Master Thesis Management Control in Healthcare “The influence of case-mix management on medical specialists in general hospitals”

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Master Thesis

Management Control in Healthcare

“The influence of case-mix management on medical specialists in

general hospitals”

by

BORIS VERNOOIJS

University of Groningen Faculty of Economics and Business

MSc Business Administration

Specialization Organizational & Management Control June 2015

Supervisor: dr. B. Crom

Second supervisor: dr. E.G. van de Mortel

Star Numanstraat 65a 9714 JK Groningen b.vernooijs@student.rug.nl

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2 ABSTRACT

In the last decade, the Dutch Healthcare system is rapidly changing, and is moving towards a market-oriented approach. The role of the Dutch government has changed significantly, where it shifts responsibilities towards Healthcare insurers. These Healthcare insurers became the leader in negotiations with Healthcare providers about the ‘production’ of Healthcare. The production agreements are settled in the so-called ‘case-mix’ of the Healthcare provider. Where previous literature is focusing on the technical and administrative aspects of case-mix management, this study focuses on the psychological effects of case-mix management on medical specialists. By using the Job Demands-Resource model as starting point in this case study, this paper attempted to find specific stressors and sources of energy that are linked to the introduction of case-mix management in Healthcare. It was found that role ambiguity, lack of supervisory support, and work overload may be seen as stressors and cause some negative emotional states for medical specialists, like cynicism, whereas job autonomy may be a source of energy for medical specialists which may cause positive reactions, like job satisfaction.

Keywords: Case-mix management, Healthcare, medical specialists, Job Demands-Resource model, psychological effects

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3 TABLE OF CONTENTS

1. INTRODUCTION ………..……… 5

2. LITERATURE REVIEW ……… 8

2.1 Case-mix in Healthcare ……….. 8

2.2 Diagnose Treatment Combinations ……….. 9

2.3 Effects of case-mix management ………. 10

2.4 The Job Demands-Resource model ………..………. 12

3. METHODOLOGY ……….………. 19

3.1 Case study research ………..……… 19

3.2 Data collection ………19 3.2.1 Selection of cases ……….………...19 3.2.2 Data collection ……….………..19 3.3 Analysis ………21 3.3.1 Unit of analysis ………..21 3.3.2 Process of analysis ……….……….22 3.4 Quality criteria ………..……….23

3.5 Components of the Job Demands-Resource model ……….……23

3.5.1 Stressors (X1) ……….……….24

3.5.2 Stress reactions (X2) ……….………….24

3.5.3 Negative outcomes (X3) ………..24

3.5.4 Sources of energy (Y1) ………..25

3.5.5 Well-being (Y2) ………..………25

3.5.6 Positive outcomes (Y3) ……….25

4. RESULTS ………..………..27

4.1 Stressors (X1) ……….……….27

4.1.1 Role ambiguity ………..……….27

4.1.2 Lack of supervisory support ………..28

4.1.3 Work overload ………30

4.2 Stress reactions (X2) ………..………….………..32

4.3 Negative outcomes (X3) ……….……….33

4.4 Sources of energy (Y1) ……….34

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5.3 Managerial implications and recommendations ….………42

5.4 Limitations ………42

5.5 Suggestions for future research ………43

REFERENCES ………45

APPENDIX A ……….………50

APPENDIX B ………. 61

MODELS Figure 1. The Job Demands-Resource model ………13

TABLES Table 1. Example questions about effects of case-mix management on medical specialists .21 Table 2. Example questions about actions that medical specialists are taking ……….22

Table 3. Components of the Health impairment process ……….24

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5

1 INTRODUCTION

Most of the GPs in the Netherlands are not able to reject contract offers from Healthcare insurers, while they do not agree the content of those contracts (‘’Huisartsen ontevreden over zorgverzekeraars’’, 2015). This is a message that one can see a lot in Dutch newspapers nowadays. In the last decade, the Dutch Healthcare system is moving towards a market-oriented approach. The role of the Dutch government has changed significantly, where it shifts responsibilities towards Healthcare insurers (Hofdijk & Nolthenius, 2001). In this way, the power of these Healthcare insurers is growing massively. The public opinion about this changing Healthcare system seems positive as costs decrease and quality increase (‘’Zorgverzekeraar kiest ziekenhuis’’, 2008). However, medical specialists seem to be more skeptical about the growing power of these Healthcare insurers (‘’Huisartsen ontevreden over zorgverzekeraars’’, 2015).

In February 2005, a case-mix management system was introduced in the Dutch Healthcare (Oostenbrink & Rutten, 2006). The objective of this new system is that the Healthcare providers make production arrangements with the Healthcare insurers (Hofdijk & Nolthenius, 2001). Case-mix in Healthcare is seen as the mix and volume of different types of patients (Ma & Demeulemeester, 2013) and case-mix management can be seen as the management of clinical activities on the basis of patient categories and the resource allocation associated with those activities (Doolin, 1999). The case-mix in the Netherlands is based on so-called Diagnosis Treatment Combinations (‘DBCs’) and those are used for the reimbursement of hospital and medical specialist care (Oostenbrink & Rutten, 2006). Since 2008, the DBC system is further developed and is now called DOT (‘DBCs on their way to transparency’) which is based on an improved declaration system for Dutch hospitals (‘’Bekostiging ziekenhuiszorg’’, n.d.). According to Oostenbrink & Rutten (2006), the purpose of using DBCs (DOT) is to support the transformation from a supply-led to a demand-led system in Dutch Healthcare.

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6 Motchenkova & Seinen, 2011). It seems clear that Healthcare providers feel increasing pressure by the interests of the Healthcare insurers, in particular the management of these Healthcare providers involved in the negotiations. But what about the medical specialists? The people who actually treat patients, the people who are actually ‘on the floor’, do they feel pressure from these specific changes? Are they still able to do their work in a good way or are they, in a certain way, hindered through these changes? As mentioned before, there are some signals that there is reluctance from medical specialists about the growing pressure from Healthcare insurers (‘’Huisartsen ontevreden over zorgverzekeraars’’, 2015). One can state that this may lead to negative psychological and behavioral effects on their profession and their daily activities.

Most research in this field is looking to the administrative, and therefore more technical, aspects of case-mix management in Healthcare, and focuses for example on the different types of case-mix management in Healthcare (Malenka, McLerran, Roos, Fisher & Wennberg, 1994; Hirdes, Botz, Kozak & Lepp, 1996), changing physicians’ behavior with the use of financial incentives (Hillman, Pauly & Kerstein, 1989), influencing and controlling social situations (Covaleski, Dirsmith & Michelman, 1993), or ways to improve case-mix management based on funding activities (Madden, Marshall & Race, 2013). These technical approaches to case-mix management are very important and contribute to the field, because it can help practitioners to use case-mix management in a more effective way. However, there are some researchers who point at the need for a better understanding of psychological effects of case-mix management (Caldon, Walters, Reed, Murphy, Worley & Reed, 2005). More research about these specific effects on medical specialists can help by evaluating the new situation, with respect to the insurance companies and their connections to primary care (Van Weel, Schers & Timmermans, 2012). Also from within the Healthcare system, there are raising questions regarding the effects of case-mix management on, for example, job satisfaction of medical specialists (Hees, Mengelberg, Velthuys & Van der Zee, 2006). One can state that a better understanding of these effects on medical specialists can contribute to the improvement of the Healthcare system as a whole.

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7 approach in the field of psychological research in the Healthcare sector. In a more practical way, this research may contribute to the quality of Healthcare systems. Medical specialists play an important role in hospitals, taking into account their expertise in the field and their relations within the hospital. If negative effects of case-mix management on medical specialists are known and if these negative outcomes can be tackled, medical specialist are better able to do their jobs in the best possible way and this will improve the quality of Healthcare. Thus, the research question of this paper is:

How does case-mix management influence medical specialists in general hospitals?

Sub questions:

How do medical specialists experience their relationship with parties involved in case-mix management?

What are the effects of these experiences for medical specialists and how do they cope with these effects?

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2 LITERATURE REVIEW

In this section, the basic concepts of case-mix management in Healthcare will be explained. After that, the concept of Diagnose Treatment Combinations will be introduced. In this given context, there will be an overview of the known effects of case-mix management on medical specialists. Finally, there is an introduction of the Job Demands-Resource model, which gives the theoretical framework of this study. Finally, on the basis of previous literature about the Job Demands-Resource model, some first predictions about the findings of this study are outlined.

2.1 Case-mix in Healthcare

In February 2005, a case-mix management system was introduced in the Dutch Healthcare (Oostenbrink & Rutten, 2006). The objective of this new system is that the Healthcare providers make production arrangements with the Healthcare insurers (Hofdijk & Nolthenius, 2001). These production arrangements are about the specific characteristics and volume of different types of patients in hospitals and can be seen as the case-mix of a hospital (Ma & Demeulemeester, 2013). A case-mix is a distinct set of patient attributes, which include intensity of illness, risk of complications, difficulty of treatment and the resource intensity (Averill, Muldoon, Vertrees, Goldfield, Mullin, Fineran & Grant, 1998). The patient case mix of a hospital contains, for example, the annual number of patients with a specific form of cancer that can be threated. According to Averill et al. (1998), there is a distinction between the so-called clinical perspective, as of the medical specialists, and the administrative perspective. From a clinical perspective, case-mix refers to the patient condition and the treatment difficulty associated with providing care. The administrative perspective of case-mix is concerned with the resource intensity and therefore the specific demands that patients place on a Healthcare provider.

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9 Doolin, 1999). In this way, the information from case-mix management allows the evaluation of particular ‘production’ lines and departments in terms of financial and non-financial information and outcomes. It is mainly used as a control tool for managers and service providers, where “the detailed information provided by the case-mix system offered management the possibility to increase control over Healthcare professionals, either directly or indirectly” (Doolin, 1999).

The composition of the case-mix in hospitals is based on a consensus between different stakeholders of the organization. The most common stakeholders of these hospitals are the physicians, patients, the government and the Healthcare insurers (Omachonu & Einspruch, 2010). As mentioned earlier, the power of Healthcare insurers in developing the case-mix in hospitals is rapidly growing in the last years (Hofdijk & Nolthenius, 2001; Halbersma et al., 2011). The Dutch government shifted responsibilities towards these Healthcare insurers, who become the leaders in contract negotiations with Healthcare providers. According to Halbersma et al. (2011), the changes in the Dutch Healthcare system are based on a model of managed competition for hospitals in combination with the already existing mandatory Healthcare insurance system.

2.2 Diagnose Treatment Combinations

In the Netherlands, patient categories (determined by diagnosis, age and treatment type) are part of a system called DBC (Oostenbrink & Rutten, 2006), and stands for Diagnose Treatment Combination. Those DBCs are defined as “the whole set of activities and interventions of the hospital and medical specialist resulting from the first consultation and diagnosis of the medical specialist in the hospital” (Oostenbrink & Rutten, 2006). With these DBCs, integrated funding of hospitals and payment of medical specialists is possible (Hofdijk & Nolthenius, 2001). Since 2008, the DBC system is further developed and is now called DOT (‘DBCs on their way to transparency’) which is based on an improved declaration system for Dutch hospitals (‘’Bekostiging ziekenhuiszorg’’, n.d.). The general goal of this improvement is the simplification of the old system, with transparency and recognizability as important pillars.

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10 Groups (Fetter, Shin, Freeman, Averill & Thompson, 1980; Roger France, 2003). In most European countries, DRG systems have become the basis for hospital payment (Cots, Chiarello, Salvador & Quentin, 2011). Cots et al. (2011) state that DRG-based payment systems are different from other payment systems, because DRG-based systems provide a specific set of incentives to a group of patients with similar clinical characteristics.

The Dutch DBC (DOT) system is subjected to an ongoing debate since the introduction in 2005 (Veeninga, 2006). Criticism on the new system is based on (1) privacy issues for patients, (2) the influence of Healthcare insurers with respect to the quality of care, and (3) different technical issues (Hees, Mengelberg, Velthuys & van der Zee, 2006). According to Cots et al. (2011), it is also necessary to be aware of fraud in this system. They state that there is a possibility for Healthcare providers to perform procedures with higher paying DRGs and therefore receive higher payments for lower quality service.

As mentioned before, the DBC (DOT) system is a tool to cope with the different costs in Healthcare. Where it was originally also intended to be a quality improvement mechanism, there are increasing signs that the DBC (DOT) system forms an obstacle to quality improvement (Custers, Arah & Klazinga, 2007). According to the authors, the amount of income for a medical specialist is based on the number of consultations. Every quality improvement activity that results in longer patient visits will not benefit the medical specialist and will therefore influence their overall productivity/income ratio in a negative way. Custers et al. (2007) concludes that ‘’the new reimbursement system might, therefore, discourage the provision of appropriate care if it is time-consuming’’. As such, it seems that the new reimbursement systems in the Netherlands are mainly focusing on increasing efficiency, rather than increasing the quality of care. One can state that this might have some important influences on medical specialists, because these specialists will always strive to maximize the quality of care for the patient.

2.3 Effects of case-mix management

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11 In recent literature, there seems to be some evidence that successful implementation of a case-mix in the Healthcare sector is dependent on the involvement of medical specialists in this process (Lehtonen, 2007; Abernethy, 1996). However, previous research underlined the somewhat different view of medical specialists on professionalism compared to many other non-medical specialists. To understand this and to put this paper in the right context, now there will be a brief discussion about some specific aspects of the medical profession. These aspects will be combined with some possible connections with case-mix management. Traditionally, medical specialists are classified as dominant professionals (Abernethy, 1996). According to this article, the medical profession finds his nature in autonomy and control. For many medical specialists, professional autonomy is one of the most important parts of their vocation (Taylor & Hawley, 2010). Taylor & Hawley (2010) state that the professional autonomy of medical specialists is seen as very important because it allows doctors ‘’to refuse to give treatments they consider to be useless’’ and ‘’to resist pressures from the political and commercial sectors’’. It can therefore be stated that this form of autonomy may lead to friction between, on the one hand, the intentions of the Health insurers (e.g. lowering costs of Healthcare on the basis of shorter treatment times per patient) and on the other hand the actual performance of medical specialists. According to Abernethy (1996), a serious obstacle in the effective use of budgetary forms of control in Healthcare is the loyalty of medical specialists to their profession rather than to their organization. In this way, medical specialists might not be fully engaged in the effective use of these control mechanisms. Therefore, it could be stated that, if medical specialists feel pressure from a control mechanism such as case-mix management and this control mechanism hinders in some way their daily activities, this might lead to a negative effect on, for example, performance and job satisfaction of these medical specialists. In previous literature, many researchers focused on medical specialists and their job satisfaction in general. In recent literature, there seems to be a consensus that job satisfaction of medical specialists is positively associated with quality of medical services (Tyssen, Palmer, Solberg, Voltmer & Frank, 2013; Ribeiro, Assuncao & De Araujo, 2014; Plomp & Van der Beek, 2014).

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12 the good of the patients (Sulmasy, 1999). This seems to be somewhat contradictory for medical specialists, because with the use of case-mix management they also need to focus on their ‘agreement of the production of Healthcare’. In some situations this may lead to balancing between a form of commitment to the Health insurers about this ‘agreement’ on the one hand, and the interests of the patient on the other hand (Pellegrino, 1987). One can state that this may have negative influences on the physical and psychological state of medical specialists, also known as stressors and job-related personal conflict (Karasek, 1979). Recent literature about psychological effects of case-mix management in Healthcare is very scarce. In general, literature about case-mix management focuses on the more technical evaluation of the system. For example, Charpentier & Samuelson (1996) found that case-mix management in Swedish hospitals has led to a more cost effective approach of care. Medical specialists in this research were more aware of these different costs, but this research lacked some psychological explanations about these outcomes. In his research, Doolin (1999) mentioned some defenses from physicians in reaction to the use of case-mix management in their hospital. However, this research lacked some systematic explanation about these defenses. More recent research focused on the improvement of case-mix models in Healthcare and the assessment of performance. This assessment need to be based on the use of resources and could improve the ‘’discrimination among health episodes for case-mix analysis and funding purposes’’ (Madden et al., 2013). As such, this research focuses more on the effective use of the system by medical specialists instead of having a further look at specific psychological effects of the system. With these examples of previous research of case-mix management in mind, it is very important to find a way in which effects of case-mix management on medical specialists can be revealed and categorized in an effective and systematic way. At this point, the Job Demands-Resource model can give some important insights.

2.4 The Job Demands-Resource model

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13 assumption of the Job Demands-Resource model (see Figure 1) is that high job demands (stressors, X1) can lead to a health impairment process (X), whereas job resources (sources of energy, Y1) can lead to a motivational process (Y) and therefore productivity (Schaufeli & Taris, 2013). Job demands (X1) are ‘’those physical, social, or organizational aspects of the job that require sustained physical or mental effort and are therefore associated with certain physiological and psychological costs’’ (Demerouti et al., 2001). Examples of these job demands are interpersonal conflicts, job uncertainty and working pressure (Schaufeli & Taris, 2013). Job resources (Y1) are ‘’those physical, social, or organizational aspects of the job that may do any of the following: (a) be functional in achieving work goals; (b) reduce job demands and the associated physiological and psychological costs; (c) stimulate personal growth and development’’ (Demerouti et al., 2001). Examples of these job resources are feedback, social support and job authorization (Schaufeli & Taris, 2013).

Figure 1. The Job Demands-Resource model (Schaufeli & Taris, 2013).

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14 positive states (i.e. well-being, Y2). The presence of sources of energy (Y1) can lead to a more positive process, known as the ‘motivational process’ (Y). This positive process forms the basis of a state of well-being (intrinsic motivation) and at the end this may lead to work engagement (extrinsic motivation) and better performance (Y3) (Mastenbroek et al., 2014). These two underlying psychological processes play an important role in the model. The health impairment process (X) is seen as effect of poorly designed jobs or chronic job demands that ‘’exhaust employees’ mental and physical resources and may therefore lead to the depletion of energy and to health problems’’ (Bakker & Demerouti, 2007). On the other hand, the motivational process (Y) relies on the motivational potential of job resources who are assumed to lead to work engagement and, in the end, to better performance. It is stated that these processes (X and Y) have an important interacting potential, whereas several job resources (Y1) may buffer the impact of several job demands (X1) (Bakker & Demerouti, 2007). According to Bakker et al. (2005), ‘’the buffering variable can reduce the tendency of organizational properties to generate specific stressors, alter the perceptions and cognitions evoked by such stressors, (…) and reduce the health-damaging consequences of these stressors’’.

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15 As one can see in Figure 1, there are also dotted lines shown in this model. As previously mentioned, these lines combine both stressors (X1) and sources of energy (Y1) in an interactive way. According to Schaufeli & Taris (2013), there is evidence that sources of energy can reduce the negative effects from job demands on stress reactions (dotted line between X1 and X2). This is also known as stress-buffering (Karasek, 1979), where sources of energy can be used to cope with the effect of stressors during an individuals’ job. This interaction-effect follows directly from the previously given definition of sources of energy, who may help to reduce the effect of job demands on exhaustion (Schaufeli & Taris, 2013). On the basis of previous studies, it is possible to give some examples of the use of the Job Demands-Resource model in practice. With these examples it is possible to make some first predictions of outcomes in this specific research about case-mix management in Healthcare. Demerouti et al. (2001) found that, regarding job demands (X1), physical workload, time pressure, and unfavorable shift-work schedules all have been related to stress reactions (X2) and therefore feelings of emotional exhaustion (X3). Regarding job resources (Y1), Demerouti et al. (2001) found that job control, participation in decision making, and support from supervisors all have been related to forms of well-being (Y2) and also decreasing stress reactions (line between Y1 and X2). There is support for these findings about specific job resources (Bakker, Demerouti, De Boer & Schaufeli, 2003), where these authors also found that job control and participation in decision making may be input for the motivational process (Y) in the Job Demands-Resource model. Bakker et al. (2003) state that employees who can draw upon those specific job resources (Y1) ‘’might be more motivated to do their job (Y2)’’ and ‘’feel stronger commitment to their organization (Y3)’’, whereas job demands (X1) were indirectly the most important predictors of absence duration (X3). In another study, Hakanen, Bakker & Schaufeli (2006) used the Job Demands-Resource model to examine teachers’ working conditions. Findings from this paper showed that job resources (Y1) like job control and supervisory support will lead to stronger commitment (Y3) from teachers and engagement in their work (Y2). On the other hand, Hakanen et al. (2006) suggest that ‘’lack of those important job resources to meet the job demands (X1) may be associated with burnout (X2), which may further undermine work engagement (line between

X2 and Y2) and may lead to lower organizational commitment (line between X2 and Y3)’’.

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16 showed that job resources such as a positive team climate ‘’offsets the psychological costs associated with high levels of emotional demands and role conflicts’’. In this way, a positive team climate can contribute to the reduction of negative reactions (line between Y1 and X2). Even though previous examples are from research that was not focusing on the medical profession in particular, it can be stated that these findings may have some important insights to give some first expectations for this research. As mentioned earlier, employees’ job control (Y1) can be positively related to well-being (Y2). In the Healthcare sector, job control can be seen as part of professional autonomy for medical specialists. One can state that job control and job autonomy are interwoven concepts and are based on the same assumptions. According to Spector (1986), job autonomy is ‘’the extent to which individual employees can structure and control how and when they do their particular job tasks’’. Taken this in consideration, it seems obvious that job autonomy is an important source of energy (Y1) for medical specialists. As seen in previous literature, this may lead to medical specialists who are more motivated to do their work and feel stronger commitment to their organization. However, it can be stated that lack of job autonomy can decrease their job control and this may cause stress reactions (X2). This is because they are not feeling able anymore to ‘control’ their decisions during work. So if, for example, the lack of job autonomy for medical specialists is an effect of case-mix management, one can state that, according to the Job Demands-Resource model, this may become a stressor (X1). Finally, this may cause negative outcomes (X3) like, in the worst case, absenteeism. Therefore, it is expected that job autonomy is an important source of energy (Y1) for medical specialists, whereas lack of job autonomy is seen as an important stressor (X1).

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17 (according to the Diagnose Treatment Combination), he or she does not stick to the previously made ‘production agreement’. Therefore, it is expected that time pressure from case-mix management can be an important stressor (X1) for medical specialists.

Another interesting finding from previous literature is that supervisory support can be an important source of energy (Y1). With the growing power of Healthcare insurers in mind, it can be stated that these organizations nowadays taking a more supervisory role over medical specialists. Therefore, it seems legitimate to say that this is an important part of case-mix management in Healthcare. If medical specialists feel no, or at least not enough, support from Healthcare insurers in their day-to-day business, there seems to be a chance that this may result in a stressor (X1). As stated by Hakanen et al. (2006), lack of this source of energy can, in the end, undermine work engagement (line between X2 and Y2) and organizational commitment (line between X2 and Y3). Therefore, it is expected that supervisory support from Healthcare insurers is an important source of energy (Y1) for medical specialists, whereas lack of supervisory support from Healthcare insurers is seen as an important stressor (X1).

As mentioned in their research, Clausen et al. (2012) found that a positive team climate may contribute to the reduction of an individuals’ negative effects from stressors (X1) and their resulting stress reactions (X2). If case-mix management has a negative influence on a medical specialist (there are a lot of different, possible stressors to think about), then it can be stated that a positive team climate in the hospital may contribute to the reduction of negative reactions from these stressors. In this way, medical specialists may be better able to cope with these negative effects of case-mix management. Therefore, it is expected that a positive team climate in a hospital can reduce the experience of stress reactions of medical specialists (line between Y1 and X2).

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3 METHODOLOGY

As mentioned earlier, this paper tries to provide a better understanding of the influence of case-mix management on medical managers. After some first indications from previous literature, it was stated that little is known about this specific, psychological area in Healthcare. Therefore, the knowledge generating process ‘theory development’ is the best way to contribute to this particular research area. Theory development is needed because this specific area in Healthcare has not been well addressed in academic literature so far. 3.1 Case study research

This paper generates information with the use of a case study. Case study research is very suitable for research in Healthcare systems (Yin, 1999). According to Yin (1999), this is driven by “developments in managed care that link their multiple components in new ways, producing ‘mega-systems’ of great complexity”. Besides that, the author states that “the systems’ rules are in a high-flux state, continually and rapidly changing”. According to Yin (1999), these conditions favor the use of case studies, over other research methods, to gain insights in complex Healthcare systems. Through this qualitative research method, data is derived that is rich in detail about the influence of case-mix management on medical specialists in Healthcare organizations.

3.2 Data collection

3.2.1 Selection of case

The interviews for this research are conducted within a general hospital in the Netherlands. The choice for this specific hospital is based on the connections between the University of Groningen and the hospital that were already established. This contributed to a full support of this study from the hospital and their medical specialists. Besides this, the general hospital that is used for this study has a variety of departments with their own specializations. This may have a positive influence on the validity of this study.

3.2.2 Data collection

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20 Knowledge’ and ‘Google Scholar’. These search engines are well-known and with using them both, it is stated that all the relevant literature was found. The search terms included ‘CASEMIX’, ‘CASEMIX MANAGEMENT’, ‘PHYSICIANS’, and more specific for the situation in the Netherlands was the use of the terms ‘DBC’, ‘DOT’, and ‘DUTCH HEALTHCARE’. After the conception of case-mix management and the specific situation in the Netherlands, this paper has introduced some indications of particular effects of case-mix management on medical specialists. These particular effects are all mentioned in previous literature about case-mix management that was already in use. Therefore, no new search terms are used for this step in the research process.

This paper uses the Job Demands-Resource model as conceptual framework to interpret the results of the study. The model was found in recent psychological literature, in the field of work psychology. The used model was originally found in Dutch, therefore translations were needed to fit the conceptual framework into this paper. The terms of the model are marked with numbers to make interpreting the model as easy as possible. Even though the Job Demands-Resource model is well-known in English literature, it was not possible to find a complete model like this Dutch model in previous literature. A possible explanation is that most literature about the Job Demands-Resource model is focusing on specific parts of the model, and therefore lacks to give an overall view of the model. As such, to give a complete as possible framework, this Dutch model is used. The following Dutch terms where translated in English: ‘Uitputtingsproces’ – Health impairment process (X); ‘Stressoren’ – Stressors (X1); ‘Stressreacties (burnout)’ – Stress reactions (Burnout) (X2); ‘Negatieve uitkomsten (o.a. gezondheidsklachten)’ – Negative outcomes (e.g. exhaustion) (X3); ‘Motivationeel proces’ – Motivational process (Y); ‘Energiebronnen’ – Sources of energy (Y1); ‘Welbevinden (bevlogenheid)’ – Well-being (Enthusiasm) (Y2); ‘Positieve uitkomsten (o.a. prestatie)’ – Positive outcomes (e.g. performance) (Y3). The terms ‘Health impairment process’ and ‘Motivational process’ are well-known and most commonly used in English literature (Demerouti et al., 2001; Clausen et al., 2012; Mastenbroek et al., 2014) and were therefore not subjected to specific translations in this paper.

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21 interviews with 9 medical managers within their specialization from a large, Dutch general hospital. The interviews are semi-structured where answers can be given with a possibly wide variety. Quotes from the interviews are used to give arguments and examples stated in this paper. This study extends previous research from Pre-Master students at the University of Groningen by using and analyzing the set of secondary data as a whole, whereas previous research was focused on specific parts of the dataset.

3.3 Analysis

3.3.1 Unit of analysis

The following interview questions were used in previous case study research, which is also the input for the research in this paper. As mentioned before, these semi-structured interviews, which are conducted by Pre-Master students at the University of Groningen, are used as secondary data. Table 1 contains examples of interview questions about the specific effects of case-mix management that medical specialists experience. Table 2 gives some examples of interview questions about the specific actions that medical specialists are taking in relation to these effects.

Table 1. Example questions about effects of case-mix management on medical specialists 1. Are you trying to ignore negative feelings?

2. Are you sometimes thinking about changing jobs? 3. Did you sometimes call in sick?

4. Do you think that there are other important effects? 5. What is, in your eyes, the most desirable situation?

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22 Table 2. Example questions about actions that medical specialists are taking

1. What consequences and actions do these effects have? 2. What about your colleagues, how do they react?

3. If you compare the current situation with the most desirable situation, what is the difference?

4. Did you and your colleagues sometimes raised your voice against the new system?

3.3.2 Process of analysis

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3.4 Quality criteria

The most important quality criteria in every research are controllability, reliability, and validity (Yin, 2014; Van Aken et al., 2012). If the study meets these quality criteria, there is less reason to question the results of the study. To make the research in this paper controllable, it has to be clear how the study is executed. This is explained in this ‘Methodology’ section, with examples of used interview questions (see section 3.3.1), with an explanation about the use of quotes from the interviews (see section 3.3.2), and with a specific framework that is used in order to make sense of the analysis in a structured way (see section 3.5). These detailed descriptions enable others to replicate the study and is as precisely as possible (Van Aken et al., 2012). For the reliability of this paper, the study is independent of the characteristics of this study. In this way, this paper is aware of potential sources of bias (Van Aken et al., 2012). An important benefit from using secondary data is that potential researcher bias is controlled by using insights of different researchers (from previous research). This is done by coding the same interviews. In this way, there is no chance that codes will be overlooked. The interview questions, used to form the dataset for this paper, are critically assessed by Pre-Master students at the University of Groningen. To make the total assessment complete, three Professors of the University of Groningen and the head of the hospitals’ research department have validated the interview questions. In this way, this study is aware of construct validity (Van Aken et al., 2012).

3.5 Components of the Job Demands-Resource model

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24 section 2.5). To give a clear overview of the used components, the components are defined as follows:

3.5.1 Stressors (X1)

Work overload: quantitative, demanding aspects of the job including working hard and time

pressure (Bakker, Demerouti & Euwema, 2005). Role conflict: occurs when an individual experiences conflicting demands at work (Alarcon, 2011). Role ambiguity: the extent to which an individual is unclear about his or her responsibilities at work or when the role-related information is unclear (Alarcon, 2011). Lack of supervisory support: see ‘supervisory support’, section 3.5.4.

3.5.2 Stress reactions (X2)

Cynicism: indifference or a distant attitude towards work (Bakker et al., 2005). Burnout:

syndrome characterized by a loss of enthusiasm for work, depersonalization and a low sense of personal accomplishment (Shanafelt et al., 2012). Fear: psychological state in which an employee protects itself from environmental threats (Fanselow, 1984).

3.5.3 Negative outcomes (X3)

Exhaustion: related to negative outcomes from work including feeling burned out and feeling

tired in the morning (Bakker et al., 2005). Absenteeism: time and frequency that an employee is unusual absent during working hours (Bakker et al., 2003).

Table 3. Components of the Health impairment process

Health impairment process (X)

Stressors (X1) Stress reactions (X2) Negative outcomes (X3)  Work overload  Role conflict  Role ambiguity  Lack of supervisory support (*)  Cynicism  Burnout  Fear (*)  Exhaustion  Absenteeism

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25 3.5.4 Sources of energy (Y1)

Social support: support from colleagues that is functional in achieving work goals (Bakker et

al., 2005). Supervisory support: related to leaders’ appreciation and support (Bakker et al., 2005). Job autonomy: workers’ control over the execution of tasks (Bakker et al., 2005).

Performance feedback: communication between supervisor and employee in a constructive

way (Bakker et al., 2005). Decision involvement: workers’ participation in specific decision making situations (Schaufeli & Bakker, 2004).

3.5.5 Well-being (Y2)

Professional efficacy: encompasses both social and non-social aspects of occupational

accomplishments (Schaufeli & Bakker, 2004). Job engagement: a positive work-related state of mind that is characterized by vigor and dedication (Schaufeli & Bakker, 2004). Job

satisfaction: workers’ general satisfaction with the job, including internal work motivation

(Tims, Bakker & Derks, 2013).

3.5.6 Positive outcomes (Y3)

Employee creativity: the generation of novel and useful ideas by employees (De Jonge,

Spoor, Sonnentag, Dormann & Van den Tooren, 2012). Organizational commitment: workers’ identification with and involvement in the organization (Bakker et al., 2003). Job

performance: the achievement of organizational tasks, may be measured in quantity or

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26 Table 4. Components of the Motivational process

Motivational process (Y)

Sources of energy (Y1) Well-being (Y2) Positive outcomes (Y3)  Social support  Supervisory support  Job autonomy  Performance feedback  Decision involvement  Professional efficacy  Job engagement  Job satisfaction  Employee creativity  Organizational commitment  Job performance

Components marked with (*) are not explicitly found in previous literature, but are new components that are derived from this study.

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4 RESULTS

After extensively analyzing the written interview transcripts, the outcomes of this study indicate some specific components of the Job Demands-Resource model as mentioned in the previous section. A description of the results of the analysis, including the components from the Job Demands-Resource model, is stated below. The description is based on citations from the interviews. The findings in this section are structured as follows. First, the specific components of the Health impairment process (X) from the interviews are outlined. As stated earlier in this paper (see section 2.4), these components are stressors (X1), stress reactions (X2), and negative outcomes (X3). Second, the specific components of the Motivational process (Y) are mentioned. These components are, as seen previously in this paper (see section 2.4), sources of energy (Y1), well-being (Y2), and positive outcomes (Y3). However, there were no specific positive outcomes (Y3) mentioned in the interviews. Therefore, only components from sources of energy (Y1) and well-being (Y2) can be found in this section.

4.1 Stressors (X1)

4.1.1 Role ambiguity

After the introduction of the new case-mix system in the Netherlands, the medical specialists in the General hospital in this case study were subjected to changes. These changes, in particular the production agreements with the Healthcare insurers (see section 2.1), do not always have a positive influence on the medical specialists. Medical specialist 1 states that the given information about the production agreement is not always clear and this causes difficulties:

‘And now it is the case that we have production ceiling (…) If you exactly should know this at the start of the year, then you can say how many patients per month you should treat, and you could organize a year. However, this wasn’t clear. (…) So it was not a construal entity. And nearly at the end of the

year they announce that you are, for example, 5% lower than the estimated goal. Then it is almost impossible to correct it. So that is hard.’

(Medical specialist 1)

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28 section 2.2), the general goal of the improvement of the DBC system is the simplification of the old system. However, in practice this seems not always the case:

‘There are many ways to Rome. And these are completely vague. The road is the same, but how should I call this road. It makes a lot of difference in declaring the way of the receipt, this leads to choices that are not based on the content, but on the strategic aim. This of course, is definitely not the

intention. The DOT system should obviate this. However, it hasn’t done it.’

(Medical specialist 2)

At this point, it is notable that there seems to be a pattern in these reactions. Many of the medical specialists in this Dutch hospital have mentioned these forms of role ambiguity after the introduction of the new declaration system. Medical specialist 6 seems most dissatisfied with this changing work environment:

‘(…) it’s a terrible complicated system. It is so difficult and I have done it earlier with those DBC’s, well it was tear-shedding. I’m very precise, but at the end of the month I had about 100 of these things I

had to review, and at a certain moment you don’t understand it anymore. (…) it’s just way to complicated. Just hardly to understand.’

According to other medical specialists, it seems quite normal from their supervisor’s point of view that medical specialists expand their daily activities with administrative tasks. For example, one medical specialist state that the daily activities in the hospital can be compared with ‘running business’:

‘You didn’t became a doctor to put down all these numbers on paper, at least not me. The most doctors don’t. And in the end you sort of run your own business, I think that you have to know some

basic knowledge of this, but that wasn’t my aim in the first place when I studied Medicine.’

It seems clear that these forms of role ambiguity have a negative influence on medical specialists, in the sense that these examples can be seen as important stressor (X1) in their daily activities.

4.1.2 Lack of supervisory support

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29 feel that Healthcare insurers are only focusing on cutting costs and other financial issues, instead of striving for the highest quality of care:

‘Yes it is for a hospital - to have a good financial position - great that an insurer is keen on you. But as a doctor you’d rather focus on what you’re founded keen on. Now I can sublimely provide care without the insurer knowing it or is interested. Since the insurers are solely thinking in financial

terms.’

Another medical specialist has the same opinion, and thinks that the Healthcare insurers are not enough focusing on the quality of care. This is inconsistent with their own point of view:

‘And now we’re in a situation that not only the Healthcare insurer decide on our cash flows, but also on the content of the Healthcare. While on the content - the choices that they make - is not founded on you are very good so you’ll get more money and we like to do business with you. No, are you the cheapest, than we like to do business with you. And it means that this aspect, the quality, no longer

has a high priority, they call it everywhere, but at the moment you really start negotiating, the priority is completely faded away.’

Besides the fact that Healthcare insurers are only thinking in financial terms, some medical specialists state that these Healthcare insurers do not have sufficient experience to make good decisions about case-mix management. The actual knowledge of the Healthcare insurers about the medical profession is therefore questioned:

‘The knowledge about the facts is limited, the decision making authority of people you talk with is also limited. It be completely bureaucratic red tape organizations. (…) A lot of talking is done and the

practice is opposite; there is limited support for the intended experiments.’

As one can see with these examples, lack of supervisory support in case-mix management seems to be a stressor for medical specialists. Important to notice is the fact that the growing power of the Healthcare insurers leads to many supervisory activities, but, as stated by many medical specialists, in the end this will not always lead to supervisory support. As mentioned by medical specialist 9, this causes some negative influences:

‘When it is imposed or at least the organization throws it at you, then it’s a difficult story. Why is it difficult? Because as a medical specialist you are trained for the past fifteen years to eventually make decisions on your own. Of course, you have a team, but in the end you are alone on the OR to make a

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specialists to hear: “you have to do this and do that.” Especially because these orders are from people who don’t have the professional knowledge that you own. You are the one who practice the job every

day.’

4.1.3 Work overload

A third stressor that is mentioned in the interviews is work overload. The new production agreements with Healthcare insurers may have negative influences on medical specialists. For example, medical specialist 4 states that some colleagues feel too much time pressure in this new situation:

‘(…) also because with a few colleagues within the department emotions exist that the pressure is too high.’

This view is supported by medical specialist 9, who states that, in some cases, the available treatment time is too short in the new system. This may cause stressful situations for medical specialists:

‘(…) I think it hits the work floor, when you, instead of five minutes or ten minutes for a patient, now have only five minutes, because this is your time limitation and you have to see a certain amount of patients to reach your production goals. Then the stress may get a lot higher. You can imagine that,

when you have to do more in less time.’

Besides this ‘functional’ problem, medical specialist 9 also mentioned a financial issue related to this:

‘At a certain moment you also have to do a number of things of which you say, according to me I do way too much or I have the idea that I have to do a lot more for what I get for it.’

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31 from many medical specialists, who feel affected in their autonomy. This medical specialist gives an example:

‘Well, to give an example. The hospital has an appointment with a top predicate for Menzis, where spine patients within 3 weeks has to be seen in the hospital. What happens is that there is limited capacity. What then happens is that Menzis start to call and say: “Hey, you don’t do it within 3 weeks and our insured people have to be seen within 3 weeks”. Than the patient gets priority on the basis of

where the patient is insured. (…) This goes straight against the feeling of justice concerning the provision of medical care to anyone. I notice this also with colleagues who are fed up with forcing you

to provide care on the basis of where someone is insured. That is not what we want, since we just want to provide care to the public. (…) An important issue is the professional autonomy. People became medical specialist, because they want to be able to decide together with the patient. When the management wants to intervene too much, people get affected in their professional autonomy.’

According to this specific example, one can state that this lack of job autonomy is seen as a stressor for medical specialists. As mentioned earlier in this paper, this stressor can be seen in terms of the ‘mirror image’ of the Job Demands-Resource model (see section 2.4). As stated in previous literature (see also section 3.5.4), job autonomy is a source of energy (Y1) for employees in many work-related situations. However, according to the medical specialists in this case study, lack of job autonomy may have the opposite effect and ‘turns’ in this way into a stressor (Y1). This seems also the case for a stressor that is, in this paper, called lack of decision involvement. One medical specialist states that medical specialists are not involved in making the production agreements with the Healthcare insurers, and thinks that this is a bit strange:

‘And especially because I don’t make those appointments myself, that pinches a little bit in my opinion.’

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4.2 Stress reactions (X2)

As mentioned in the previous paragraph (see section 4.1.1), role ambiguity (X1) is found as an important stressor after the introduction of case-mix management in this Dutch general hospital. As stated by medical specialist 2, role ambiguity (X1) leads to a somewhat cynical attitude towards the new situation. Unclear information about their production agreements has caused some psychological reactions, as they feel somewhat despondent and powerless: ‘(…) that are the effects in which I’m disappointed and despondent. I try to neglect and under press

these feelings as much as possible, since I don’t have the power to change these effects.’

These psychological reactions can be best defined as cynicism. Medical specialist 6 felt also somewhat cynical, in reaction on the lack of supervisory support (X1). In particular when Healthcare insurers do not see the ‘added value’ of, for example, specific treatments in the hospital:

‘Well the feeling of powerlessness. Powerless because you’ve build something really great with each other in the hospital. (…) The staff is satisfied, patients give the hospital a ‘nine’-rating. Everybody is very satisfied about the hospital and the Healthcare insurer says in one mark: ‘’gone’’. Powerlessness,

you don’t know it, you feel like that you think Jesus Christ! This isn’t normal anymore. So yes, powerlessness.’

Two stress reactions are found that were not particularly linked to specific stressors, but were mentioned by a few medical specialists. These are fear and job dissatisfaction (see also section 3.5.2). According to medical specialist 1, after the introduction of case-mix management, some colleagues were a bit anxiously about the specific changes in their hospital:

‘(..) and that makes everybody a little anxious. And that, consequently, creates camps.’

(Medical specialist 1)

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‘That I also don’t know it anymore at a certain moment. What do I have to do next year? Can I continue or are we going to be a different hospital? Do we become another IC? I don’t know. (…) And I

am really afraid that later this year this will have a lot of consequences for the patient. Not good.’ (Medical specialist 6)

Some medical specialist pointed at their job dissatisfaction after the introduction of case-mix management in the hospital. Especially the production agreements gave rise to a less satisfied attitude towards their job:

‘(…) it’s a little bit divide and conquer what the insurers are doing, you have to look out. It does make it less fun. (…) With all those production goals I don’t get a lot job satisfaction.’

According to medical specialist 7, there were more colleagues who had the same opinion about this:

‘Yes, everybody gets cranky about it of course. (…) and then the job satisfaction will be affected.’

In summary, cynicism, fear and job dissatisfaction are specific stress reactions that are found from the interviews. As mentioned earlier, these stress reactions (X2) may be input for negative physiological and psychological outcomes (X3) for medical specialists (see section 2.4). The negative outcomes that are found in this case study are outlined in the next paragraph.

4.3 Negative outcomes (X3)

The two most important negative outcomes from the interviews are lack of organizational

commitment and exhaustion. For example, medical specialist 7 feels sometimes distrust to

the management:

‘When the management starts to make agreements that are not transparently established and have negative effects that are not conform the professionalism and autonomy, this will lead to a lack of

confidence.’

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34 (see section 3.5.6). Notably, one medical specialist can imagine some situations wherein medical specialists might be tempted to commit fraud:

‘Undoubtable there are doctors in the Netherlands who do this. However, it’s within the margin, since you can’t do it on a large scale. You have to have a sick, frustrated mind to gather your money in this

way. Presumably this will be the specialists who don’t have the directing, not the control on their production goal. (…) they find it unjustified and dishonest.’

It is stated that this is an ultimate form of lacking organizational commitment, and therefore this seems not the case very often. One specific example of exhaustion comes from medical specialist 6 who states that, due to decisions of the Healthcare insurers in constituting a case-mix, there were colleagues who had some bad sleep:

‘The effects which I experienced from the production goals… Well degree of stress. I have built a wonderful IC here with my colleagues and my whole IC team which is wiped out in one fell swoop by

the Healthcare insurer. So we haven’t slept well.’

Summarized, there are different negative influences of case-mix management that were mentioned by medical specialists in the interviews. According to the interviews, the most important stressors (X1) are role ambiguity, lack of supervisory support, and work overload. These stressors cause stress reactions (X2), as seen in section 4.2, like cynicism, fear, and job

dissatisfaction. In the end, this may lead to negative outcomes (X3), like lack of organizational commitment and exhaustion. However, there are also positive effects to

mention at this point. In fact, as previously stated, it is possible to see specific components of the Job Demands-Resource model in two ways. This is the so-called ‘mirror image’ of the model (see section 2.4). This, among other ‘positive’ components, will be outlined in the next part of this section.

4.4 Sources of energy (Y1)

4.4.1 Supervisory support

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35 that good communication and support from the Healthcare insurer can contribute to a positive feeling for medical specialists:

‘I think that what I could, I have done. Deliberate with the Board of Directors and the Chairman of the medical staff to discuss how we can turn back time, that we are not influenced by external factors. In what way we can make our qualities even more visible and how we are going to use it in combination with the Healthcare insurer. (…) Well and the Healthcare insurer wrote back that it’s not the aim that

we decide on our own, we’ll go with you in conclave. Talk together.’

In addition, medical specialist 5 thinks that a dialogue between medical specialists and their supervisor, and the resulting support, can reduce specific ‘tensions’. Medical specialist 5 stated that these ‘tensions’ (i.e. stressors, X1) and their resulting stress reactions (X2) may be reduced with supervisory support:

‘But when a tension creates, you’ll have to start the conversation that the degree of effort, your ambitions and job satisfaction does not collaborate, then you need to consult.’

4.4.2 Job autonomy

It is clear that, for medical specialists, professional autonomy is one of the most important parts of their vocation (see also section 2.3). Therefore, it is not surprisingly that job

autonomy is seen as important source of energy (Y1). Medical specialist 3, for example,

thinks that through autonomy and control, medical specialists are more able to know what is expected from them. According to this medical specialist, this might be a positive effect of case-mix management:

‘When you take care that you’ll have control - since that is what it is about, control on your job or privately - than you’ll feel a lot better than when you are threatened. (…) Yes it is clear to me what is

expected from me.’

Medical specialist 9 states that it is important that medical specialists can make their own decisions on the work floor. However, it is important that the results of these decisions are visible for medical specialists:

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instruments to measure this. When you see this yourself and you approached and thought it in this way, then of course this will give a boost.’

Another interesting form of job autonomy is mentioned by medical specialist 2 and 7. They see their autonomy as ‘tool’ to cope with negative effects from case-mix management. This is done by simply ignoring negative feelings or specific stressors:

‘A specialist has a lot of freedom in movement. He could try to avoid things.’

In some way, one can state that ignoring specific stressors (X1) or stress reactions (X2) can be seen as source of energy (Y1). Medical specialist 7 goes one step further, when stating that medical specialists do have the power to ignore managerial decisions from Healthcare insurers:

‘Oh, that is just counteracted. So it will be boycotted. Since the power lays in the hands of the specialists. It sort of lays in the hands of the hospital, however the specialists have more influence on

what happens on the work floor. So if from higher hands it is shouted that you have to see Menzis patients earlier, than it could be the case that if you as management delegate this to the secretary,

this will be boycotted gigantically and negatively perceived by the specialists.’

One of the other sources of energy that is worthwhile to mention at this point is

performance feedback. Medical specialist 1 states that the ‘directing role’ of the Healthcare

insurers brings some positive effects. On so-called ‘market days’, every medical specialist can show their daily activities and they can convince the Healthcare insurer that the medical specialist is delivering good care:

‘So that market day is introduced 3 or 4 years ago, that someone could show what he was doing in a hospital. (…) that it exists is an improvement. I think it is a good thing.’

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‘Well, a good thing is transparency. So everything is a lot more transparent, what is happening everywhere and what the quality is, and I think this is a very good effect. We are put down on a balance scale, however this forces you to expose yourself and you have to explain why you think that

things are going in the right way and why you have it well-arranged. Transparency is a very good effect.’

Finally, one medical specialist stated that decision involvement is an important source of energy. According to this medical specialist, the Healthcare insurers and the hospital should involve medical specialists in the decision making process about production agreements:

‘Well yes, what kind of effects it should have is the connection with the hospital. That you are one complete entity. That you make agreements with each other, what are the things that are going to

happen within the hospital, and what can I - as a radar - do about it. So this connection with the entity. That is for me personally the most important input for the agreements on the production

goals.’

These sources of energy (Y1), with supervisory support, job autonomy, and performance

feedback as most important, may be input for the Motivational process (Y) as stated in

section 2.4. Whereas most sources of energy can cause emotional states as ‘well-being’ and ‘enthusiasm’ (see next paragraph), results from the interviews show that sources of energy may also be used to reduce the relation between stressors and stress reactions (see Figure 1, line between X1 and X2). This will be further discussed in the ‘Discussion’ section.

4.5 Well-being (Y2)

According to medical specialist 9, job autonomy (Y1) that follows from case-mix management can, maybe not surprisingly, contribute to a higher job satisfaction for medical specialists:

‘I think that when you take my situation in consideration, you can decide on your own how to practice your job, then the job satisfaction will increase further.’

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38 management, this might be positive for occupational accomplishments. As seen in the previous section, aspects of occupational accomplishments are part of professional efficacy. Therefore, this could be a component of well-being:

‘When it would be there than I can imagine all sorts of effects that you should feel here indeed, because than you get the adhesion, and then it is also nice that when you make a plan and this will

lead to something, you’ll get enthusiastic about it.’

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5 DISCUSSION

In this section, first there will be a discussion about the most important findings from the previous ‘Results’ section. After that, theoretical and managerial implications from this study will be mentioned. This part will be completed with recommendations for the Healthcare sector, according to the findings of this study. This paper will end up with some limitations of this study and some recommended directions for future research.

5.1 Findings

It can be concluded that case-mix management forced some changes in the working area of medical specialists. The new DBC (DOT) system was originally intended to introduce an improved declaration system in Dutch hospitals, as simplification of the old system. However, findings from this study show that, in general, medical specialists have negative opinions about the new system. In first instance, this seems in line with the expectations at the beginning of this study (see ‘Introduction’ section). On the basis of the Job Demands-Resource model, it was possible to find some specific components of, on the one hand, the Health impairment process (X, see Figure 1), and, on the other hand, the Motivational process (Y, see Figure 1). The most important findings are discussed below.

Findings of this study suggest that role ambiguity can be seen as an important stressor (X1) for medical specialists. Firstly, this was caused by unclear information about production agreements. Secondly, it was stated that the added administrative tasks were too difficult for some of the medical specialists. In general terms, if organizations implement new systems, it might be expected that this causes some issues and problems in the first, lets say, year after introduction. When looking to the DBC (DOT) system in Dutch Healthcare, this study is done after approximately seven years after introduction. One can state that this would be long enough to optimize the system in a way that the users, in this specific case the medical specialists, are not faced with role ambiguity at this stage. Findings from this study suggest that role ambiguity (X1) causes a cynical attitude (X2) from medical specialists. This cynicism included feelings of disappointment and powerlessness.