prescribed providers with clear roles and responsibilities (Noordeg raaf, 2015a). In accordance with the manag erial logic, insurers will tr y to instal hierarchical str uctures in the deliver y of care ser vices. T hrough hierarchical coordination of care provision, insurers can control the ways in which care is provided and hence safeguard cost-efficiency and guarantee quality.
According to the manag erial logic, professional work has to establish au -thority on the basis of results and continuous improvement which are realized through extended monitoring and subsequent actions (Noordeg raaf, 2015b). All of this ser ves the insurer's primar y interest in enhancing profit. Only when care pro-vision is clearly str uctured and monitored, can costs be contained and controlled, and can a cer tain deg ree of (consumer-oriented) quality be guaranteed. If this is realized, an insurer will have a competitive advantag e on the insurance market. Hence, medical professionals will have to establish their authority by extensive ac-counting to their manag ement, i.e., healthcare insurers.
Private healthcare insurers are driven by a profit-motive. As such, they stimulate cost-containment in care deliver y by medical professionals. T he provi-sion of care according to the manag erial logic is controlled and manag ed strictly in order to maximize effective and efficient deliver y of care and related ser vices.
Table 3.2 The managerial logic str ucturing contr olled car e pr ovision 7
Table 3.2 lists the three principles of manag erialism in care provision. A manag er-ial logic will lead to the installment of a ‘controlled mode’ of doing professional work. Controlled professionalism clearly contrasts to the mode of working that a professional logic prescribes. Professionals are motivated to do a g ood job just for the sake of it (Sennett, 2008) and hence coordinate work through specialized skills and knowledg e, establish authority by exer ting their exper tise, and value quality (as was established in section 3.1). Insurers on the other hand, are stimulated by the profit-motive. T heir strive for profitability inf licts strict hierarchies and estab-lishes extensive accounting in professional work. Fur ther more, their ambition leads them to force professionals to contain costs.
IV PROFESSIONAL RESPONSES TO FORCES AFFECTING PROFES-
SIONAL WORK
Privatization of healthcare insurers implies that work practices of professionals are affected by a new logic. In this chapter I will discuss the two primar y theories on affected professionalism and introduce an alter native. T his alter native theor y is fur ther investig ated and operationalized for empirical investig ation using process-tracing methodolog y (Beach & Pedersen, 2010). T his alter native theor y is under-investig ated. It is therefore rather interesting to empirically establish its merits.
4.1 Theories on Af fected Professional Work
Professionalism in its pure for m requires skill, exper tise, and quality assessment to be independent from manag erial targ ets and bureaucratic administration (No-ordeg raaf, 2007). T he rationale is that professionals in their daily practice do not need to consider the costs of treatment, but the necessity of it. Never theless, in accordance with the manag erial logic, insurers tr y to control professional practice.
Principles Controlled professionalism
Coordination Hierarchy
Authority Accountability
Value Cost-containment
This table is adopted and adapted from Noordegraaf, 2015a.
T hey thereby affect the core of the professional logic. Manag erialism does not af-fect the content of professional work directly. However, the central focus of the manag erial logic on profitability affects professional practices because cost-effi-ciency is imposed into the work practices of care professionals. As a consequence of this, professional autonomy and discretion are affected, and hence professional work is believed to deprofessionalize (e.g. Broadbent et al., 2005).
When medical professionals experience deprofessionalizing tendencies, we can contemplate on the effects of this. If a deprofessionalized system of care provision is established, cost-efficiency might indeed be expected to be realized. However, the other aim of the Dutch model —professional quality in care deliv-er y— will be at risk. T he professional standard of quality is suppressed by the manag erial profit-targ et imposed upon professional work.
Other scholars have obser ved and argued for the re-establishment of the professional logic (e.g. Freidson, 2001; Tonkens, 2003). T he controlled mode of doing professional work is not considered to be professional because it lacks sub-stantive strength and disciplinar y control (Noordeg raaf, 2007), and hence this might lead professionals to completely reject manag erial interference in their work. Freidson (2001) has argued for the re-establishment of professional control, to counter the deprofessionalizing tendencies that result from manag erial interfer-ence. Professionals have to be reinstated with their exper tise and autonomous control, and have to be re-g ranted the power to decide about cases and treatment. As such, reprofessionalized care professionals, in contrast to deprofession -alized care providers, have a free hand in establishing professional quality in care deliver y. If the medical professional indeed is re-professionalized as a response to the introduction of regulated competition, this policy aim can be expected to be realized. However, the aim to provide cost-efficient care is endang ered in a re-professionalized care provision system. T his is because professionalism does not consider the cost-efficiency of care deliver y. Moreover, if re-professionalized care professionals completely reject any for m of control that tries to establish cost-ef-ficiency, this policy objective cannot be expected to be attained.
4.2 An Alter native Theor y: Hybridizing Professional Work
T he above described theories view professionalism as unable to accommodate out-side inf luences. When confronted with outout-side interference, professionalism will either be adversely affected or reject the possibility of incorporating these into existing work practices. Scholarly proponents of the so called hybrid logic view pro-fessional practices as inherently ref lective (e.g. Schön, 1983; Noordeg raaf, 2007).
T hey dispute theories that consider professionals as instr umental problem solvers unable to incor porate outside inf luences. T hey contend that pressured by alien logics —manag erialism in this case— professionals will adapt their own logic pro-ductively. Conditions for professional work have chang ed through privatization and subsequent manag erial interference. Professionals are no long er able to oper-ate within the compound of their own logic. According to proponents of the hy-brid logic of professionalism, professionals will relate and adapt to the sur round-ings they operate in. In fact, they will establish a mode of doing professional work that neg otiates pure with controlled professionalism, and hence establish a productive mode of doing work in a chang ed environment.
In this neg otiated mode, professional work is coordinated though cooperation and interaction with other professionals as well as with manag ement (Noordeg raaf, 2015a). Within this mode, professionals link their own action to manag erial tar-g ets and conditions (Ray & Hinnintar-gs, 2009). When the professional and the man-ag erial logic come tog ether, mixed coordination arises because professional work is now coordinated by multiple logics. In order to coordinate professional action, both coordination through exper t skills and knowledg e and through hierarchical str uctures are needed (cf. Adler et al., 2008). Cooperation and interaction between the professional and the manag er is therefore central to neg otiated care provision.
According to the manag erial logic, authority is established through extensive accounting by controlled professionals. In the neg otiated mode, authority is estab-lished through the deliver y of r eliable treatment and related ser vices. Reliability implies that professional exper tise, and hence a cer tain deg ree of autonomy is recognized and g ranted to professionals. Never theless, accounting is also indis-pensable for the deliver y of reliable care. Professional self-g over nance and man-ag erial monitoring are combined (cf. Byrkjef lot & Krman-agh Jespersen, 2014) to en-sure transparency to the professional body, the manag ement, and the consumers of professional ser vices. As such, accounting and autonomy are combined to es-tablish reliability in treatment and ser vice deliver y.
Reliability bears with it a quality dimension. Professional autonomy, moni-toring of and improving upon treatment and ser vices delivered are aimed at guar-anteeing a cer tain deg ree of professional quality. Moreover, reliability also aims to realize cost-efficiency in care deliver y. T his is realized by transparency, monitor-ing and benchmarkmonitor-ing. T his aim is fur ther suppor ted by the main value drivmonitor-ing hybrid professionals. “Hybrid professional work offers the best of both worlds: it provides quality, but also secures [..] efficiency” (Noordeg raaf, 2015a, p. 9). Quali-ty is ensured by both professional skill and exper tise, and efficiency by installing
cooperative relations with insurers and extended transparency and monitoring, amongst others
Table 4.2 The hybrid logic structuring negotiated car e pr ovision 8
A hybrid logic in professional work establishes a neg otiated mode of professional-ism, where work is both professional and controlled at the same time. Table 4.2 lists the three main principles str ucturing neg otiate care provision.
4.3 Conceptualizing and Operationalizing Hybridized Professional Work
Hybrid care professionals strive for cost-efficient deliver y that can live up to a professional standard of quality. Hence, the Dutch healthcare model should pro-mote a hybrid logic and neg otiated professionalism in care deliver y. Where depro-fessionalized care deliver y is ineffective because quality is at risk, (re-)profession-alized deliver y is inefficient because the costs of work are not considered, neg oti-ated care provision in fact both follows a professional standard for quality as well as a manag erial cost-efficiency targ et.
T he final chapter of this thesis investig ates whether a hybrid logic is pro -moted in the Dutch healthcare system and adopted by GPs. In this parag raph I use process-tracing methodolog y as proposed by Beach and Pedersen (2010) to opera-tionalize hybridity in care provision for empirical investig ation.
According to the processtracing methodolog y a mechanism has to be de -rived from theor y that can “hypothetically link X with the outcome Y” (Ibid., p. 5). According to theor y, privatization of healthcare insurers will realize its aims through hybrid care deliver y. T he policy aims are realized through the establish-ment of neg otiated professionalism in care provision. T his can be said to be the mechanism causing the realization of the policy aims. Figure 4.1 displays the theor y
Negotiated professionalism
Coordination Cooperation and interaction
Authority Reliability
that links the policy measure with the proposed outcomes through the hypothe-sized mechanism.
Figure 4.1 T heor y and the mechanism ‘causing’ professional quality and cost-efficiency
T he second step in process-tracing is to develop a set of hypothesized obser vable implications of what we can expect to see in the empirical evidence (Ibid.) T heor y sug g ests that neg otiated professionalism as a mechanism can ‘cause’ the realiza-tion of the policy aims if each par t of the mechanism exists empirically.
Table 4.3 A conceptualization and operationalization of neg otiated professionalism as a mechanism
In table 4.3 the three par ts of the mechanism are conceptualized and the expected obser vable implication of each par t is listed. T he final step in of process-tracing is to g ather evidence to see “whether the obser vable implications of each par t of the mechanism actually exist of not” (Ibid., p. 5). T he process-tracing method can be used to establish the presence or absence of a hypothesized mechanism through inspection of the obser vable implications of it in a specific case. More-over, by this process, research tests whether the hypothesized mechanism operates as was hypothesized (e.g. Pawson & Tilley, 2009).
V THE IMPLICATIONS OF PRIVATIZATION IN GENERAL PRACTI-TIONER CARE
In 2006 healthcare insurers were privatized, effectively introducing market-orien-tation in the healthcare domain. In this thesis the Dutch model was defined as a hybrid model. T his means that healthcare is not the sole domain of private insurers because the provision of care was established to be unavoidably professional (e.g. Brock et al., 1999). Hybridity implies a continuous balancing of two g over nance str uctures; market versus professional (e.g. Freidson, 2001; Noordeg raaf, 2007). I have operationalized the two g over nance str uctures as two logics. Moreover, I have shown that combining the two may lead professional provision of care either to deprofessionalize or may lead professionals to re-establish a professional logic.
Conceptualization Operationalization
1 Professionals coordinated their work through
cooperation and interaction with the managerial context
Expect to see GPs and insurers to cooperate and interact with each other to provide care to patients
2 Professionals establish their autonomy through
producing reliable care;
Expect to see GPs to work transparent,
administer their work, and be willing to participate in monitoring and accounting
3 Professionals value the efficient delivery of high
quality care.
Expect GPs to value both the quality and the cost-efficiency of the care that they provide to their patient
I have also introduced and alter native theor y that proposes that professionals hy-bridize as a result of combining the two logics into one provision system. T he Dutch model was installed in 2006 to realize professional provision of care, while at the same time guaranteeing cost-efficiency. Hence, a hybrid model was erected. Neither deprofessionalized, nor re-professionalized provision was argued to real-ize both g oals. T herefore, a hybrid model ultimately calls for hybrid professionals to provide care that is upheld by a professional standard of quality and is cost-ef-ficient.
T his final chapter of this thesis investig ates (1) what the effect of privatiz-ing healthcare insurers has been on the professionalism of GPs, and (2) to what extent the two objectives can be expected to be attained in a system with priva-tized healthcare insurers and professional providers. In the previous chapter a mechanistic approach was adopted to conceptualize a mechanism causing the poli -cy objectives to materialize. Neg otiated professionalism in provision was hypothe-sized to be the mechanism that links the privatization of insurers with these g oals. T his mechanism was hypothesized to be comprised of three par ts. In this final empirical chapter, the professionalism of GPs is investig ated to see whether they display negotiated pr ofessionalism —as conceptualized and operationalized in chapter four— in their work. And, whether we can expect the two policy g oals to be real-ized by it.
5.1 Operationalization and Methodolog y
In the previous chapter the process-tracing method was utilized. T his method can be used to test whether a plausible mechanism causing an outcome is actually present in the evidence of a given case and whether it operates as is expected. In chapter four the first two steps of the process-tracing method —as laid out by Beach and Pedersen (2010)— were taken. Firstly, the mechanism linking the policy measure to the intended outcome was derived from theor y. Secondly, this mecha-nism was operationalized as a set of related par ts. Moreover, each conceptual par t of the mechanism was operationalized as having an obser vable implication in the empirical evidence. T he final step in this method is to see “whether the obser v-able implication of each par t of the mechanism actually exist or not” (Beach & Pedersen, 2010, p.5).
To that end, evidence has to be g athered on the professionalism of care providers. T his means that an appropriate data g athering method has to be adopted. I g athered evidence on professionalism in GPcare provision through inter -viewing both GPs and healthcare insurers. More specifically, I examined the
process of care-contracting. In this process insurers contract in care that is pro-vided by GPs. In these contracts remunerations for work as well as the ter ms and conditions of care provision are defined. In my empirical research I focused on the contracting-in of general practitioner-care. GPs in par ticular are an interesting population of medical professionals to study. Firstly, GPs can be argued to be the sub-discipline of the medical profession pre eminently that is most directly af-fected by privatization. GPs are in direct contact with healthcare insurers for re-muneration contracts —where, for instance, medical professionals in hospital are not. Secondly, GPs are the g atekeepers of specialized care. In this role, they are ver y cost-effective (LHV, 2012). Almost 90% of all care-requests GPs receive, are dealt with for roughly 3% of the total public care budg et. Hence, when it comes to cost-efficiency (one of the policy aims), care provision by GPs is of pivotal impor tance.
I have fur ther specified the case of contracting-in GP-care to an exemplifying case study (Br yman, 2008). In the Netherlands, GPs are org anized locally. T he pop-ulation of GPs I studied are g eog raphically located in the Nijmeg en area, in the east of the Netherlands. T hrough the GP-association in Nijmeg en, CIHN, I was able to inter view eleven GPs 9. Tog ether with the local GP-association, I was able
to compose a list of 31 GPs. T hese GPs were selected out of the 241 members on the basis that they were directly involved with contracting-out care. Out of these 31, eleven GPs made time for an inter view of about one hour 10. T hese inter views
were complemented with an inter view with one GP in the Amsterdam area. T he experience of the Amsterdam GP did not contrast to the experience of the Nij-meg en GPs, which could be taken to be a verification of the transferability of this research 11 12, . T he selected case offers a suitable context for examining care-con
-tracting. On a small scale, the processes, the attitudes of the ag ents involved, and
See the annex of this thesis for a further description of the sample.
9
For the interview item list see the annex of this thesis.
10
See the annex of this thesis for a further discussion of transferability and the quality of the empirical re
11
-search in general.
Care-contracting practices are a hot debate topic in the Netherlands. GPs oppose the powerful and intru
12
-sive position of healthcare insurers. Investigating conflict and dissatisfaction can be risky, as the research may be biased because only the dissatisfied respond to an interview-call. I have tried to estimated the mea-sure of bias by looking at whether or not respondents sympathize with the national organization of dissatis-fied GPs. In the total population, 69% of the GPs sympathize with this organization (Het roer moet om, 2015) (69% of all GPs in the Netherlands have signed a manifesto expressing their dissatisfaction towards con-tracting-practices), compared to 67% (8/12) in my sample. This can be taken as an indication that the
re-the consequences of care-contracting on re-the professionalism of GPs can be inves-tig ated.
A research design based on a case study lacks the preconditions for g eneral-ization. Never theless, the aim of the exemplifying case study is not to g eneralize, but rather to capture the processes of the specific case, and to theorize on them (Yin, 2003). T he criticism to single case studies is that they would only yield one reasonable theoretical outcome: the g eneration of hypothesis that may be tested in other, more numerous cases (Rueschemeyer, 2003). However, Reuschemeyer (2003), amongst others, has argued that single case studies can develop new theo-retical ideas that can be tested in the same study. Moreover, within the case the results of theor y testing can be used to explain outcomes. T his view is shared by Beach and Pedersen (2010) who adopt a mechanistic ontolog y of causation that underlies their process-tracing method. Case-based studies can yield theoretical g ains, can be used to test theor y, and can offer compelling causal explanations be-cause a single case does not represent a single obser vation. Instead a case is com-prised of an intricate web of interconnected obser vations. As such, a case repre-sents many data points. Reuschemeyer (2003) notes that the advantag e of the sin-gle case study is in fact the close attention that can be given to the complexities residing in the case. Because of the inherent confrontation of theoretical claims with empirical evidence that is made in qualitative case analysis, case studies enjoy two significant advantag es over quantitate research: “it per mits a much more di-rect and frequently repeated inter play between theoretical development and data, a n d i t a l l ow s f o r a c l o s e r m a t ch i n g o f c o n c e p t u a l i n t e n t a n d e m p i r i c a l evidence” (Ibid., p. 318). Hence, a single case study design fits the aim of this thesis; examining the consequences of privatization on professionalism, and the extent to which the Dutch system can be expected to realize quality and cost-effi-ciency in GP-care provision.
Out of the total of twelve inter views, eleven were conducted face-to-face, and one on the phone. T heoretical saturation was reached early on in the research, implicating that new data did not offer new infor mation to that which had been attained earlier (Br yman, 2008). T his also means that the relationships residing in the data are well established and validated within the sample (Strauss & Corbin, 1998, p. 212). Never theless, I continued the research process until the list of 31 GPs was exhausted to establish that there were no deviant cases 13.
Deviant case analysis is an attribute of the grounded theory approach. See the Annex for a more detailed
13
Fur ther more, I have conducted inter views with the two big g est healthcare insurers in the Nijmeg en area 14. T he inter view data were triangulated with docu
mentation on contractingin care provided by both the inter viewed healthcare in -surers 15 16, . T he empirical evidence of this thesis consists of twelve inter view tran
-scripts with GPs, two with healthcare insurers, and the care-contracts of both these insurers. My research into the practices of contracting-in GP-care in Nij-meg en was preceded by an inter view with the Dutch Care Authority ( Nederlandse Zor g autoriteit, NZa) to familiarize myself with the detailed practices of contract -ing-in care. T he inter view data were transcribed and analyzed using a qualitative data analysis prog ram. T his prog ram was use to inductively compose an empirical-ly g rounded theor y that can explain what the effects of privatization on profes-sionalism have been, and whether the Dutch system can be expected to realize both quality and cost-efficiency 17. A g rounded theor y (GT) approach was adopted
to analyze the empirical evidence. T he GT approach depar ts from a different epis-temological standpoint 18, as does the process-tracing methodolog y. A GT ap
-proach insists that there are no pconceived ideas or hypothesis prior to the re-search process (Glaser & Strauss, 1967). However, the aim of this thesis is to test the presence and the working of a hypothesized mechanism. T herefore, GT as a method of analysis seems a mismatch. Never theless, GT offers researchers —even when theoretical propositions are developed prior to the research process— clear directions on how to sor t, g roup and categ orize the empirical evidence. Hence, I perceive —as do others (e.g. Allan, 2003; Silver man, 2006)— there to be no real anomaly between process-tracing as a method to map, conceptualize and opera-tionalize research and the GT approach as a method to analyze empirical evidence and subsequently constr uct an empirical theor y.
The way the system works is that a GP contracts-out care to the insurer that has the highest proportion of
14
insured patients within his or her practice. Because historically insurers operated locally, there is a regional clustering of patients with insurers. In the Nijmegen area both VGZ and CZ have the highest proportion of patients in the area compared to the other insurers. Hence, GPs contract-out care to one of these two insur-ers. The other insurers adopt the contract that GPs agree upon with one of the biggest insurinsur-ers.
I have chosen to triangulated the interview data with care-contracts to (dis)confirm claims made by both
15
GPs and/or insurers. Cross-verification from two sources and combining research methods (interviewing and document analysis) has been found to be a powerful technique for data validation (Bogdan & Biklen, 2006). In this way, the claims both GPs and insurers made on contracting practices, could be verified by comparing them to the actual care-contracts. As such, triangulation is a strategy that adds rigor to an inquiry (Denzin & Lincoln, 2000).
See the annex of this thesis for links to the care-contracts used to triangulate the interview data.
16
See the annex of this thesis for a further discussion of the method of analysis.
5.2 Investigating Negotiated Professionalism
What have been the effects of privatizing healthcare insurers on the professional -ism of care providers? By privatizing healthcare insurers, the Dutch model became a hybrid model. In such a model, quality and cost-efficiency can only be realized through care provision by hybrid professionals. T herefore, it is of g reat impor-tance to investig ate if care providers display hybrid professionalism. In this para-g raph I investipara-g ate whether the hypothesized obser vable implications of nepara-g otiat-ed professionalism are present in the empirical evidence that was g atherotiat-ed. Coor-dinating work, establishing autonomy, and professional values are subsequently analyzed 19.
5.2.1 Coordinating w ork
T he respondents indicated that their work is mainly str uctured by cooperation and interaction. Firstly, they cooperate with healthcare insurers, and secondly, they collaborate with other GPs and other medical professionals. Cooperation with healthcare insurers is a necessity in the work of GPs because they depend on them for reimbursements. T his could be said to be a minimal for m of cooperation. How-ever, I obser ved that GPs indeed view cooperation with insurers as indispensable to their work. To them, providing care is much more than responsively curing ill-nesses. T hey, in fact, actively devise projects that they believe ser ve their patients. Examples that were given to me were special projects devised for elderly which involved day-care plans and activities, or a project that activated people with symptoms of obesity and attempted to better their lifestyle. In order to implement these projects, GPs have to convince insurers that they need supplementar y fi-nancing. T his can be said to be a more substantial for m of cooperation GPs seek with healthcare insurers. One respondent notes that in fact GPs and insurers have to interact and cooperate in order to provide care:
Cooperation with healthcare insurers and GPs is indispensable to care provision because (1) GPs are dependent on insurers for reimbursements and (2) GPs have to persuade insurers to g rant them supplementar y financing for projects they wish
This section concentrates on the evidence gathered through interviewing GPs. Hence, when I refer to ‘re
19
-spondents’ this indicates the interviewed GPs. The evidence gathered through interviewing healthcare insur-ers is presented in the subsequent paragraph.
If together you want to provide good care, you must be interac8ng. If you are not coop-‐ era8ng, you cannot provide good care. (respondent number 7)
to implement 20. Cooperation between insurers and GPs is fur ther characterized by
r ecipr ocity. On the one hand GPs request supplementar y financing for projects, while on the other, insurers reward GPs if they collaborate with them to realize expediency in care provision. To exemplify: GPs can g et a reward if they realize expediency in medication prescription. GPs can receive a reward of € 0,20 per pa-tient if in total, they prescribe between 83% and 84% of the medication g enerical-ly. If they prescribe 85% or more g enerically, they will receive a reward of € 0,40 per patient per year 21. T his is just one example. T here are more ways in which in
-surers reward GPs for their effor ts concer ning expediency. Both the inter viewed GPs and insurers admit that these ‘expediency-effor ts’ are in fact devised to con-tain costs. GPs are suppor tive of this kind of endeavors:
GPs are open to cooperate with insurers in order to contain costs in care provi-sion 22. A four th dimension of cooperation I analyzed to be present is collaboration
between GPs and between GPs and other medical professionals. T he complex na-ture of some of the illnesses GPs are confronted with, requires more intensive and multidisciplinar y care then a single GP can provide. T his kind of intensive and interdisciplinar y care is org anized in so-called care-chains. As one GP notes 23:
The minimal form of cooperation is indispensable to work as a GP. Hence all the respondents actively dis
20
-play this form of cooperation. The identified substantial form can be said to be ‘optional’. No one is forcing them to devise projects. Nevertheless, all the respondents refer to their substantial cooperation with health-care insurers in order to establish such projects or other additional forms of health-care.
This example was drawn from the GP care-contract of VGZ 2015.
21
In fact, all of the respondents actively cooperate with insurers to ensure expediency, i.e. all of them pre
22
-scribe generically.
All of the respondents collaborate with other GPs and medical professionals from other disciplines. All in
23
fact, are a member of the ‘local care-chain’. In such care-chains interdisciplinary care is provided and GPs collaborate to ensure that their patients can get care any time of the day and night. To that end GPs share their night-shifts with each other. The case selection I made ensures that all the respondents are a member of the local care-chain. Nevertheless, all of the GPs in the Nijmegen area are. Hence, the sample is not
bi-I am O.K. with expedient medica8on prescribing. It is actually quite reasonable to com-‐ mit to this. You can save a lot of money with it. (respondent number 2)
There is a growing necessity to collaborate with other medical disciplines. (respondent number 11)
5.2.1 Establishing autonomy
T he empirical evidence sug g ests that GPs feel the need to be transparent in their work:
T he respondents state that transpar enc y in work is required because financial means are scarce, and ever ybody, including GPs have to account for expenses 24.
Secondly, GPs argue that they have to measure and monitor their work and that administration therefore is necessar y. T his is argument is twofold. Firstly, ad-ministering is seen as par t of efficient ser vice deliver y. GPs define efficiency here as containing costs. T hey note that if they do not administer their work it is not possible to be cost-efficient because they have no over view of the care provision process. Secondly, and related to this is the view that accounting enables GPs to provide qualitative g ood care:
Care provision is a ‘holistic’ affair. T his implies that treating illness is no straight-forward task, but instead a ref lective practice. If GPs do not administer how they treat a specific patient, so they argue, they will not be able to provide the care that is appropriate to a specific patient and hence, will not be able to be cost-ef-fective. T his will be discussed more in the next section when we investig ate the central value in GP-work.
5.2.1 Pr ofessional values
T he GP-respondents view delivering ‘g ood care’ as their main g oal. T hey mainly describe g ood care along two lines:
All respondents subscribe to this view. However, they also note that transparency and accounting have
24
their limits. More on this is discussed in the subsequent paragraph.
We extensively have to administer our work and turn in numbers. I think that is a good thing. The 8mes that you received a bag of money and didn’t have to account to nobody are over. (respondent number 6)
You have to see it like this. Transparency, especially the things that are easy to compute, is not wrong. Some things you just have to measure and administer otherwise you can-‐ not provide good care. (respondent number 2)
Good care is […] qualita8ve good en efficient. Qualita8ve good care is care that is deliv-‐ ered in accordance to the ins8tu8onalized professional guidelines. Efficient care is care that is deployed sensible. (respondent number 4)
Good care thus involves both qualitative care that is delivered in accordance with the institutionalized pr ofessional guidelines and efficient in that financial means are not to be squandered. To suppor t this:
T his shows that GPs do consider the costs of care. Moreover, they indicated that they assume it to be their responsibility to actively discuss the necessity of cer tain treatments with their patients, especially because ever more is possible due to technological advancements. Here they explicitly refer to their adopted task of not squandering financial means.
T he empirical evidence sug g ests that GPs value the provision of g ood care. T hey weigh the ‘g oodness’ of the provided care by two components: whether it is provided in accordance with professional guidelines; and whether money is squan-dered by the provision of it.
T his discussion leads to the conclusion that GPs, in fact, seem to exhibit neg oti-ated professionalism in care provision. T he first par t of neg otioti-ated professional-ism was conceptualized as ‘professionals that coordinated their work through co-operation and interaction with the manag erial context’. T his was co-operationalized as cooperation and interaction between GPs and insurers in the process of care provision to patients. Indeed, the empirical evidence sug g est that GPs and insur-ers cooperate with one another. Cooperation with the insurer takes place at different levels: minimal; substantial; reciprocal. Moreover the empirical evidence sug -g ests that GP-work is fur ther coordinated throu-gh professional collaboration.
Moreover, GPs were hypothesized to establish their authority through work-ing transparently, administer it, and be open to monitorwork-ing and accountwork-ing to in-surers. Ag ain the empirical evidence sug g est that GP indeed establish their pro-fessional authority by administering their work and working transparent. Trans-parency is directed at both a g eneral audience and insurers in par ticular. In more theoretical ter ms, the empirical evidence sug g ests that GPs establish their authori-ty through reliable care provision. Finally, GPs were hypothesized to value both quality and cost-efficiency. T he data indicates that GPs value the provision of g ood care which is measure by the quality of it which is defined by the profes-sional guidelines and whether or not money is squandered by the provision of care, i.e. whether care is provided cost-efficiently.
Costs of care have to play a role. Financial means are not endless, and moreover, there are ever more possibili8es. We will have to find a balance. (respondent number 1)
