The many meanings of money : exploring health care professionals’ experience of economic governance

Introduction: Ensuring health care to the public is fundamental to the welfare state and consumes a substantial part of national expenditures. Health care systems across developed countries face challenges of increasing demand and limited resources, and efforts are made to push provider organizations to increase efficiency and still maintain quality of care. The use of increased competition and reimbursement models to stimulate specific provider behaviors has gained increased attention in health care governance. However, the literature evaluating the impact of economic governance strategies is complex and appears inconclusive. Surprisingly few studies take the perspective of health care professionals, although their response to economic governance requirements is essential for change to occur at the organizational level. Insights from management research may enrich studies exploring professionals’ perspectives of economic governance by highlighting the important role of managers, who serve as a link between organizational demands and staff. In health care contexts, managers’ abilities to adapt the external demands to the care delivery process and to professional values have shown to be a key factor for organizational output. The literature on motivation also contributes by proposing that the influence of external rewards depends on its interplay with intrinsic motivation, based on individuals’ beliefs and preferences. Motivational research in the public sector proposes that the intrinsic reward from meeting patient needs is a particularly strong motivator for health care professionals. This thesis intends to bridge the macro-, meso- and micro-levels of health care systems by exploring how economic governance models are experienced by health care professionals when filtered through organizational layers (rather than the governance model itself), using insights from management and motivational literature to guide the studies.

Aim: The overall aim of the thesis is to explore health care professionals’ experience of economic governance, at the manager and staff level. The thesis studies specifically aim to explore the consequences of a particular economic governance model including patient choice, from the perspective of professionals (Study I), the strategies managers use as intermediaries between the economic governance model and staff (Study II), and staff experiences of economic efficiency requirements in health care (Study IV). The thesis also includes a method study (Study III) aiming at developing a self-assessment scale, capturing staff experiences of governance of economic efficiency and quality, and assessing its psychometric properties.

Methods: The thesis explores two empirical settings. Case 1 includes a regional patient choice model in elective orthopedics, including governance strategies of increased patient choice, increased provider competition, specialization of providers, and financial incentives. Case 2 includes the use of annual budgets in a public university hospital setting facing substantial economic constraints. In this case there is a specific focus on the Department of Rehabilitation Medicine. The thesis comprises multiple study designs and methods. Studies I and II apply an exploratory qualitative design, based on interview data from professionals in key positions, who hold managerial responsibilities. Study III applies methods for scale development and focuses on professionals at the staff level. Although the psychometric assessment is based on quantitative (survey) data and methods, the development process also includes qualitative methods. Study IV focuses on professionals at the staff level and applies a sequential mixed method design, using qualitative interview data to enrich the understanding of the survey data collected in Study III.

Findings: Study I showed that the patient choice model had implications for the organization of care, for patients, for professionals’ work environments and for education and research activities, as perceived by professionals. Further, their analysis identified consequences at the provider level and for the health care system as a whole. Study II showed that professional managers applied strategies to function as intermediaries between the patient choice model and their staff, aligning external requirements with professional values. Study III describes the development and pilot study of the GOV-EQ scale. The scale showed promising psychometric qualities and captured health care staffs’ experiences of governance, including economic efficiency requirements (Subscale A) and quality requirements (Subscale B). Study IV showed that staff was knowledgeable and motivated to consider economic efficiency requirements in clinical work, conditioned that patients were not put at risk. Nevertheless, staff members experienced little influence over resource allocation and identified limitations to the overall system’s abilities to meet patient needs. Study IV further revealed that staff experiences of economic efficiency requirements included a system-level perspective, caring for the entire patient journey across stakeholders, and that they assessed the fairness of the system as a whole.

Conclusions: The thesis concludes that professionals at the staff and manager level are well aware of economic efficiency requirements and intrinsically motivated to manage resources carefully. Their engagement does not seem limited to organizational roles, but is guided by a common concern that the overall health care system fairly provides value for patients and supports a sustainable work environment and knowledge development for the professional community. The thesis confirms the priority of the professional ethos and concludes that economic governance models should be aligned with patient needs and health care quality. The thesis also confirms the importance of managerial strategies that take professional values and motivation into account. The thesis concludes that professionals may be a valuable source of knowledge when evaluating economic governance strategies, having system-level awareness and a concern for the entire patient journey across stakeholders. The thesis highlights the need for increased collaboration and dialogue that brings professionals and policy makers together, to attain economic governance models that efficiently support (and balance) the multiple aims of health care and that are perceived as valid, in the sense that professionals find the requirements imposed on them as reasonable.

List of scientific papers

I. Korlén, S., Amer-Wåhlin, I., Lindgren, P., & von Thiele Schwarz, U. (2017). Professionals’ perspectives on a market-inspired policy reform: A guiding light to the blind spots of measurement. Health Services Management Research. 30(3): 148-155.
https://doi.org/10.1177/0951484817708941

II. Korlén, S., Essén, A., Lindgren, P., Amer-Wåhlin, I., & von Thiele Schwarz, U. (2017). Managerial strategies to make incentives meaningful and motivating. Journal of Health Organization and Management. 31(2), 126-141.
https://doi.org/10.1108/JHOM-06-2016-0122

III. Korlén, S., Richter, A., Amer-Wåhlin, I., Lindgren, P., & von Thiele Schwarz, U. (2018). The development and validation of a scale to explore staff experience of governance of economic efficiency and quality (GOV-EQ) of health care. BMC Health Services Research. 18:963, 1-13.
https://doi.org/10.1186/s12913-018-3765-7

IV. Korlén, S., Amer-Wåhlin, I., Lindgren, P., & von Thiele Schwarz, U. Exploring staff experience of economic efficiency requirements in health care - a mixed method study. [Submitted]