Physician Responses to Activity-Based Hospital Reimbursement Models in Public Healthcare Systems: Exploring the Cases of England and Turkey

Abstract

The implementation of cost and activity management policies under New Public Management reforms has the potential to restrict medical practice through determining the scope of health services provided by physicians. Activity-based reimbursement models create a dilemma for physicians when trying to achieve efficiency and cost-control while maintaining high-quality patient care. Physicians, however, are able to resist and re-shape top-down policies as street-level bureaucrats, within the discretionary space created by their clinical autonomy. This thesis explores the ways in which local infrastructure, contingencies, and practice influence physician's discretion towards activity-based hospital reimbursement models at public hospitals in England and Turkey. It focuses on two publicly funded health systems with contexts not completely divergent, but with different histories and trajectories. This interpretivist qualitative study brings policy implementation literature to understand diverse responses of physicians to financial regulations in health services provision. It develops a theoretical framework to locate discretionary practices across contexts based on the level of divergence from policies. Using empirical data collected through semi-structured interviews with physicians and staff working in managerial and administrative roles, this thesis shows that universally applied policy tools, such as activity-based hospital reimbursement models, must be examined within country-specific circumstances to capture an accurate picture of what does work (or not) under which circumstances. The nature of medical practice does not align with input-oriented policies, and medical standardisation for the purposes of cost and activity management creates obstacles for physicians in the provision of care. Physicians encounter role conflict under reimbursement restrictions, but their professional status and level of perceived autonomy enables them to deviate from actual policies when necessary. However, physician motivations are not purely altruistic. As street-level bureaucrats, physicians pursue complex set of goals which encompass seeking patient benefit, managing workload, and obtaining financial benefits. Moreover, physician behaviour is subjected to individual and organisational contingencies, with their practices shaped at the level of specific organisations and even sub-organisational units, such as different medical specialties. Therefore, the extent of physicians' clinical autonomy depends on policy contexts and their individual perceptions of professional status, resulting in a spectrum of discretionary practices ranging from 'citizen-agents' to 'policy-alienation'.

Date of Award	6 Jan 2025
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Liz Richardson (Supervisor) & Jonathan Hammond (Supervisor)