University of Groningen Through the physician’s lens. A micro-level perspective on the structural adaptation of professional work Gifford, Rachel

University of Groningen

Through the physician’s lens. A micro-level perspective on the structural adaptation of professional work

Gifford, Rachel

DOI:

10.33612/diss.172180526

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Publication date: 2021

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Gifford, R. (2021). Through the physician’s lens. A micro-level perspective on the structural adaptation of professional work. University of Groningen, SOM research school. https://doi.org/10.33612/diss.172180526

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CHAPTER 1. INTRODUCTION

1.1 Motivation for this study

Healthcare is undergoing rapid changes. Aging populations, disease burden and growing disease complexity all threaten the sustainability of the healthcare system (OECD 2016). As a result, there is increased pressure on healthcare systems and actors to restructure their

healthcare delivery systems (Scanlon et al. 2020) in order to achieve the health system goals of affordability, access, and quality (i.e., the triple aim) (Berwick 2008). The need and pressure for reform is especially high at the level of secondary care (i.e., hospital care) given its high costs (Jeurissen et al. 2016; OECD 2016) and fragmentation (Hewett et al. 2009; Nolte et al. 2012) that restricts integrated working. However, despite a wide range of scholarship and policy shifts, how best to organize hospital care in order to improve care delivery processes remains an open question. The restructuring of secondary care continues to face considerable challenges, and many proposed solutions prove difficult to translate from theory to practice, indicating a potential mismatch between the two. With this thesis, I attempt to bridge the divide between theory and practice by offering a micro-level view into the challenges, the effects, and the complexities of organizing secondary care delivery. I focus centrally on how to organize hospital-based medical specialists and bring forward the perspective of clinicians themselves. The empirical results reveal the relational and cultural barriers that are often overlooked, but play a crucial role in determining the outcome of reform efforts.

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Change in the Professional Bureaucracy does not sweep in from new administrators taking office to announce major reforms, nor from government technostructures intent on bringing the professionals under their control. Rather change seeps in from the slow process

of changing the professionals…

(Mintzberg 1983: 213)

1.2 Introduction

To sustain costs while also improving care quality, scholars and policymakers alike have highlighted the need for the reorganization of healthcare systems. In particular, there is increasing emphasis on implementing new models of financing and restructuring care delivery processes (Burns et al. 2020; Kaplan & Porter 2013). Yet, the question of how to best

organize and incentivize healthcare professionals to achieve health system goals remains an open empirical question that is often difficult to answer in practice. Even in the theorizing of potential solutions there remains contestation and it remains an arduous task to measure the effects of [re]organization given the complexity of healthcare system design (OECD 2016). For example, there has been a plethora of literature written about payment reform, with most scholars agreeing on the need to move away from fee-for-service (FFS) payments but

disagreeing on how to do so (de Brantes 2012). Some scholars advocate for bundled payments to increase value and promote integration (Porter & Kaplan 2016), with others emphasizing the benefits of pay for performance (Eijkenaar 2012) for quality outcomes. Some scholars promote the need for a shift in physicians employment status, advocating the move of self-employed physicians into [salaried] employment contracts while others raise concerns and question if the benefits of employment exceed the costs (Abdulsalam et al. 2018; Burns & Pauly 2018; Burns et al. 2020). In addition, the empirical data either lags behind or offers mixed results on the effectiveness of payment and organizational reform (Baker et al. 2018; Burns et al. 2020; Flodgren et al. 2011; OECD 2016).

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In this thesis I therefore decided to focus my attention on better understanding the mechanisms behind physicians’ response to reorganization efforts, so that I can offer meaningful insights to the ongoing practical puzzle of how best to organize healthcare professionals in order to improve healthcare delivery processes. I focus centrally on the organization, position and governance of hospital based medical specialists who play a key and central role in the healthcare system. Physicians’ behaviors have a significant effect on care delivery outcomes and overall system performance (Burns & Pauly 2018; Yanchus et al. 2020). Consequently, the aim of many reform efforts is to try to shift or influence physician behavior, most often through structural reforms such as altering payment and employment models (Lagaarde & Blaauw 2017) or reorganizing work (e.g., standardization,

multidisciplinary teams). However, research has indicated that despite reform efforts, professionals often continue to work in historical and established ways (Currie et al. 2012; Kellogg 2009) and professional resistance remains an issue (Powell & Davies 2012). The central research question of this thesis is therefore to better understand how physicians perceive and respond to such structural adaptations in their work.

To this aim I1 _{conducted three case studies in hospital organizations that underwent a}

recent structural change. Each chapter examines, through the lens of physicians themselves, how current pressures and efforts to reform healthcare play out at the ground level. Each chapter works to uncover the underlying mechanisms that influence how providers perceive and respond to these disruptions. Chapter 2 and 3 examine two responses to a 2015 budgetary reform that put pressure on physicians to move from self-employment to employment.

Chapter 2 examines how self-employed physicians came to interpret the reform as a threat, and unveil their sensemaking process that resulted in new organizational forms (medical

1 _{While this thesis is my original work, the research presented here is the product of teamwork. All empirical}

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specialist companies; MSBs). Chapter 3 examines the effects of moving physicians in one organization to employment contracts, unveiling the importance of aligning reform with professional values and considering effects of payment reform in multiple domains. Lastly, in chapter 4, I examine how physicians respond to the structural reorganization of emergency care delivery that attempted to improve integration in the acute care chain by co-locating medical specialists in the emergency department.

While the focus in healthcare reform is often on structural change (i.e., concentrating care, payment reform, creation of supporting professions), our research reveals that

reorganizing healthcare delivery also involves important relational and cultural shifts that tend to be overlooked (Burns et al. 2020). In this thesis, I therefore emphasize and uncover the importance of relational and cultural elements in health system design. For example, chapter 2 demonstrates the influence of the broader institutional context on how physicians make sense of and respond to disruption. I show how institutional logics are interpreted on the ground to influence physician behavior and relations with other stakeholders, and how these

interpretations [may] lead to unanticipated field level change. Chapter 3 highlights the importance of professional values when considering structural reforms and in chapter 4 we unveil the role professional boundaries play in integration efforts and care delivery processes. Refocusing attention on these relational and cultural elements can help open up our current theorizing and allow us to understand why so many reforms result in unintended

consequences or resistance.

This thesis offers an interdisciplinary approach by utilizing theories across multiple disciplines (i.e., healthcare management, sociology, psychology, supply chain management) to explore the challenges to and perceptions of physicians about current and ongoing reforms in healthcare. By investigating tangible examples of reorganization in practice, we were able to gain timely and important insights about relevant micro-dynamics and their influence on

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broader system processes and functioning. Micro-dynamics can be defined as ‘the relational, interdependent organizing aspects of group life that arise from individual and interpersonal attitudes, behaviors, and interactions and which have been shown to be critically important to understanding social dynamics, including change’ (Woiceshyn et al. 2020: 63). In the

following section, I detail the importance of taking a micro-level perspective (focusing on physicians) and increasing our focus on and understanding of relational and cultural dynamics when considering healthcare organization and reform.

1.3 Scientific foundations

Healthcare represents a complex institutional field (Reay et al. 2017) that faces immense challenges and shifting institutional, political, and societal pressures (Noordegraf 2020). Healthcare is also a unique organizational context given the centrality and dominance of professionals and their influence on service delivery processes (Nordenflycht 2010). Therefore, this sector offers a challenge to existing theoretical frameworks (Lewis & Brown 2012; Senot et al. 2016) and requires unique solutions. In this thesis, we focus in particular on the organization of hospital based medical specialists. Secondary care is an important area of focus given that it accounts for a significant margin of healthcare expenditure and is the target of ongoing societal and political pressures (OECD 2016; Quentin et al. 2018). We examine the challenges and outcomes associated with the organization of medical specialists in secondary care by drawing upon multiple theoretical frameworks that allow us to reveal processes, mechanisms, and barriers that influence ongoing reorganization efforts.

In the following sub-sections, I detail current issues that exist in practice as they relate to the organization of physicians and secondary care and consider several modes of

organizing and their proposed effects. Within each section, I introduce relevant theoretical underpinnings that can help us further investigate and provide deeper insights into these timely issues. The first section considers the historical organization and position of medical

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specialists and situates this in relation to ongoing reforms and pressures. I then explore two specific pressures that influence the organization and position of medical specialist, namely (1) rising costs and payment reforms and (2) integrating care delivery.

1.3.1 The organization and position of medical specialists

Physicians have historically held a highly autonomous and central role in healthcare systems. To this day, physicians retain high levels of authority, also over other professionals (Toth 2015) and have high levels of autonomy in their work. In the sociological literature on the professions (Abbott 1988; Freidson 1970) physicians are seen as part of what is

considered an ‘ideal profession’ (Freidson 1970) which affords its members many privileges. According to Elliot Freidson’s early work (1970; 1984), physicians, as an archetype

profession, have total control over the content of their own work (professional autonomy), are self-governing (meaning that peers both establish criteria for legitimacy and assess quality), and hold professional authority granting them superiority over other workers in the healthcare domain. The professions are granted autonomy and discretion on the basis of their unique tacit and expertise knowledge (Freidson 1984), and their commitment to the common good (Racko et al. 2017) or what Parsons (1939) formerly conceptualized as a ‘moral responsibility’. These attributes make up what others scholars, in line with Freidson’s work, label the concept of medical dominance (Coburn 2006; Toth 2015).

Freidson (2001) labeled professionalism as the ‘third logic’, stating it as an alternative and often competing logic to the dominant logics of bureaucracy and the market that exist in modern society. Such ‘institutional logics’ provide a framework for how members behave, their interactions, what practices are considered legitimate [or illegitimate] and prescribe a set of norms, values and beliefs (Thornton & Ocasio 1999). The dominant ‘ideal’ logics

(Thornton & Ocasio 2008) in modern healthcare systems are considered to be what has been called a managerial or ‘business-like logic’ (Reay & Hinings 2009), bringing an increasing

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focus on cost cutting, efficiency and managerial oversight, and a logic of medical professionalism (Currie & Spyridonidos 2016; Koelewijn et al. 2014) that emphasizes physician autonomy and discretion in care delivery.

As prototypical professionals, physicians have enjoyed a protected position in society (Noordegraaf 2020) and medical dominance has meant that physicians have maintained a central position in healthcare systems and society, enjoying power, prestige and good compensation. However, while physicians still maintain a central and dominant position in healthcare systems, scholars have recognized that the status and position of physicians has been slowly changing (Freidson 2001; Noordegraaf 2011; Waring & Currie 2009), with major shifts occurring beginning in the mid to late 20th century (Timmermans & Oh 2010) and continuing through modern-day. Increasing managerialism (Kitchener 2002; Noordegraaf 2016) and corporatization of medicine (Waring & Bishop 2013), as well as decreasing public trust (Timmermans & Oh 2010) and calls for more oversight of the professions have changed the landscape of medicine (Freidson 2001).

The professions, and professionalism itself, is therefore becoming reconfigured (Noordegraaf 2020) by increasing pressures in society and societal shifts. Relevant to the medical domain and physicians in particular, are shifts happening in the economic, societal and cultural spheres that place increasing pressure on physicians to reconfigure their work in new ways (e.g., working in multidisciplinary teams), to become more efficient, to take on responsibility for care costs and organization, and to work in more transparent and

standardized ways (Waring & Currie 2009). This thesis explores two major shifts; (1) the pressure on the economic and employment position of physicians stemming from a need to continue rising healthcare costs and (2) the push towards more integrated care delivery (e.g., multidisciplinary working) stemming from increasing disease complexity and prevalence. These two shifts are described in the following sections.

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1.3.2 Rising costs and payment reform

In recent years, due to increasing pressures on already strained healthcare systems, many western countries have initiated further system reforms, increasingly introducing market forces into healthcare in order to control costs and create incentives for greater quality. The policy agenda has focused primarily on reforms in the areas of payment and system delivery in order to achieve the goals of efficiency, transparency, quality and cost effectiveness (Burns & Muller 2008; Kroneman et al. 2016; Petasnick 2007). Primarily, attention has been focused on eliminating the production-based incentive that has traditionally led to high provision of services and inflation of costs (Burns & Pauly 2018) in order to move towards value (Porter & Kaplan 2016). Self-employed physicians (i.e., working in private practice) tend to be paid in some form of fee-for-service or activity-based payment (e.g., diagnostic-related groups, DRGs) (OECD 2020), and therefore are often the targets of reform. In particular, pressures to move physicians into employment are evident across countries such as the USA, Canada, and the Netherlands, where the majority of hospital-based specialists are self-employed (Quentin et al. 2018).

Self-employed physicians work as independent contractors within their own specialty or multispecialty businesses, and work on the basis of production (e.g., fee-for-service or DRG based contracts). The production-based incentive has been pinpointed as a driver of low value healthcare (Porter & Kaplan 2016), leading to high costs, overtreatment, and poorer quality outcomes (OECD 2016). Therefore, healthcare systems have worked to replace production incentives by pushing for payment innovation, such as introducing quality-based payments or bundled payment episodes for certain disease pathways to stimulate integrated care (De Vries et al. 2019). However, these payment innovations largely rely on good measurement indicators (Porter & Lee 2013; Porter 2010), and may lead to increased

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The effects of such payment models have also remained mixed in the literature, with some innovations showing higher costs in the short term (Tsiachristas et al. 2011).

In addition, the employment of physicians has been debated in recent years, with increased pressure on further [economically] integrating clinicians into the hospital. Trends towards the economic integration of physicians and physician practices intro hospital systems has been growing (Baker et al. 2018; Post et al. 2017) with tighter forms of integration, such as employment, increasing (Baker et al. 2014). Employment arrangements are seen as a way to further address the issue of rising costs and improve hospital efficiency (Burns & Pauly 2002; Leleu et al. 2018). It is also viewed as a mechanism to better integrate physicians and hospitals and thus create better alignment in the system (Burns & Muller 2008; Nguyen et al. 2018) enabling hospitals to better pursue organizational aims and goals.

Chapter 2 and 3 explore the issues of physician payment reform. In particular, these chapters explore how physicians responded to pressures to further economically integrate with the hospital as a result of a 2015 budgetary reform in the Netherlands. In chapter 2 we explore the sensemaking of physicians in response to the pressure to further economically integrate with the hospital, and consider in the broader sense, how shifting institutional and societal environments play out on the ground floor for physicians in the hospital environment. By considering how these shifts play out for, and are interpreted by, physicians, we are able to uncover how physicians make sense of such pressures and reform attempts, offering crucial insights for policymakers and scholars into the importance, for example, of considering the existing and historical cognitive and cultural frames when enacting reform. Chapter 3 focuses centrally on the effects of shifting physicians to employment contracts and considers how such a move interacts with core professional values. By centralizing the importance of professional values, we also are able to offer insights into the mixed effects of employment

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found in the current literature, and question if the benefits of employment outweigh the [potential] costs.

1.3.3 The importance and challenge of integrating care delivery

Due to demographic shifts and increasing patient complexity, integrated care is essential to provide quality, cost-effective and efficient care for today’s patients (Nolte et al. 2012). In hospitals, care delivery requires constant collaboration between a variety of

professionals (Senot 2016) that have had different socialization, educational backgrounds, training, and experience. Care delivery requires ongoing, sometimes rapid and ad-hoc collaboration between medical specialists, between physicians and nurses, and across departments and functional roles. This poses a challenge as professionals from different backgrounds operate according to different norms, values, and have different approaches to care delivery and treatment (Currie et al. 2012; Hewett et al. 2009; Powell & Davies 2012). These so called ‘professional boundaries’ create barriers to collaboration, and can impede care delivery processes as professionals work to maintain jurisdictions or reinforce knowledge domains (Abott 1988; Currie & White 2012; Martin et al. 2009; Neizen & Mathijssen 2014).

Due to clinical and technological advances, healthcare delivery has become increasingly differentiated, creating boundaries not only across different professions and professional groups (e.g., nurses and doctors, social care and clinical care) but also within the same professional groups (Comeau-vallee & Langley 2019; Powell & Davies 2012).

Differentiation enables efficiency and productivity by dividing labor and allowing for

specialization, which is increasingly important to tackle complex diseases. On the other hand, differentiation also leads to fragmentation and a high need for coordination (Lawrence & Lorsch 1967; Lillrank 2010; 2012) making it more difficult to effectively organize and manage healthcare services (Bohmer 2009). Within the hospital, physicians are differentiated into specialty departments, working mainly independently and in specialty siloes, with limited

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coordination (Thijssen et al. 2013) and integration between providers (Drupsteen et al. 2013; 2016; Hewett 2009).

Finding a way to overcome such resulting fragmentation is a core focus of healthcare systems worldwide (OECD 2016) as integrated care delivery is increasingly needed to provide cost-effective, quality, and safe care (Nolte et al. 2012). Chapter 4 focuses explicitly on uncovering the barriers to integration between physicians involved in emergency care delivery. We examine here the impact of structural adaptations on professional integration, and unveil the unique boundaries that exist between physicians who are differentiated [by specialty] but share mutual responsibility for providing emergency care. Our findings help to unveil the boundaries that exist between physicians at the interfaces of care delivery, and explore the effect of these boundaries on care delivery processes (patient flow, speed) in the supply chain.

1.4 Objectives and outline

To address the central question of how physicians respond to structural adaptations in their work, we have conducted three empirical studies in hospital settings. In particular we wanted to understand how current efforts to reform hospital organization are perceived and play out at the ground level so that we may uncover important micro-dynamics that influence the outcome of care [re]organization. In each chapter we develop and address specific

research questions that will help to expand our understanding of hospital [re]organization and design. We also make various theoretical contributions in our pursuit of this more practical knowledge. Rather than restrict our research to one field of study, we take an interdisciplinary approach, drawing upon and expanding theoretical knowledge across the fields of sociology, healthcare management, psychology, and supply chain management in order to provide timely practical and novel theoretical contributions. In the next section, we outline these studies and highlight the central research question(s) and theoretical framework applied in each chapter.

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Chapter 2

Chapter 2 examines the responses of medical specialists to a budgetary reform that resulted in the creation of new organizational forms and modes of hospital-physician governance. We carried out an exploratory case study in two large general hospitals in the Netherlands to gain in-depth insights into the process and outcome of this reform. As part of this study, we interviewed 48 hospital based medical specialists and analyzed over 400 pages of archival data. This setting provides useful insights regarding field stability in complex institutional fields, where multiple, competing logics coexist for a prolonged period (see also Reay & Hinings 2009). We conceptualize the field as an ongoing institutional settlement, where shared agreements are negotiated between stakeholders enabling the dominant logic of medical professionalism and a business-like logic to coexist peacefully and allow for field stability. However, while the literature acknowledges the formation and existence of settlements, we know little about their evolution, and particularly little about what happens once these settlements are disrupted.

Considering the continued pressure on the healthcare field and the interdependence between field actors (i.e., hospitals and physicians), it is important to better understand how actors can respond to such disruptions and work to maintain field stability. We question: when an established (settled) field is disrupted, how can actors make sense of and navigate

competing institutional pressures as they attempt to re-settle the field? We employ a

sensemaking frame (Weick 1995) to examine the process of medical specialists in responding to pressures towards employment and showcase how institutional tensions play a core role in the way in which medical professionals interpret and ultimately respond to governmental targets. By examining the sensemaking process of professionals in response to this reform, we uncover how traditional ways of organizing have become connected to core professional values and embedded within dominant institutional logics (Goodrick and Reay 2011; Reay

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and Hinings 2009). Institutional logics function as ‘taken-for-granted social prescriptions’ (Battilana & Dorado, 2010, p. 1420) that ‘provide the formal and informal rules of action, interaction, and interpretation that guide and constrain decision makers’ (Thornton & Ocasio 1999). Examples of institutional logics in the medical context are a medical professional logic and a business-like logic.

When modes of practice become connected to core values and institutional logics, policies aimed at reforming these practices can function as a significant disruption, bringing tensions to the surface and triggering threat perceptions. By not accounting for the

institutional context, and the embedded norms, values and practices that exist within a field and across professions, policymakers initiated a reform that resulted in new organizational forms and altered the relations between physicians and organizations. Resulting in the concentration of power of self-employed medical specialists, the field has now been transformed in new and unexpected ways, with significant consequences at both the organizational and field level (Koelewijn et al. 2016). Our findings in this chapter offers insights into how professionals respond to disruption in complex fields and highlights the centrality and importance of interpretive and relational processes for both field stability and successful change.

Research question:

 When an established (settled) field is disrupted, how can actors make sense of and navigate institutional complexity as they attempt to re-settle the field?

Chapter 3

Chapter 3 expands upon the first study and alternatively considers the process and outcomes of medical specialists becoming employees of a hospital organization. In this chapter we conducted a mixed-method study at one medium sized hospital in the Netherlands. We employed an exploratory sequential design, beginning with 21 qualitative interviews with

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medical specialists. Building upon the emergent insights, we then designed a brief online survey to further explore emergent insights within the organization. Here we consider what the effects of moving physicians away from self-employment and towards more bureaucratic modes of control (Scott 1982) by economically integrating them with the hospital. We question: how does moving to employment directly affect physicians? In particular, we investigate the effects of employment on physicians in three domains; in patient care

(perceived effect on care delivery and quality), in the individual domain (professional values, job satisfaction) and the organizational domain (hospital-physician relations, including organizational identification and trust). Here we emphasize the importance of focusing on the organizational arrangement of physicians and disentangling employment and payment when assessing the effects of employment. Secondly, by focusing on core professional values and effects in multiple domains, we add important empirical evidence to the ongoing debate regarding physician payment and governance (Burns & Muller 2008; Burns et al. 2020) and shed light on the mixed-results that currently plague the literature on physician employment (Baker et al. 2018; Burns & Muller 2008; Post et al. 2017). We again unveil, and emphasize, the importance of considering the effects of organizational models on core professional values and professional relations.

Research Questions

 How does moving to employment directly affect physicians?

 What are the effects of employment on patient care (perceived effect on care delivery and quality), in the individual domain (professional values, job satisfaction) and in the organizational domain (on hospital-physician relations including organizational identification and trust)?

Chapter 4

Lastly, in chapter 4 we carried out a final case study to explore how physicians respond to internal reorganization and integration efforts. We examine a case of emergency

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care reorganization, focusing on uncovering the unique barriers (i.e., relational and cultural barriers) to integration between professionals in emergency care delivery. We conducted on-site observations and interviewed 28 emergency physicians and medical specialists over an 18-month period (beginning, middle and post reorganization). Here we focus on revealing barriers to intra-professional integration (between members of the same profession across different specialties), offering insights into the mechanisms that inhibit integration across the supply chain within hospital care. We also explore how these mechanisms come to impact care delivery processes, namely patient flow and speed. We combine the professional literature on boundaries (Abbott 1988) with the literature on supply chain integration (Flynn et al. 2010; Leuschner et al. 2011) to understand how integration functions at this level and demonstrate how boundaries may influence care processes. We also unveil why some

integration efforts fail or may result in backlash and offer important insights for organizations in their implementation of integration efforts.

Research Questions:

 What boundaries exist at the level of professionals in the supply chain?

 How do professional boundaries influence integration efforts and supply chain performance?

Chapter 5

I close this thesis with a general discussion. Here I summarize the main findings from each empirical chapter, and highlight our key theoretical contributions to the issue of

physician and hospital [re]organization. In this section I integrate our empirical findings to contribute to the organization studies and healthcare management literature and make practical recommendations for policymakers in their pursuit of secondary care reform.