Professionalism & Performance-based Contracting: Transparency, accountability or interference?

Abstract

Currently, there is an intense debate on the “marketization” of health care and its consequences for the work of professionals. With the introduction of performance-based contracting, health insurers in the Netherlands are now expected to transform from passive payers to prudent and critical purchasers of health care who evaluate care providers according to performance criteria. Yet, this may put pressure on healthcare professionals who traditionally work in an autonomous environment, because the market and managerial principles embedded in performance-based contracting contrarily seek to strengthen health insurers’ control over professional work. To date, the lack of empirical comparative research – inclusive of several professional groups in different service domains – makes it difficult to decide what the actual consequences of market-based policies for professional work actually are. In response to this gap, using a mixed-methods design, this study examines how distinct market and managerialist principles “work” across the distinct institutional settings of hospital care and home care in the Netherlands. Specific attention is paid to degrees of professionalism as an explanatory factor for differences in development, implementation and consequences of performance-based contracting for professional work. The conclusions of this study challenge the common assertions on the relationship between market and managerialist principles and professionalism. The study shows that performance-based contracting may trigger different types of mechanisms of varying intensity in terms of affecting professional work. First, the transparency mechanism makes professional work more transparent for health insurers, by providing them information on what happened, how it happened, and what its outcomes were. Second, the accountability mechanism means that the individual professional is to be held accountable for and explain to the insurer those actions for which he has responsibility and authority. Third, the interference mechanism entails that purchasers interfere directly with professional decision-making processes in a way that professional standards and protocols are increasingly submitted to “external” criteria as defined by actors that do not belong to the “inner circle” of the corporate profession. The study discovers that the way in which performance-based contracting is implemented, the mechanism that it triggers – transparency, accountability, interference – and subsequently the consequences it has for professionals’ individual autonomy and intrinsic job satisfaction, are dependent on the particular institutional position of professionals and managers in the healthcare sector. On the one hand, this study illustrates that the consequences of performance-based contracting for the individual autonomy and intrinsic job satisfaction of medical specialists, hospital nurses and home care workers are limited. On the other hand it shows that in their daily work healthcare professions are increasingly confronted with policies of insurers that seek to measure and evaluate professional work. Remarkably, the medical profession, characterized by a high degree of professionalism, is better able to influence the development of performance-based contracting. But at the same time individual medical specialists are more than the less professionalized hospital nurses and home care workers negatively affected by performance-based contracting in terms of individual autonomy and intrinsic job satisfaction. The results of this study have implications for healthcare professionals, policy makers, health insurers and managers of healthcare organizations.