In this section, implications for stakeholders in the health care value chain are discussed, which are payers, providers and producers. Payers refers to policymakers, regulators and payers. Providers refers to hospital management and practitioners (physicians). Producers refer to the pharmaceutical and medical technology industry. In addition, institutions are added, as there may be implications for medical education and research. Finally, implications for patients are also provided.
Deriving guidelines for policy making and practice from research is in itself a complex phenomenon. Realist synthesis and evaluation (Pawson et al., 2004) emerged as an approach to synthesise ‘what works, for whom, in which circumstances…’. The realist synthesis methodology suggested by Pawson et al.
(2004) is focused on gaining insights from the respondent perspective about the relationship between context, intervention, mechanism and outcomes (CIMO).
Pawson (2006) states that “the generative model calls for a more complex and systemic understanding of connectivity. It says that to infer a causal outcome (O) between two events (X and Y), one needs to understand the underlying generative mechanism (M) that connects them and the context (C) in which the relationship occurs”. Thus, intervention may be considered the trigger for change (Pawson, 2006 p. 27). In this context, interventions aim to change health status.
Mechanisms describe what it is about the intervention that triggers change to occur. Pawson (2006) p. 23, defines mechanisms “as engines of explanation in realist synthesis”, as “we rely on mechanisms to tell us why interconnections should occur”. Employing the CIMO logic to the results in this study is of value, as it helps derive clear implications for policy and practice.
The context in which this study is conducted is that of funded (e.g. prepaid) health care. When health care is prepaid, fee for service does not regulate demand
is that the physician does not have mechanisms at his/her disposal to regulate demand (McGuire, 2001). Thus, if demand increases and resources are fixed, the effort per patient may decrease as a result. Evidence from this study suggests that physicians adjust effort into the delivery of health care in line with demand.
Physicians therefore seem to accept variability in effort as a consequence of variability in demand. However, empirical data revealed that physicians’ believe this to result is lower quality.
It is also possible for an employer to take advantage of a physician’s ethical constraints and organize health care delivery in such a way that the physician is forced to supply more effort to make sure the patient attains an acceptable outcome (McGuire, 2001 p. 61). In other words, an employer may provide limited resources and hope that physicians’ loyalty to patients will make the physicians provide the necessary effort. This case would be an example of how the health care service delivery is organized and resourced.
Intervention in the CIMO context is to be understood as physician effort supplied into the delivery of health care, and consequently, quality in health care. The underlying generative mechanism is the physicians’ perception of behavioural control. Outcome is considered as quality in health care. Therefore, in a context of prepaid health care, physician effort supplied into the production of health care is dependent on the physicians’ perception of behavioural control of that effort.
Therefore, the implication is that quality in healthcare is dependent on empowering physicians’ to make bounded decisions in a complex context.
1.12.1 Implications for Payers
Payers in this context refers to payers in the health care value chain, as defined by Burns et al. (2002). However, in addition to payers and financial intermediaries, policy makers and regulators are considered in this section. The reason for the inclusion of policymakers and regulators is that they influence and regulate the fiscal policies supporting the health care value chain.
The findings of this study may be of interest to payers for three main reasons.
First, payers by way of simple monitoring and incentives, leave a great deal of authority concerning diagnosis and treatment with the physician (McGuire, 2001 p. 527). In other words, physicians are free to make clinical choices that drive the cost without being responsible for the financial outcome of the choice. Second, over reliance on medical sub-specialization and physician experience may have a paradoxical effect on quality of health care delivered (Choudhry et al., 2005).
Finally, there is a lack of evidence supporting the hypothesis that more is better when it comes to cost of health care (Wennberg et al., 2002). In this study when physicians were questioned about barriers to quality in health care they revealed that they believe that more material and human resources equate to improved quality.
1.12.2 Implications for Health Care Institutions (Providers)
In this case, the central provider is the physician; however, in the context of practice characteristics, it may also be larger organizational units such as
practice characteristics being a potent influencer on physician prescribing behaviour.
This study provides important insights for institutions for three main reasons.
First, the supply of physician effort is strongly linked to quality in health care delivery. Thus, health care organization may be able to influence quality in health care by considering factors influencing physicians’ supply of effort and the underlying mechanisms for such influence. Second, the study shows how institutions are organized and resourced may influence quality in health care.
Finally, this study suggests that physician competency is an influencer of physicians’ supplied effort, and hence quality in health care. Thus, the importance of medical training should not be underestimated.
Health care organisations would benefit from considering the findings in this study when:
Structuring medical departments
Deciding on resourcing
When controlling physician’s activities and duties
When planning physicians’ careers with respect to current and future competency needs
It is argued that although uncertainty can be reduced, it can never be completely eliminated from decision-making. Therefore, most decision-making performed in medicine contains an irreducible intuitive element, and is thus vulnerable to these biases and heuristics. Given that few medical curricula overtly address the process of medical decision-making, both medical students and physicians remain vulnerable to these effects on their own (and their patients') decision-making. Insight via education appears to be the major means by which to develop more advanced models of decision-making.
A part of the interviews focused on asking respondents about what they would do differently if the mentioned barriers did not exist; the majority of physicians responded that they would do more of what they were already doing.
“I would spend more time on diagnostics, making sure that we follow national and international standards for establishing diagnosis, more time on treatment and evaluation of effect and follow up, I would spend more time talking to the patients and next of kin ensuring better and more complete information. I would spend more time developing professionally and discussing cases with colleagues.” (ID #: 26)
The consequence, as indicated in the projective questions of the semi-structured interviews, would be an improvement in health care service delivery in general.
“I would probably make fewer mistakes, fewer complaints, patients would be more satisfied, expenses would probably decrease, things would go smoother, we would use less time and may be able to treat more patients.
It would be more fun to work, less complaints from colleagues, time to develop as a physician.” (ID #: 15)
This was an unexpected finding, but quite intriguing. If physicians would simply do more of what they were already doing if the barriers did not exist, this reveals that barriers influence volition (i.e. the cognitive process of decision-making), or at least the perception of perceived behavioural control, at some level.
Control of volition is an underlying assumption of the Theory of Planned Behaviour (TPB) (Ajzen, 1991). Evidence in this study strongly suggests that perceived behavioural control is a central mechanism by which enablers and barriers exert influence. In an ideal world where barriers do not exist, physicians will not do anything different other than doing more of what they are already doing. Thus, the evidence indicates that physicians would not change what they are doing, but the effort supplied by physicians would actually be affected. It is therefore argued that “the will to act” (behavioural intent) is present in a clinical setting and may be considered a constant. As such, it is possible for the TPB constituents, attitude and social norm, to be considered constant in a clinical setting.
From a practitioner perspective and personal experience, this is plausible, as the drive to help others may be considered strong in the medical profession because there is a concern for medical ethics (Arrow, 1963). Thus, the combination of both intent and perceived behavioural control may be used to predict actual behaviour, as asserted by Ajzen (1991) p. 184. Keeping behavioural intent constant, the probability of actual behaviour becomes dependent on perceived behavioural control, which in TPB, is assumed to be dependent on prerequisite opportunity and resource. The availability of requisite opportunities and resources (e.g., time, money, skills, cooperation of others) collectively represent physicians’ actual control over behaviour related to health care service delivery (Ajzen, 1985, Ajzen, 1991 p. 182).
1.12.3 Implications for Producers of Medicines
The author, content that changing the business model from person-to-person to business-to-business is necessary. Such a change allows for strategic and operational alignment between health care providers and the producers of medicines in a health care value chain context. However, this change requires a change in the mind set of current and future pharmaceutical marketers. Current practice is internal recruitment from sales to marketing and business-to-business models are not necessarily within the skill set or “comfort zone” of current marketers. Thus, the author argue that a move away from current practice of recruiting managers and executives from an increasingly irrelevant salesforce background is necessary.