Controlling medical specialists: Hospital reforms in the Netherlands

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Abstract
Despite waves of budget cuts and structural reorganizations, physicians in most of Europe have not been subject to managerial controls like those that have emerged in the United States and to a lesser degree in Britain. This paper examines one of the most dramatic instances in which physicians resisted managerial and governmental control and explains recent changes in this pattern. From 1982 through 1992, Dutch hospital specialists successfully blocked efforts by governmental regulators, insurers, and hospital managers to control the specialists' activities so as to reduce hospital costs, integrate care activities, and assure quality. Gradually the specialists began to lose their budgetary and operational autonomy and signed agreements with hospitals and insurers to integrate the specialists' fees into hospital budgets. These new fiscal arrangements increase the hospital managers' economic control over specialists and create possibilities for the enhancement of other types of managerial control. The organizational and political forces behind these changes are analyzed, along with their implications for future patterns of professional control in the Netherlands and for the integration of professional and managerial functions within Dutch hospitals.