The actual compensations and costs of a doctors’ practice

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The actual compensations and costs

of a doctors’ practice

A literature review and an empirical study of a doctors’ practice

Melissa Kramer Groningen, July 2008 University of Groningen

Master of Science in Business Administration

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Master thesis Melissa Kramer

The actual compensations and costs

of a doctors’ practice

A literature review and an empirical study of a doctors’ practice

Groningen, July 2008 Master thesis

University of Groningen

Faculty of Economics and Business

Master of Science in Business Administration

Specialisation Organizational & Management Control

Author: Melissa Kramer

Student number: 1661086

Supervisor: prof. dr. G.J. van Helden

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SUMMARY

In the last decade and especially in the last twenty years, many developments have taken place regarding Dutch general practitioners. The needs of patients have changed and general practitioners experience more work pressure, the quality of general practitioners has become more important and the health care funding system has faced many changes. With regard to the latter change, particular groups argue that the present funding system in 2008 is not suitable to cover all direct and indirect costs of the general practitioner and to give general practitioners a standard income. It is argued that the compensations are too low to cover all these costs.

To research this statement an empirical research is performed in a doctors’ practice in The Netherlands. The transformation function of the doctors’ practice is divided into input, throughput and output. The input consists of the costs of all resources within the doctors’ practice, namely resources with regard to the building, personnel and equipment and with regard to other resources. The resources and the costs of the resources are established by means of internal documents. The throughput concerns the activities of general practitioners, practice nurses and health care assistants and these are determined by means of an observation study and interviews. The output of the doctors’ practice consists of fixed annual compensations per patient, compensations per treatment or activity and supplementary compensations. These compensations are established by means of a document study.

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1 INTRODUCTION

The introduction gives an overview of the background of the paper, explains the research question and the research methodology and ends with the structure of the paper.

1.1 Background

The first reform in public management was at the beginning of the 20th_{century in the United States;}

a progressive movement promoted the separation of politics and administration and a more competent management (Groot and Budding, 2008, p. 2). Around 1980, these reforms resulted in the first developments of New Public Management (NPM) (Groot and Budding, 2008, p. 2) in many countries and nowadays, NPM is so omnipresent in public sector organisations that it hardly amounts to a distinctive reform programme anymore (Dunleavy et al, 1994).

There are many definitions of NPM, due to different interpretations in many countries. Hood (1991, pp. 4-5) argues that there are seven overlapping components which appear in most of the definitions of NPM. The components are a hands-on professional management, standards and measures of performance, an emphasis on output controls, private sector styles of management and parsimony in resource use and a shift to decentralisation of units and to greater competition.

Dutch developments regarding general practitioners can be divided into two different developments, namely developments concerning the patient and developments concerning the general practitioner. The developments concerning the patient are not part of the reforms of NPM but can be seen as a cause of introducing NPM. Examples of these developments are changing needs of patients and a more mature attitude of patients. Examples of developments concerning the general practitioner are more work pressure, more focus on quality of the doctors’ practice and the introduction of a new health care funding system. The focus on quality of the doctors’ practice can be linked to the overlapping components of NPM, as described by Hood (1991, pp. 4-5). This focus comes from governmental organisations but mostly from nongovernmental organisations, like NHG which introduced a hallmark for general practitioners who work in line with their standards. These standards promote systematic work and continuous improvements for better quality of care. Hoods’ component standards and measures of performance also highlight improvements for better quality of care. The new funding system can also be linked to the overlapping NPM components of Hood (1991, pp. 4-5) because the new funding system is based on the number and kind of patients within a doctors’ practice and on performed tasks. The measured performance is thus linked to the received funding of general practitioners. This is part of the NPM component of Hood which emphasises output controls.

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1.2 Research question

Based on these arguments that these compensations for general practitioners are below actual compensations, the research question of this paper can be defined. The research question is as follows:

Are the compensations for general practitioners in 2008 – as determined by the Dutch Care Authority –, too low to cover all actual costs of the doctors’ practice and to give general practitioners a standard income as established by the Landelijke Huisartsen Vereniging ?

1.3 Research methodology

The research question is answered by means of a literature review and an empirical research of a doctors’ practice in The Netherlands. The review deals with literature in the domain of New Public Management and health care and developments of general practitioners in The Netherlands. The results of this review are used as a basis for the empirical research. This research focuses on the input, throughput and output of a doctors’ practice. The input and the output are mainly based on internal documents and the throughput is mainly based on an observational study of the performance of general practitioners and their assistance.

1.4 Structure of the paper

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2 NEW PUBLIC MANAGEMENT

This chapter discusses the international accounting literature with regard to New Public Management (NPM). The first section describes new public management in a general way and the second section addresses this theme with regard to the health care system and general practitioners. 2.1 New public management until now

The first reform in public management was at the beginning of the 20th_{century in the United States.}

A progressive movement argued in favour of changing politics and administration by means of promoting the separation of politics and administration as well as a more competent management (Groot and Budding, 2008, p. 2).

Many years later in the late 1970s and early 1980s, these reforms lead to the first developments of NPM (Groot and Budding, 2008, p. 2). These developments emerged in the United Kingdom and the United States and the governments of New Zealand and Australia soon followed. Due to these successes the NPM reforms received also attention in other countries. After further developments the NPM was hailed as a paradigm shift in public administration (Haque, 2007, p. 179).

NPM has become so popular because of its linkages with some administrative trends. Firstly, the government made attempts to decrease public spending and staffing (Dunsire et al, 1989). Additionally, there was a shift towards privatization and away from core government institutions (Hood, 1991, p. 3). Next was the development of automation and particularly information technology in the production and distribution of public services (Hood, 1991, p. 3) and lastly, there was a development of a more international agenda. The international agenda paid much attention to general issues of public management, policy design, decision styles and intergovernmental cooperation (Hood, 1991, p. 3).

Dunleavy (et al, 1994) even argues that NPM is nowadays so omnipresent in the public sector organisations that it hardly amounts to a distinctive reform programme anymore.

2.2 Description of new public management

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In sum, there are many definitions of new public management but there are seven overlapping components or doctrines which appear in most of these discussions, see table 1.

Doctrine Meaning Typical justification

Hands-on professional management

Active and visible discretionary control of organizations from persons at the top

Accountability requires clear assignment of responsibility for action

Standards and measures of performance

Definitions of goals, targets and indicators of success, preferably expressed in quantitative terms

Accountability requires clear statement of goals and efficiency requires 'hard look' at objectives Emphasis on

output controls

Resource allocation, link between rewards and measured performance and less centralisation

Need to highlight results rather than procedures Shift to

decentralisation of units

Establish units around products, operate on decentralized budgets and deal with one another on an 'arms length' basis

Need to create manageable units, gain efficiency advantages by use of contracts or franchise arrangements

Shift to greater competition

Move to term contracts and public tendering procedures

Rivalry is the key to lower costs and better standards

Highlight styles of management in private sector

Move away from military-style 'public service ethic', greater

flexibility in hiring and rewards and greater use of public relation

techniques

Need to use private sector management tools

Highlight parsimony in resource use

Cut direct costs, raise labour discipline and limit 'compliance costs'

Need to check resource demands and 'do more with less'

Table 1. Aspects of new public management (Hood, 1991, pp. 4-5)

Table 1 shows that NPM stresses to measure performance, greater competition, output control resulting in more efficiency and effectiveness of the public sector. Lapsley (2008) confirms this by explaining three mechanisms of change of new public management. These mechanisms of change are structural reforms – particularly decentralisation –, performance measurement to motivate people and incentives, like payment by results.

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2.3 Criticisms on new public management

Despite the popularity of new public management, there is also some criticism. Dunleavy (et al, 1994) comes up with four kinds of critique, which are described next:

 Fatalist critique: fatalists do not believe in controllability of interactions between nature and human. Applying this view to public management means that these people argue that basic problems of public sector management, like system failures and corruption, are omnipresent. There is no system or program which eliminates these problems;

 Individualist critique: individualists have a positive point of view with regard to interactions of human and nature. Linking this to public management implies, that the critique of individualists is that NPM is an unsatisfactory half-way-house between the traditional structure of public administration and a system which is fully based on enforceable contracts and individual legal rights. The remedy for this is to replace quasi-contracts by justiciable contracts and more privatization rather than corporatization;

 Hierarchist critique: this view believes that humans can manage nature, as long as management remains tightly defined and human and nature systems do not change radically. Applied to NPM: hierarchists argue that NPM reformers must be careful not to let the process of change get out of hand, irreversibly damaging the overall manageability of the public service. The remedy for this critique is to centralise capacity, to oblige consults over policy and to change voluntary contracts into obligatory contracts;

 Egalitarian critique: an egalitarian is the most pessimistic about human and nature interactions. They argue that large-scale miscalculations are caused by elitist decision-making and large concentrations of organisational power. Applied to NPM: large-scale marketizing reforms increase the risks of corruption. This may result in a public sector which is less understandable, accountable and accessible to its citizens, despite contrary objectives. The remedy for this problem is to empower citizens and more anticorruption machinery.

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3 NEW PUBLIC MANAGEMENT AND HEALTH CARE

NPM in general and NPM with regard to general practitioners have emerged in the United Kingdom (UK). Because of this, this chapter describes NPM with respect to health care and general practitioners in the UK. Firstly, there is a general description of the UK health care system and general practitioners. The section follows by an overview of programs of NPM in the sector of general practitioners. This section makes also clear that there is a lot of resistance which is contradictory to the introduction of new public management in New Zealand. Furthermore, medical education in the UK is discussed.

3.1 Health care system in the UK

A graphical overview of the health care system in the (UK) (www.health.nsw.gov.au) is depicted in figure 1.

National Health Service (NHS) Strategic Health Authorities (SHAs)

Primary Care Trusts (PCTs)

Figure 1. Health care system in the UK

An important note about figure 1 is that it only applies to England and not to Wales and Scotland. Wales and Scotland also have a National Health Service (NHS), but other parts differ. Due to this, only the system of England is discussed.

The NHS is a national organisation in the UK. Its purpose is to secure improvement to physical and mental health of the population and to prevent, diagnose and treat illness. This purpose will be achieved by providing health services at primary, secondary and tertiary levels. The NHS is largely funded through taxation (73.5 percent); the other funds are received from contributions of national insurances (20.4 percent) and charges, like prescriptions and dental and optical charges (6.1 percent). Most expenditures of NHS (about 75 percent) are spent to Primary Care Trusts (PCTs); the other 25 percent is spent to teaching and research.

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for managing the performance of health care organisations and for building the capacity of health services locally.

Within each area of the SHA are established PCTs, with a total of 303 in England. Each PCT represents a specific local population of around 200,000 people. The trusts are responsible for improving the health of the community and tackling health inequalities, developing primary and community health services and commissioning secondary care services to meet local needs and national standards. PCTs perform care predominantly from NHS organisations but also from private providers. Compensations from NHS are allocated directly on a formula basis taking account of population and its age distribution, additional need and unavoidable variations in the costs of providing services.

General practitioners in the health care system in the UK undertake the role of a traditional gatekeeper in relation to secondary care. This means that general practitioners – and dentistry, pharmacy and optometry in primary care – take charge of 90 percent of total care. There are two developments with regard to general practitioners. Firstly, general practitioners increasingly employ other health care professionals to provide care, like nurses and therapists. Furthermore, the remuneration of general practitioners was based on the quantity of care provided. Recently a shift was made to compensate general practitioners based on the quality of care they provide by linking income to quality.

Undergraduate medical training normally lasts for five years after which general practitioners have one year general practice by means of training in an approved practice. After a successful completion of this practical year a general practitioner can practice independently.

3.2 Resistance to the health care system in the UK

General practitioners had difficulties in accepting the establishing of the PCTs in the UK. There was much resistance. In her article, Broadbent (et al, 2001) describes, theoretically and empirically, the way general practitioners resist to these perceived unwanted changes.

There are two forms of resistance (Broadbent et al, 2001, pp. 566-567). The first form is the private form of resistance, at which changes have been internally absorbed through less obvious processes. In case of the general practitioner the changes are absorbed by practice nurses, therapists or other assistance in the doctors’ practice. Due to this, general practitioners remain largely unaffected by changes. The other form of resistance is the public form of resistance. An example in case of the general practitioner might be to create a group of general practitioners to deal with the intended change strategy at source rather than leave the organisation themselves with the problem of absorption.

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secondary care. There were many voluntary general practitioners, but before the evaluation of these pilots took place, the policy had again moved on and the idea of PCT was launched (HMSO, 1997). In 1997, a pilot was introduced for commissioning groups (present PCT is part of these groups). In the past, general practitioners used mostly the private form of resistance. In reaction to the changes described above general practitioners established together the National Association of Commissioning General Practitioners, which is a public form of resistance. Broadbent (2001, pp. 566-567) also explains this. General practitioners united to protect their underlying normative value (this value reflects taken for granted assumptions) of providing equitable care to all. To protect these values a more outgoing deliberate public strategy had to be adopted in order to challenge the institutional steering media (these ensure that systems continue to reflect normative values, like money, power and law (Broadbent et al, 2001, pp. 568-569). This could not be left to an internal absorption process.

Concluding it can be said that there was much resistance because the changes of the government attacked the normative values. Despite these changes are not directly linked with new public management, it might be possible that general practitioners would resist in the same way to that kind of changes. A total opposite reaction to changes with regard to new public management is described by Jacobs (1998). In his paper Jacobs describes a change in health care structure and an introduction of costs, budgets and variance reports for general practitioners in New Zealand. In 1991 the health care structures altered to create an internal market structure. Instead of a regional institute for purchasing and providing of secondary care Regional Health Authorities (RHA) were established to purchase care and Crown Health Enterprises were established to provide care (Upton, 1991). In this structure, health service providers were no longer funded directly by the state, but indirectly through contracts with RHAs. Providers of primary care must organise themselves into collective groups, called Independent Practice Associations (IPAs). For general practitioners this would result in a simplified process of negotiating and a stronger negotiating position with RHAs, a spread of administrative costs and protection of a united front. After determining the contracts with the RHA, the researched IPA focused on cost reduction of laboratory tests and pharmaceuticals. This was achieved by the introduction of monthly reports about the number of laboratory tests and pharmaceuticals categorised per general practitioner. General practitioners were content with these monthly reports because it created a new level of visibility. Important was that general practitioners did not see these changes as a threat to their autonomy because the implementation of the reforms was initiated by other general practitioners instead of administrators or the government.

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The resistance of general practitioners in the UK as described by Broadbent (et al, 2001) can also be seen from another point of view: hybridisation between the medical profession and accounting practices. Jacobs (2005) describes and investigates this relationship in Germany, Italy and the UK. When there is no relationship between these two variables this is called polarisation. When there is a relationship this is called hybridisation, which expresses itself in accounting practices during medical profession and performing managerial tasks through general practitioners. Earlier studies found out that hybridisation exists when there are no powerful professional associations and there is established a clear accounting jurisdiction (Abbott, 1988). Applying this to Germany, Italy and the UK, then the health care sector in Germany should be significantly hybridised, the health care sector in Italy should be hybridised to a lesser extent and the health care sector in the UK should not be hybridised at all (Kurunmäki, 2004). After many interviews with medics in the three counties it is clear that medical education pays less attention to accounting practices, while especially medics from Germany and Italy are interested in these practices. Jacobs (2005) concludes that in Germany, Italy and the UK is polarisation rather than hybridisation. This is in contrast with expectations of Kurunmäki (2004).

By linking this article (Jacobs, 2005) to Broadbent (et al, 2001) some questions raise, which may need further research:

 Does hybridisation of medical profession and accounting practices result in less resistance of accounting changes ?;

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3.3 Pros and cons of NPM in health care

This section makes two links. The first link is between NPM in the health care sector and doctrines of Hood (see table 1). The other link is between criticisms to NPM and resistance to NPM.

Some NPM reforms in the UK and especially in New Zealand can be linked to the doctrines of Hood (1991, pp. 4-5, see also table 1). Firstly, the main NPM reform concerns decentralisation of purchasing, providing and funding care. Subsequently, there is a shift from highlighting procedures to highlighting results, which is also a doctrine of Hood, namely emphasis on output controls. Next, the funding of care in the UK is organised by governmental Primary Care Trusts (PCTs) but the funding in New Zealand is organised by non-governmental Regional Health Authorities (RHAs). These RHAs are linked to two doctrines of Hood. The first doctrine is the shift to greater competition, which consists among others of a move to contracts. Due to an indirect funding by the state by means of contracts with RHAs they are part of this doctrine. The second doctrine is the shift to decentralisation of units. RHAs and PCTs are decentralised to be closer to health care, which results in manageable units. The use of contracts with RHAs in New Zealand also leads to gaining of efficiency advantages. Another obvious link between the situation in New Zealand and the doctrines of Hood is the introduction of monthly reports about the number of laboratory tests and pharmaceuticals. This introduction can be linked to the doctrine which contents the emphasis of parsimony in resource use, the use of standards and measures of performance and – as mentioned above – an emphasis on output controls. All of these doctrines have the (indirect) objective to improve efficiency within the doctors’ practice.

There are several links between criticism on NPM and resistance on NPM. The three main core elements of resistance as described by Broadbent (et al, 2001) are affection of normative values of general practitioners, polarisation of medical profession and accounting practices and introducing NPM reforms by governmental institutes.

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4 DEVELOPMENTS OF GENERAL PRACTITIONERS IN

THE NETHERLANDS

This chapter explains developments of general practitioners in The Netherlands. Firstly, general developments in the last decade are discussed. Further, developments of approximately the last twenty years are addressed. These developments are classified into developments with regard to the patient and the general practitioner. Lastly, there is a short look into the near future.

4.1 General developments of the general practitioner in the last decade

Until 1955 the profession of general practitioner in The Netherlands was vague and unstructured (Berg et al, 2005, pp. 17-18). A description of the profession, a national organisation of general practitioners and a study of general practitioners did not exist. To improve the position of general practitioners Landelijke Huisartsen Vereniging (LHV) was already established in 1946 and Nederlands Huisartsen Genootschap (NHG) became established in 1956.

In 1981 after research, discussions and conferences LHV came with a description of the general practitioner which consisted of nine points and four requirements of the profession. Important were the concepts continuous, integral and personal. Six years later LHV expanded this definition with a definition of all tasks of the general practitioner (Berg et al, 2005, pp. 18-19). The tasks were categorised into four categories:

 Tasks with regard to the process of assistance, like diagnostic tasks and referring patients;

 Tasks which are in line with specific categories of patients, for example babies and elderly people;

 Support tasks, like administration and education;

 Tasks related to wishes from government, society and profession of general practitioners, like signalling dangers for health and participate in studies of general practitioners.

4.2 Developments during the last twenty years

In approximately the last twenty years there have been many developments with regard to general practitioners. In this section these developments are divided into developments concerning the patient and developments concerning the general practitioner.

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The patients of the general practitioner have changed. The needs of patients have changed due to many developments, like ageing of the population and greater mobility of patients (NHG, 2006, p. 7) and a growing number of people with a chronic disorder (Visie Huisartsenzorg, 2006, p. 2). These changing needs contributed to a larger demand to the profession of general practitioners in previous years and this demand will probably increase further (Berg et al, 2005, p. 23). Secondly, patients have become more mature due to more availability of information in papers and on internet. A consequence is a changing role of general practitioners from treaters and deciders to advisors and coaches.

Developments concerning the general practitioner

The general practitioner faced many different changes in the last years and these changes are still ongoing. The most important changes focus on the work of the general practitioner, quality of the doctors’ practice and the health care funding system with regard to general practitioners.

Firstly, changes with regard to the work of general practitioners are mainly concerned with performing more work while simultaneously a shortage of general practitioners of 20 percent is estimated for 2012. More work of general practitioners is due to:

 Expansion of the field of activity (Maes, 2003, p. 5);

 Increasing technological possibilities, like screening of risk factors (Visie Huisartsenzorg, 2006, p. 2);

 Integral care is needed because more suppliers of care are involved in assistance (Visie Huisartsenzorg, 2006, p. 2);

 Changes in care through shifts of tasks from hospital care to primary care (NHG, 2006, p. 8);  Developments concerning the patient, which are already discussed in the previous paragraph. The shortage of general practitioners is among others caused by more work but also by changing needs of the patient, retirement of a great number of general practitioners and changing views about working hours and increasing desires for part-time work (Vogelaar, 2005, p. 1).

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practices and delegation to practice nurses is increasing. Furthermore, general practitioners can increase efficiency and effectiveness, for example by means of using electronic files of patients. Secondly, quality of the general practitioner and his practice is an important issue for an adequate care of patients. NHG developed a system to accredit practices (www.npa.artsennet.nl). When a practice receives this hallmark, it means that general practitioners work systematically and continuously for better quality of care. General practitioners have to work in line with standards of NHG (www.npa.artsennet.nl). Each standard consists of rules which are concerned with the treatment and diagnosis of considerate disorders in the practice of the general practitioner. Herewith it is important to improve the quality of medical treatments.

The hallmark has received much support: on 7-4-2005 the first Dutch doctors’ practices received the hallmark and almost two years later there are emitted 75 hallmarks (www.npa.artsennet.nl), which is about 1.7 percent of the total number of doctors’ practices (Hingstman 2007, p. 13). In February 2008 there are already emitted 230 hallmarks, which means a rapid growth of the number of emitted hallmarks.

Thirdly, the compensations of general practitioners are received from health insurers and – among others – depend on the number of patients and the kind of care general practitioners deliver.

The old funding system made a distinction between National Health patients and patients who are insured by private companies. Both categories had their own compensations for standard income for general practitioners and to keep the practice (Maes, 2003, p.14-15). On 1-1-2006 the new health care system was introduced which does not make a distinction between patients. The system consists of different compensations to general practitioners (Vogelaar, 2005, p. 3-6):

 Compensation of 9 per consult. The standard number of consults per patient is estimated on 3.53 per calendar-year;

 Fixed annual compensations of 52 per enrolled patient per calendar-year;

 Supplementary compensations categorized by three modules: a module for assistance in the doctors’ practice, a module for particular groups of patients, like elderly people and a module for modernization and innovation;

 The compensations for passers-by also existed in the old funding system. It is meant for incidental and acute care for patients who do not live in the same place of residence as the general practitioner.

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the fixed annual compensations and the compensations for passers-by are lower than estimated and the modules assistance and modernization and innovation are higher than estimated, which means that many general practitioners have used these modules. The other group (De Vrije Huisarts, 2006) argues in favour of some changes with regard to the new funding system. This group puts forward the idea that every change must be focused on improving primary care and the coaching role of the general practitioner. Firstly, the fixed annual compensations per patient have to be increased to 74 because of the implementation of the new funding system and because general practitioners need more time to declare. Next, modules for assistance and modernization and innovation must be implemented on a large scale, more extensive and without a maximum amount of money. Furthermore, the government must pay for the hallmark of NHG and the implementation of an electronic file of patients. Additionally, the compensations for passers-by are valid for every patient who needs incidental and acute care regardless the place of residence of the patient.

Both evaluation groups show that more money is needed for care delivered by general practitioners. This view can be confirmed by two other sources, namely a consultant company which researched on behalf of LHV the standard income for general practitioners (HayGroup, 2001) and an auditing firm which determined the standard costs for a doctors’ practice (Deloitte & Touche, 2000).

HayGroup compared the function of general practitioners with functions in the market to determine a standard income which includes irregular working hours, working hours at nights and in weekends, compensations for retiring, disabling and health care costs and a fixed amount for working conditions. On 1-7-2007 the standard income was 132,547 while the actual income was 104,212 (CTG, 2002). Deloitte & Touche determined standard costs of the doctors’ practice and separated these costs into thirteen categories, including costs for furniture, accommodation and administration. Table 2 shows that the actual compensations are much lower than the standard compensations which are needed to cover all costs. Also, the difference between actual and standard compensations has increased from 53.41 percent in 2000 to 61.68 percent in 2002.

Actual compensations Standard compensations Difference

2000 87,512 134,253 53.41 percent

2002 86,935 140,555 61.68 percent

Table 2. Actual and standard compensations of costs (Deloitte & Touche, 2000)

Both arguments of HayGroup and Deloitte give rise to the argument that compensations for standard income and costs for general practitioners are below actual compensations.

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Due to all developments with regard to general practitioners it seems reasonable to establish some goals in the near future and to argue for some reforms. NHG (2006, pp. 7-18) prepared goals with regard to the policy for the period 2006 – 2011. These goals are classified into four categories:  Care of general practitioners which is generalistic and has a focus on the context, like topical

electronic files of patients to guarantee continuity and cooperation between general practitioners;

 General practitioners must act as a key person, particularly by giving direct accessibility and possibilities to refer to other health suppliers;

 Quality and efficiency, like implementation of the hallmark of NHG on a large scale;  Stimulate professionalizing, education and research, which is a task of NHG.

Visie Huisartensorg (2006, p. 3) established ideas to adapt general practitioners to the current developments. Firstly, primary care must stimulate and support healthy behaviour. Furthermore, the role of general practitioners must change to an advisor or coach. General practitioners have to change their role and to develop cooperation with others. Moreover, shifts from hospital care to primary care are needed to prevent the more expensive hospital care from solvable problems by first line care. Additionally, general practitioners must be lightening from too much work. This can be achieved by scaling up and rearranging and delegating tasks (see previous paragraph).

4.4 NPM and Dutch developments

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5 EMPIRICAL RESEARCH IN A DOCTORS’ PRACTICE

This chapter addresses empirical research within a doctors’ practice in The Netherlands. Firstly, theory is discussed and linked to practice. Furthermore, the empirical research with regard to the observations is explained.

5.1 Design of data collection

The empirical part of this research contains a documentation study and observations. The focus is on the observation of labour to determine actual activities performed by all kinds of employees in the doctors’ practice. This research takes place within a doctors’ practice in The Netherlands.

To describe this empirical research there will be a detailed description of observations in general applied to this research in the doctors’ practice. Firstly, the relationship between the observer and the participant is explained and the content of the data collection is described. This is followed by a description of the processes within a doctors’ practice which is also linked to the observations. The documentation study is not explained separately but is part of the description of the observation. Cooper (et al, 2006, pp. 229-230) describes three perspectives to explain the relationship between observer and participant. Firstly, the observation is direct or indirect. In a direct observation the recording is done by mechanical or electronic means and in an indirect observation the recording is done by the observer, who personally monitors what takes place. Applying this to the empirical research, indirect observation is at stake. Next, the presence of the observer is known or unknown. In this research the observed employees know about the presence of the observer. Finally, the observer is a participant or a non-participant of the observed processes. Applying this to the empirical research, it means that the observer is a non-participant of the doctors’ practice.

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times. The health care assistants are not observed because their activities are relatively standard and their activities are already described in a detailed way. In chapter five is a detailed overview of the when-question of the observations. The how-question determines whether an observation is direct or indirect. As mentioned before, the observation is an indirect observation with an observer who monitors the activities. The where-question is also already mentioned: the observation takes place in the doctors’ practice of a health care centre. In this centre are established different kinds of care suppliers to deliver integrated, broad and multidisciplinary care to patients, including general practitioners, pharmacists, physiotherapists, speech therapists, social workers, home care and primary care psychologists. The doctors’ practice consists of four general practitioners, two practice nurses and seven health care assistants. This doctors’ practice does not possess a hallmark of the NHG, but they are preparing to receive this hallmark.

The processes within a doctors’ practice can be described by means of a simple and general model, which is presented in figure 2.

Input Throughput Output

Figure 2. Model of input, throughput and output

Applying this model to a doctors’ practice, implies that the stage of input consists of resources, the stage of throughput consists of activities of all employees and the stage of output consists of received compensations for the delivered care. Each of these stages consist of different kinds of categories (Maes, 2007), which are displayed in table 3.

Input Throughput Output (CTG, 2007)

 Resources with regard to building of the doctors’ practice

 Resources with regard to personnel

 Resources with regard to equipment  Other resources  Activities of general practitioners  Activities of practice nurses

 Activities of health care assistants

 Other activities

 Fixed annual

compensations per patient  Compensations per

treatment or activity  Compensations for

activities with regard to control the doctors’ practice building

 Compensations for indirect time for the patient

 Compensations for being on duty of the general practitioners

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5.2 Empirical research

This section describes the empirical research in the doctors’ practice in a chronological sequence. After selecting a doctors’ practice to perform observations, there was a meeting with all general practitioners to explain expectations of both parties and to make the observations definite. The next step was to get more insight in the doctors’ practice and the employees which would be observed. This is done by means of an analysis of the annual report of 2006, set up a weakly schedule of the activities of all employees and by means of other internal documents. Examples of used internal documents are schedules of irregular duties of general practitioners at evenings, nights and in weekends, documents with regard to the number of tasks of each general practitioner performed in 2007 and 2008 and documents to set up the schedule of activities of each employee. After this, the general model of input, throughput and output is applied to the doctors’ practice. The input and the output are established based on internal documents and on information given by general practitioners, practice nurses and health care assistants. The throughput is determined by means of observations. After analysing the weekly schedules of general practitioners, practice nurses and health care assistants, the following observations have taken place; three blocks of consulting hours of general practitioners on a Monday, Wednesday and a Thursday morning are observed. On Monday all general practitioners are present, on Wednesday this holds for three general practitioners and on Thursday for two general practitioners. During observations the time patients come in and leave the room of general practitioners are observed. This results in an average of consulting time, an average of administrative time after the patient has left and an average of number of patients treated. These actual data are compared with the agenda established by the health care assistants, after which conclusions can be drawn. The same sort of observations took place for practice nurses but only one block of consulting hours is observed. Between the blocks of consulting hours of general practitioners in the morning and afternoon there is time which is used in a variable way, for example to visit patients, to call patients, to join meetings and to do paper work. The general practitioners mentioned that it is difficult to analyse this time because the way it is used, differs to a large extent. Due to this, on a Monday and a Thursday two blocks of this time of 2.5 hours are observed and analysed.

As can be seen, general practitioners are observed in a detailed way, practice nurses are observed in a less detailed way and health care assistants are not observed at all. This is done for two reasons. The first reason is that the time of health care assistants is already detailed determined in their weekly schedules and this counts for general practitioners and practice nurse in a lesser degree. The second reason is that health care assistants perform relatively standardised tasks in comparison with general practitioners and practice nurses.

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6 INPUT OF A DOCTORS’ PRACTICE

Maes (2007) found out that the input of a doctors’ practice is relatively standard. As mentioned before, each practice consists of resources with regard to the building, personnel and equipment and to other resources. Each of these aspects is applied to the researched doctors’ practice and is explained next.

6.1 Resources with regard to the building

The partnership of general practitioners does not own the building. The building is owned by an owner of real estate, who bought more pharmacies in the past and who does not have any other interests in the doctors’ practice. The housing costs in 2006 were 78,937 and consisted for 71 percent of rent of the building. The remaining 29 percent consists mainly of gas and electricity, cleaning costs and other costs. To convert the housing costs of 2006 to 2008 two corrections have to be made. The first correction is with regard to rent of the building. The actual rent in 2008 is 4,868 per month. The second correction is a correction regarding inflation in the period 2006 – 2008 with 4.1 percent (www.cbs.nl and www.cpb.nl) to the remaining housing costs, which is 29 percent of the total housing costs. This results in a total of housing costs of 82,246 (4,868 * 12 + (78,937 + 4.1%) * 29%) in 2008.

6.2 Resources with regard to personnel

General practitioners, practice nurses and health care assistants are working in the researched doctors’ practice.

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(176 * 52) hours a year, based on a standard number of 9,400 patients. The researched doctor’s practice has 7,970 patients, which means that a correction for the difference between the numbers of patients has to be made. After the correction, the standard number of working hours is 7,760 hours. Actually, the four general practitioners work 8,666 hours a year, which means that they work 11.67 percent more than the standard hours of general practitioners as determined by NIVEL (www.nivel.nl).

In 2006 and 2008 two practice nurses worked in the doctors’ practice with a total of 44 working hours a week. In 2006 six health care assistants were working with a total of 150 working hours a week. In 2008 the number of health care assistants and the total working hours a week both increased to seven and 180 respectively. This increase is caused by engaging a new assistant due to more work which needed to be done. These figures are summarised in table 4.

2008 2006 Number of employees Total regular working hours a week* Total working hours in 2008 Number of employees Total regular working hours a week* General practitioners 4 160 8,666 4 160 Practice nurses 2 44 2,077 2 44 Health care assistants 7 180 8,496 6 150 Total 13 382 19,239 12 354

Table 4. Number and total working hours per classification of employees

*Total regular working hours does not take into account evening-, night- and weekend duties, irregular activities, and education, see also appendix 2

The four general practitioners join a partnership with an equal share for each. The yearly business profit is divided by the general practitioners but every general practitioner receives a monthly payment of this profit in advance. This means that general practitioners have to pay all their compensations and costs – like holiday pay and travelling costs – from these monthly payments of the business profit. The monthly payment is also used for paying the deputy when general practitioners have their fixed day off every week.

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assumes 9,400 patients for four general practitioner and the researched general practitioners have 7,970 patients a correction has to be made. After this correction the standard income of the four general practitioners in 2008 concerns 664,101. This means that the general practitioners in the researched doctors’ practice receive 3.64 percent less than the standard income as determined by NIVEL (www.nivel.nl).

The costs of personnel include the salaries and other compensations of practice nurses and health care assistants. In 2006 these costs were 159,978. To use this amount of money in 2008 two corrections have to be made. The first one concerns a correction for the increase of the total working hours of health care assistants in 2008. The second correction refers to the increase in wages of personnel of general practitioners in the period from 2006 to 2008, which is estimated at two percent (www.abvokabofnv.nl). These corrections result in an estimation of costs of personnel in 2008 at 193,637 ((159,978 + 18.67%) + 2%). These amounts result in a total of costs of personnel of 775,488 and 834,383 in 2006 and in 2008, respectively.

6.3 Resources with regard to equipment

The costs with regard to equipment in 2006 are deprecations of the fixed assets in 2006, which is a total amount of 1,012. Assuming that there are continuous investments and applying a correction of inflation of 4.1 percent, the costs of equipment are 1,053 in 2008.

6.4 Other resources

The other business costs of the doctors’ practice contain mainly of costs for computers and instruments. In 2006 these costs were 56,515, applying a correction regarding inflation in the period 2006 – 2008 of 4.1 percent results in an amount of 58,832 in 2008.

Concluding, table 5 is established. As can be seen the total costs of input have increased from 911,952 to 976,514, which is an increase of 7.08 percent.

2008 2006 Difference

Resources with regard to the building 82,246 78,937 4.19 percent

Resources with regard to personnel 834,383 775,488 7.59 percent

Resources with regard to equipment 1,053 1,012 4.05 percent

Other resources 58,832 56,515 4.10 percent

Total costs of input 976,514 911,952 7.08 percent

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7 THROUGHPUT OF A DOCTORS’ PRACTICE

In this chapter the classification of throughput of Maes (2007) is used. He classifies the throughput of a doctors’ practice in activities of general practitioner, activities of practice nurses, activities of health care assistants and other activities. Other activities consist of education and irregular meetings of general practitioners and are described as part of the activities of general practitioners. The activities are each explained below.

7.1 Activities of general practitioners

As can be seen in appendix 1, the daily activities of general practitioners are relatively fixed: in general terms, the activities do not differ per general practitioner or per working day. This made it easy to observe and analyse these activities. An overview of the data and results of the observations of general practitioners are included in appendix 3.

The block of consulting hours in the morning take place from 8.00 until 11.00 and are interrupted by a break between 10.00 and 10.30. This means that a block of consulting hours take 2.5 hours. The consults are three times observed and the results are presented in table 6.

July 2008

A B C D All

Average number of patients/ consults 13 7.5 13 13.33 11.71

Average number of single consults 13 6 11.67 12.67 10.83

Average number of double consults 0 1.5 1.33 0.67 0.88

Average duration of consult time* 10.54 11.21 9.88 9.76 10.35

Average duration of administration time 2.38 2.46 1.88 1.66 2.10

Average total duration 12.92 13.68 11.76 11.42 12.44

Average overrun of consult:

-regarding break 25 15 15.67 12 16.92

-regarding end of consults 19 19 12 1 12.75

Total overrun 44 34 27.67 13 29.67

Number of observed blocks of consulting hours of 2.5 hours

1 2 3 3 2.25

Average number of visits 2 5 5 2.5 3.63

Average total duration of visits 53 82 93 75 75.75

Average duration of visits 26.5 16.4 18.6 30.42 22.98

Number of observed visits 2 1 1 2 1.50

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Table 6. Conclusions regarding observations of consults of general practitioners * There is made a correction for double consults

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were too busy in the past. She directed to the health care assistants – who plan consults for general practitioners – that she wanted more room in her consulting hours and between her consults. The third conclusion is that the average duration of administration time differs between 1.66 minutes and 2.46 minutes. Two general practitioners mentioned that they prefer to finish administration of a patient directly after the patient has left. During the consult the general practitioner notes the symptoms of the patient in the computer and prepares a prescription for the patient. After the patient has left the general practitioner prepares short notes and – when there is no overrun of consulting hours – other administrative tasks. Otherwise, these notes are prepared at the end of the day. When a patient wants a doctors’ referral a consult of 10 minutes is relatively short. The general practitioner does not prepare this referral directly after the patient has left but at the end of the day or the following day before the consulting hours start. Thus, general practitioners prefer to finish the administrative tasks regarding a patient as soon as possible. The fourth conclusion which can be drawn deals with the duration of the consults. The average duration of each consult consists of the time of the consult and the administration time after the patient has left. Table 6 shows that the average duration takes from 11.42 minutes until 13.68 minutes while the planned time is 10 minutes – the compensations received for each consult are also based on 10 minutes. This means that the actual average duration always overruns the planned duration of consults. This can also be explained by means of the total average overrun of the consulting hours. For example, on the first observation day the consults until the break of general practitioner A were scheduled until 10.00 while the actual consults finished at 10.25. This means an overrun of time of 25 minutes. The second part of the consults was scheduled until 11.10 while the actual consults were finished at 11.29, which means an overrun of time of 19 minutes. In total, an overrun of time for general practitioner A is determined at 44 minutes. As table 6 shows, there is always overrun of consults. The overrun varies from 13 minutes until 44 minutes, which means that general practitioners spend more time to consults than is compensated.

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practitioners A and D. This results in a shorter average duration of visits of general practitioners B and C. It must be noticed that the results regarding the visits might be flattered because the number and duration of visits differ every day and only two days are observed. This might result in a lower reliability of the data. The compensation for visits is based on twenty minutes but when a visit takes longer than twenty minutes a double compensation is received. Lastly, the specification of phone calls between 11.00 and 13.30 is analysed. This specification includes all outgoing phone calls within the region in March, April and May 2008, which includes phone calls of practice nurses and assistants. This might flatter the results. The average number of daily phone calls is 19.45 and the average duration is 2.36 minutes.

7.2 Activities of practice nurses

Practice nurses perform activities with regard to often observed symptoms, like asthma and diabetes, to unburden general practitioners. Practice nurses give information and perform checkups and medical activities, like changing catheters and measuring blood pressure.

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Table 7. Conclusions regarding observations of consults of practice nurses * There is made a correction for double consults

Based on table 7 some conclusions can be drawn, most in comparison with the data of general practitioners which are presented in table 6. Firstly, in contrast with general practitioners practice nurses did not perform single consults, only double consults and one consult of thirty minutes. This also leads in a lower number of patients/ consults of practice nurses. Secondly, the average total duration of consults of general practitioners is higher than practice nurses, namely 12.44 against 10.77 minutes. This total duration can be divided into average consult time and average administration time. With regard to the average consult time, it is clear that general practitioners perform longer consults than practice nurses, namely 10.35 and 8.28 minutes. This contrasts with the administration time because the administration time of general practitioners takes less time than the administration time of practice nurses, namely 2.10 and 2.49 minutes. A reason for this might be that general practitioners delegate many tasks to health care assistants. The third conclusion deals with the overrun of consults. General practitioners have almost always overrun of their consults while practice nurses perform their consults in less time than planned. Furthermore, general practitioners perform more visits, which lead to a longer duration of visits of practice nurses.

X Y All

Average number of patients/ consults 2 2 2

Average number of single consults 0 0 0

Average number of double consults 1.5 2 1.75

Average number of consults of 30 minutes 0.5 0 0.25

Average duration of consult time* 6.73 9.83 8.28

Average duration of administration time 3.40 1.58 2.49

Average total duration 10.13 11.42 10.77

Total overrun -4 -1 -2.5

Number of observed consulting hours 2 2 2

Average number of visits 1 3 2

Average total duration of visits 43 56 49.5

Average duration of visits 43 18.67 30.83

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7.3 Activities of health care assistants

The activities of health care assistants are not observed but their daily activities and tasks are included in appendix 1. These schedules are established by means of information of health care assistants themselves and are summarised in table 8.

1 2 3 4 5 6 7 Total Percen-tage At laboratory - - 3.5 7.25 - - - 10.75 6.5 At counter 10.25 10.75 - - 23.25 9.75 12.25 66.25 40.2 Checking urine 1 1 - - 2 1 1 6 3.6 Consults 2.75 4.75 - - 1.75 1.75 4.25 15.25 9.3 Declaring - - - - 8.5 8.5 5.2 Doing results 1 1 - - 2 2 1 7 4.2 Doing insurance - 7.25 - - - 7.25 4.4 Plants - - 0.5 - - - - 0.5 0.3 Making orders - 0.5 - - - 0.5 0.3 Other activities 3.5 7.75 - 18.5 5.5 - 7.5 42.75 25.9 18.5 33 4 25.75 24.5 14.5 34.5 164.75 100

Table 8. Overview of weekly performed activities by each health care assistant

Before analysing table 8, it must be noticed that the total weekly working hours of 164.75 in table 8 are not equal to the total weekly hours of 180 in table 4. The reason for this is that health care assistants get paid the break in the morning and the break in the afternoon. Table 8 assumes a working day excluding paid breaks of 7.25 hours and table 4 assumes a working day of including paid breaks of 8 working hours.

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8 OUTPUT OF A DOCTORS’ PRACTICE

The outputs of a doctors’ practice are compensations that general practitioners receive from health care insurers. The Dutch Care Authority (Dutch: Nederlandse Zorgautoriteit, www.nza.nl) establishes these compensations and classifies them into fixed annual compensations per patient, compensations per treatment or activity and supplementary compensations. These compensations are now explained.

8.1 Fixed annual compensations per patient

For each patient the doctors’ practice receives a fixed quarterly compensation, called enrolment compensations. These compensations increase when patients live in a district with a low social status or when patients are older than 64 years. The number of patients in the researched doctors’ practice is almost stable: on 1-1-2006 were registered 7,952 patients, on 1-1-2007 7,992 patients and on 25-7-2007 7,970 patients. The assumed number of patients on 1-1-2008 is also 7,970. There were no patients who live in a district with a low social status and the ages are build up as followed; 87.21 percent of the patients is younger than 65 years, 7.38 percent is between 65 and 75 years and 5.41 percent is 75 years or older. In 2008, this results in a total of fixed annual compensations of 422,576.

8.2 Compensations per treatment or activity

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8.3 Supplementary compensations

Supplementary compensations are categorised by three modules, namely a module for assistance in the doctors’ practice, a module for particular groups of patients, like patients in a district with a low social status and a module for modernization and innovation. The researched doctors’ practice only uses the module for assistance in the doctors’ practice, which means a compensation of 1.60 per patient per quarter. Due to a number of patients of 7,970, the supplementary compensations for 2008 are 51,008.

An overview of compensations of the doctors’ practice in 2008 is presented in table 9. 2008

Total fixed annual compensations 422,576

Total compensations of treatments and activities 604,559

Total supplementary compensations 51,008

Total compensations of output 1,077,174

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9 ACTUAL COMPENSATIONS AND COSTS

This chapter describes two mark-up methods to cover indirect compensations and costs and calculates the total actual compensations and costs per hour of general practitioners and practice nurses in 2008. The chapter ends with comparing these compensations and costs to draw conclusions.

There are two mark-up methods to cover indirect compensations and costs, namely the simple and the advanced direct mark-up method. The simple direct mark-up method divides the total indirect compensations or costs by the total direct compensations or costs, which results in only one percentage to cover the indirect compensations or costs. An advantage of this method is that it is easy to use. The method has also limitations (Horngren et al, 2003). Firstly, the method is somewhat inaccurate because it assumes a fixed proportion between indirect and direct costs, while this proportion does not have to exist. Secondly, the method is not suitable to control costs because it is unclear who is responsible for high costs. Both limitations might not occur when using an advanced direct mark-up method. This method uses several direct mark-ups to cover indirect compensations or costs, which results in several percentages to cover indirect compensations or costs.

This chapter uses the advanced direct mark-up method for the indirect compensations because the three different compensations are easy to separate and because the indirect compensations are relatively diverse. The simple direct mark-up method is used to cover the indirect costs. The reason for using this method is that the costs are not diverse, 85 percent of all costs belong to the costs of personnel. Due to the limitations of the simple direct mark-up method the advanced direct mark-up method could have also been used to cover the indirect costs. This might be a possibility for further research.

To calculate actual compensations of treatments and activities of general practitioners and practice nurses, a mark-up must be added to these compensations to keep into account the fixed annual compensations for general practitioners and the supplementary compensations for the practice nurses.

As mentioned, the compensations of treatments of all general practitioners of 579,941 must be added by an advanced direct mark-up method for the received fixed annual compensations. This mark-up is calculated by dividing the fixed annual compensations by the total compensations per treatment and results in 72.87 percent (422,576 / 579,941). Adding this mark-up to the compensations per treatment of 579,941 results in the actual total compensations per general practitioner in 2008 of 115.69 (1,002,544 / 8,666) per hour and 1.93 per minute.

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total compensations including the indirect compensations. This mark-up is calculated by dividing the total supplementary compensations by the total compensations of treatments, which results in 207.2 percent (51,008 / 24,618). Together, the compensations of treatments and the mark-up concern 75,626, which means a total of actual compensations for practice nurses of 36.41 (75,626 / 2,077) per hour and 0.61 per minute.

Both direct costs per hour of general practitioners and practice nurses must be increased with a mark-up for indirect costs. This simple direct mark-up method is calculated by dividing the total indirect costs by the total direct costs. The total costs in 2008 concern 976,514, from which 678,785 direct costs, namely the costs of the general practitioners of 640,746 and the personnel costs of the practice nurses of 38,039. The other costs of 297,729 are indirect costs and contain costs regarding the building, the health care assistants, the equipment and other costs (see also table 5). The mark-up for indirect costs is thus 43.87 percent (297,729 / 678,785).

The total direct costs of general practitioners consist of last years paid profit to general practitioners with a correction for inflation and concerns 640,746. After adding the simple direct mark-up method for indirect costs of 43.87 percent results in a total of direct costs of 921,841. The actual total costs of general practitioners can now be calculated by means of dividing the total direct costs by the number of working hours of all general practitioners. This results in the actual costs per general practitioner per hour of 106.37 (921,841 / 8,666), which is 1.77 per minute.

The total direct costs of practice nurses concern a proportional part of the total personnel costs of 193,637 and include among others salaries and travelling and education costs. This part amounts 38,039 excluding the mark-up for indirect costs and 54,727 including the mark-up for indirect costs. Dividing the costs by the total of working hours of practice nurses in 2008 results in the actual costs per practice nurse of 26.35 per hour (54,727 / 2,077), which is 0.44 per minute.

Table 10 gives an overview of the total actual compensations and costs per hour per general practitioner and per practice nurse. This table shows that the hourly actual compensations of general practitioners and practice nurses are higher than the hourly actual costs, namely a difference of 8.76 percent and 38.18 percent, respectively.

Total hourly actual compensations

Total hourly actual costs

Difference

General practitioner 115.69 106.37 8.76 percent

Practice nurse 36.41 26.35 38.18 percent

Table 10. Actual compensations and costs per hour per general practitioner and practice nurse

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income with the actual working hours and income, it can be seen that the general practitioners work 11.67 percent more hours and receive 3.64 percent less income than standard.

Another note with regard to table 10 deals with the quality of care. These conclusions can only be drawn given the assumption that the quality of delivered care is appropriate because quality aspects of care are ignored in this study.

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REFERENCES

References regarding books and articles

 Abbott, A. (1988) The system of professions, Chicago: The University of Chicago Press

 Batley, R., Larbi, G. (2004) The changing role of government: the reform of public services in

developing countries, Basingstoke: Palgrave Macmillan

 Berg, M. van den, Bakker, D. de, Roosmaalen, M. van, Braspenning, J. (2005) De staat van de huisartsenzorg, NIVEL 2005, unknown city

 Broadbent, J., Jacobs, K., Laughlin, R. (2001) Organisational resistance strategies to unwanted accounting and finance changes: the case of general medical practice in the UK, Accounting,

Auditing & Accountability Journal, vol. 14, nr. 5, pp. 565-586

 Cooper, D., Schindler, P. (2006) Business research methods, New York: McGraw-Hill/ Irwin  De Vrije Huisarts (2006) Agenda en bekostigingssystematiek huisartsenzorg 2008, unknown

city

 Dent, M., Chandler, J., Barry, J. (2004) Questioning the new public management, Aldershot: Ashgate

 Deloitte & Touche (2000) Kostenmodel huisartsen solopraktijk, unknown city  Douglas, M. (l982) In the active voice, London: Routledge

 Dunleavy, P., Hood, C. (1994) From old public administration to new public management,

Public Money & Management, vol. July/ September, pp. 9-16

 CTG, brief aan Ministerie VWS (2002) Herijking normatieve inkomen voor vrije beroepsoefenaren, Utrecht

The actual compensations and costs of a doctors’ practice

The actual compensations and costs

of a doctors’ practice

A literature review and an empirical study of a doctors’ practice

The actual compensations and costs

of a doctors’ practice

A literature review and an empirical study of a doctors’ practice

SUMMARY

TABLE OF CONTENTS

1

INTRODUCTION

2

NEW PUBLIC MANAGEMENT

3

NEW PUBLIC MANAGEMENT AND HEALTH CARE

4

DEVELOPMENTS OF GENERAL PRACTITIONERS IN

THE NETHERLANDS

5

EMPIRICAL RESEARCH IN A DOCTORS’ PRACTICE

6

INPUT OF A DOCTORS’ PRACTICE

7

THROUGHPUT OF A DOCTORS’ PRACTICE

8

OUTPUT OF A DOCTORS’ PRACTICE

9

ACTUAL COMPENSATIONS AND COSTS

REFERENCES