Alignment in the Hospital-Physician Relationship: A Qualitative Multiple Case Study of Medical Specialist Enterprises in the Netherlands

Document Type : Original Article


1 Radboud University Medical Centre, Nijmegen, The Netherlands

2 Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands

3 Rotterdam School of Management, Erasmus University, Rotterdam, The Netherlands


Policy-makers and hospital boards throughout the world have implemented different measures to create and sustain effective hospital-physician relationships. The ‘integrated funding’ policy reform in the Netherlands was aimed at increasing hospital-physician alignment and led to the unforeseen formation of medical specialist enterprises (MSEs): a fiscal entity representing all self-employed physicians in a hospital. It is unknown how hospitals and MSEs perceive their alignment and how they govern the relationship. This study explores the hospital-MSE relationship, and how governance styles influence perceived alignment in this relationship.

A multiple case study of five non-academic hospitals in the Netherlands was performed. Data was derived from two sources: (1) analysis of hospital-MSE contracts and (2) semi-structured interviews with hospital and MSE board members. Contracts were analysed using a predefined contract analysis template. Interview recordings were transcribed and subsequently coded using the sensitizing concepts approach.

Contracts, relational characteristics, governance styles and perceived alignment differed substantially between cases. Two out of five contracts were prevention contracts, one was a mixed type, and two were promotion contracts. However, in all cases the contract played no role in the relationship. The use of incentives varied widely between the hospitals; most incentives were financial penalties. The governance style varied between contractual for two hospitals, mixed for one hospital and predominantly relational for two hospitals. Development of a shared business strategy was identified as an important driver of relational governance, which was perceived to boost alignment.

Large variation was observed regarding relational characteristics, governance and perceived alignment. MSE formation was perceived to have contributed to hospital-physician alignment by uniting physicians, boosting physicians’ managerial responsibilities, increasing financial alignment and developing shared business strategies. Relational governance was found to promote intensive collaboration between hospital and MSE, and thus may improve alignment in the hospital-physician relationship.


  1. Cortese D, Smoldt R. Taking steps toward integration. Health Aff (Millwood). 2007;26(1):w68-71. doi:1377/hlthaff.26.1.w68
  2. Ciliberto F, Dranove D. The effect of physician-hospital affiliations on hospital prices in California. J Health Econ. 2006;25(1):29-38. doi:1016/j.jhealeco.2005.04.008
  3. Goes JB, Zhan C. The effects of hospital-physician integration strategies on hospital financial performance. Health Serv Res. 1995;30(4):507-530.
  4. Visser M, Den Bakker J. Management control in de zorg: een kritisch essay [Management control in health care: a critical essay]. Maandblad voor Accountancy en Bedrijfseconomie. 2018;92(1/2):47-52. doi:5117/mab.92.24417
  5. Van Dijk JK, Pool J. Bouwstenen voor Personeelsmanagement in de Zorg, Deel 3: Nieuwe Vormen van Organiseren en Leidinggeven [Building Blocks for Employee Management in Health Care Part 3: New Ways of Organizing and Managing]. Bohn Stafleu van Loghum; 2003.
  6. Quentin W, Geissler A, Wittenbecher F, et al. Paying hospital specialists: experiences and lessons from eight high-income countries. Health Policy. 2018;122(5):473-484. doi:1016/j.healthpol.2018.03.005
  7. Saltman RB, Durán A, Dubois HFW. Governing Public Hospitals: Reform Strategies and the Movement towards Institutional Autonomy. WHO Regional Office for Europe; 2011. doi:1057/9781137384935_27
  8. Robinson JC. Physician-hospital integration and the economic theory of the firm. Med Care Res Rev. 1997;54(1):3-24. doi:1177/107755879705400101
  9. Kocher R, Sahni NR. Hospitals’ race to employ physicians--the logic behind a money-losing proposition. N Engl J Med. 2011;364(19):1790-1793. doi:1056/NEJMp1101959
  10. Young GJ, Nyaga GN, Zepeda ED. Hospital employment of physicians and supply chain performance: an empirical investigation. Health Care Manage Rev. 2016;41(3):244-255. doi:1097/hmr.0000000000000074
  11. Gajadien CS, Dohmen PJG, Eijkenaar F, Schut FT, van Raaij EM, Heijink R. Financial risk allocation and provider incentives in hospital-insurer contracts in The Netherlands. Eur J Health Econ. 2022:1-14. doi:1007/s10198-022-01459-5
  12. Nederlandse Zorgautoriteit. Monitor Integrale Bekostiging Medisch Specialistische Zorg 2014 [Monitor Integrated Funding Hospital Health Care 2014]. 2014.
  13. Nederlandse Zorgautoriteit. Monitor Integrale Bekostiging Medisch-Specialistische Zorg 2018 [Monitor Integrated Funding Hospital Health Care]. 2018.
  14. Minister van Volksgezondheid Welzijn en Sport. Subsidieregeling Overgang Integrale Tarieven Medisch Specialistische Zorg [Subsidy Transition Integrated Funding Hospital Health Care]. 2014.
  15. de Volkskrant. Specialisten willen niet in loondienst, ondanks subsidie [Physicians don’t want to be hospital-employed, despite subsidy]. de Volkskrant website. Published November 2014.
  16. Specialisten willen niet in dienst van ziekenhuis [Physicians do not want to be hospital-employed]. Skipr website. Published November 2014.
  17. Medisch Contact. Zorg niet gebaat bij ‘medisch-specialistisch bedrijf’ [Health care does not benefit from ’medical specialist enterprises’]. Med Contact (Bussum) website. Published January 2015.
  18. Specialisten willen en masse samen ondernemen [Specialists want to do business together en masse]. Skipr website. Published April 2014.
  19. Medisch Contact. Medisch-Specialistisch Bedrijf is zegen voor de zorg [Medical specialist enterprise is a blessing for health care]. Med Contact (Bussum) website. Published December 2015.
  20. MSB: met succes ondernemen of metastabiel? [MSE: succesful enterpreneurship or meta-stable?]. Skipr website. Published September 2015.
  21. Medisch Contact. ‘Msb geen machtsblok in ziekenhuis geworden’ [’MSE has not become a dominant power in the hospital’]. Med Contact (Bussum) website. Published October 2018.
  22. Medisch specialistisch bedrijf verlamt ziekenhuis [Medical specialist enterprise paralyzes the hospital]. Skipr website. Published October 2015.
  23. Medisch Contact. Msb moet zijn rol pakken bij conflicten [MSE Should Take Their Responsibility in Conflicts]. Med Contact (Bussum); 2017.
  24. Medisch Contact. Msb moet publieke verantwoording niet schuwen [MSE should not shy away from public accountability]. Med Contact (Bussum) website. Published November 2016.
  25. Schippers ziet MSB als vluchtheuvel. Zorgvisie; 2016.
  26. Nederlandse Zorgautoriteit. Monitor Integrale Bekostiging Medisch Specialistische Zorg 2015 [Monitor Integraded Funding Hospital Health Care 2015]. Nederlandse Zorgautoriteit; 2016.
  27. Koelewijn W, Louis H, Hooge E, Slappendel R, van der Meer N. Op Weg Naar Gezamenlijkheid [On the Way to Unity]. TIAS School for Business and Society; 2016.
  28. BDO-Benchmark Ziekenhuizen 2018 MSB-Special: Cijfers Niet Transparant - ‘Ondernemen in Het Hart van de Zorg?’ [BDO-Benchmark Hospitals 2018 MSE-Special: Figures Not Transparent - ’Enterpreneurship in the Heart of Health Care?’]. BDO; 2019.
  29. Shortell SM, Alexander JA, Budetti PP, et al. Physician-system alignment: introductory overview. Med Care. 2001;39(7 Suppl 1):I1-8. doi:1097/00005650-200107001-00001
  30. Trybou J, Gemmel P, Annemans L. The ties that bind: an integrative framework of physician-hospital alignment. BMC Health Serv Res. 2011;11:36. doi:1186/1472-6963-11-36
  31. Rhodes RAW. Understanding governance: ten years on. Organ Stud. 2007;28(8):1243-1264. doi:1177/0170840607076586
  32. Lumineau F. How contracts influence trust and distrust. J Manage. 2017; 43(5):1553-1577. doi:1177/0149206314556656
  33. Cao Z, Lumineau F. Revisiting the interplay between contractual and relational governance: a qualitative and meta-analytic investigation. J Oper Manag. 2015;33-34:15-42. doi:1016/j.jom.2014.09.009
  34. Nooteboom B. Trust, opportunism and governance: a process and control model. Organ Stud. 1996;17:985-1010. doi:1177/017084069601700605
  35. Roehrich JK, Selviaridis K, Kalra J, Van der Valk W, Fang F. Inter-organizational governance: a review, conceptualisation and extension. Prod Plan Control. 2020;31(6):453-469. doi:1080/09537287.2019.1647364
  36. Eisenhardt KM. Agency theory: an assessment and review. Acad Manage Rev. 1989;14(1):57-74. doi:5465/amr.1989.4279003
  37. Williamson OE. The Economic Institutions of Capitalism. Firms, Markets, Relational Contracting. In: Boersch C, Elschen R, eds. Das Summa Summarum des Management: Die 25 wichtigsten Werke für Strategie, Führung und Veränderung. Wiesbaden: Gabler; 2007. p. 61-75. doi:1007/978-3-8349-9320-5_6
  38. Wiseman RM, Cuevas-Rodríguez G, Gomez-Mejia LR. Towards a social theory of agency. J Manag Stud. 2012;49(1):202-222. doi:1111/j.1467-6486.2011.01016.x
  39. Cuevas-Rodríguez G, Gomez-Mejia LR, Wiseman RM. Has agency theory run its course?: Making the theory more flexible to inform the management of reward systems. Corp Gov. 2012;20(6):526-546. doi:1111/corg.12004
  40. Vandaele D, Rangarajan D, Gemmel P, Lievens A. How to govern business services exchanges: contractual and relational issues. Int J Manag Rev. 2007;9(3):237-258. doi:1111/J.1468-2370.2007.00212.x
  41. Loughry ML, Elms H. An Agency Theory Investigation of Medical Contractors versus Member Physicians. J Manag Issues. 2006;18(4):547-569.
  42. Caers R, Bois CD, Jegers M, Gieter SD, Schepers C, Pepermans R. Principal-agent relationships on the stewardship-agency axis. Nonprofit Manag Leadersh. 2006;17(1):25-47. doi:1002/nml.129
  43. Bolton SC. A simple matter of control? NHS hospital nurses and new management. J Manag Stud. 2004 Mar;41(2):317-333. doi:1111/j.1467-6486.2004.00434.x
  44. Alvesson M, Willmott H. Identity regulation as organizational control: producing the appropriate individual. J Manag Stud. 2002;39(5):619-644. doi:1111/1467-6486.00305
  45. Weber L, Mayer KJ. Designing effective contracts: exploring the influence of framing and expectations. Acad Manage Rev. 2011;36(1):53-75. doi:5465/amr.2011.55662501
  46. Lumineau F, Malhotra D. Shadow of the contract: how contract structure shapes interfirm dispute resolution. Strateg Manag J. 2011;32(5):532-555. doi:1002/smj.890
  47. Selviaridis K, van der Valk W. Framing contractual performance incentives: effects on supplier behaviour. Int J Oper Prod Manag. 2019;39(2):190-213. doi:1108/ijopm-10-2017-0586
  48. Higgins ET. Promotion and prevention: regulatory focus as a motivational principle. Adv Exp Soc Psychol. 1998;30:1-46. doi:1016/s0065-2601(08)60381-0
  49. Pinkley RL. Dimensions of conflict frame: disputant interpretations of conflict. J Appl Psychol. 1990;75(2):117-126. doi:1037/0021-9010.75.2.117
  50. Walton RE, McKersie RB. A Behavioral Theory of Labor Negotiations: An Analysis of a Social Interaction System. 2nd ed. New York: ILR Press; 1965.
  51. Dyer JH, Singh H. The relational view: cooperative strategy and sources of interorganizational competitive advantage. Acad Manag Rev. 1998; 23(4):660-679. doi:2307/259056
  52. Klein R. Strategic Partnerships versus Captive Buyer and Supplier Relationships. AMCIS 2005 Proceedings. 2005;31.
  53. Rousseau DM, Sitkin SB, Burt RS, Camerer C. Not so different after all: a cross-discipline view of trust. Acad Manag Rev. 1998;23(3):393-404. doi:5465/amr.1998.926617
  54. Lewicki RJ, McAllister DJ, Bies RJ. Trust and distrust: new relationships and realities. Acad Manag Rev. 1998;23(3):438-58. doi:2307/259288
  55. Stevens M, MacDuffie JP, Helper S. Reorienting and recalibrating inter-organizational relationships: strategies for achieving optimal trust. Organ Stud. 2015;36(9):1237-1264. doi:1177/0170840615585337
  56. Tight M. The curious case of case study: a viewpoint. International Journal of Social Research Methodology. 2010;13(4):329-339. doi:1080/1364
  57. Eisenhardt KM. Building theories from case study research. Acad Manag Rev. 1989;14(4):532-550. doi:2307/258557
  58. Gray DE. Doing Research in the Real World. 2nd ed. Thousand Oaks, CA: SAGE Publications; 2014.
  59. Johnston LG, Sabin K. Sampling hard-to-reach populations with respondent driven sampling. Methodol Innov Online. 2010;5(2):38-48. doi:4256/mio.2010.0017
  60. Bowen GA. Grounded theory and sensitizing concepts. Int J Qual Methods. 2006;5(3):12-23. doi:1177/160940690600500304
  61. Strauss AL, Corbin JM. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: SAGE Publications; 1998.
  62. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-1251. doi:1097/acm.0000000000000388
  63. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi:1093/intqhc/mzm042
  64. Keller EJ, Giafaglione B, Chrisman HB, Collins JD, Vogelzang RL. The growing pains of physician-administration relationships in an academic medical center and the effects on physician engagement. PLoS One. 2019;14(2):e0212014. doi:1371/journal.pone.0212014
  65. Kreindler SA, Larson BK, Wu FM, et al. The rules of engagement: physician engagement strategies in intergroup contexts. J Health Organ Manag. 2014;28(1):41-61. doi:1108/jhom-02-2013-0024
  66. Spyridonidis D, Hendy J, Barlow J. Understanding hybrid roles: the role of identity processes amongst physicians. Public Adm. 2015;93(2):395-411. doi:1111/padm.12114
  67. Pratt MG, Rockmann KW, Kaufmann JB. Constructing professional identity: the role of work and identity learning cycles in the customization of identity among medical residents. Acad Manage J. 2006;49(2):235-262. doi:5465/amj.2006.20786060
  68. Smith HL, Reid RA, Piland NF. Managing hospital-physician relations: a strategy scorecard. Health Care Manage Rev. 1990;15(4):23-33. doi:1097/00004010-199001540-00004
  69. Gregory D. Strategic alliances between physicians and hospitals in multihospital systems. Hosp Health Serv Adm. 1992;37(2):247-258.
  70. Biller-Andorno N, Lee TH. Ethical physician incentives--from carrots and sticks to shared purpose. N Engl J Med. 2013;368(11):980-982. doi:1056/NEJMp1300373
  71. Robinson JC. Theory and practice in the design of physician payment incentives. Milbank Q. 2001;79(2):149-177. doi:1111/1468-0009.00202
  72. Maynard A, Bloor K. Will financial incentives and penalties improve hospital care? BMJ. 2010;340:c88. doi:1136/bmj.c88
  73. Eijkenaar F. Key issues in the design of pay for performance programs. Eur J Health Econ. 2013;14(1):117-131. doi:1007/s10198-011-0347-6
  74. Emanuel EJ, Ubel PA, Kessler JB, et al. Using behavioral economics to design physician incentives that deliver high-value care. Ann Intern Med. 2016;164(2):114-119. doi:7326/m15-1330
  75. Armour BS, Pitts MM, Maclean R, et al. The effect of explicit financial incentives on physician behavior. Arch Intern Med. 2001;161(10):1261-1266. doi:1001/archinte.161.10.1261
  76. Dudley RA, Miller RH, Korenbrot TY, Luft HS. The impact of financial incentives on quality of health care. Milbank Q. 1998;76(4):649-686, 511. doi:1111/1468-0009.00109
  77. Wasserman N. Stewards, agents, and the founder discount: executive compensation in new ventures. Acad Manage J. 2006;49(5):960-976. doi:5465/amj.2006.22798177
  78. Lee PM, O’Neill HM. Ownership structures and R&D investments of U.S. and Japanese firms: agency and stewardship perspectives. Acad Manage J. 2003;46(2):212-225. doi:2307/30040615
  79. da Conceição-Heldt E. Multiple principals’ preferences, types of control mechanisms and agent’s discretion in trade negotiations. In: Delreux T, Adriaensen J, eds. The Principal Agent Model and the European Union. Cham: Springer International Publishing; 2017. p. 203-226. doi:1007/978-3-319-55137-1_9
  80. Ali AM, Yusof H. Quality in qualitative studies: the case of validity, reliability and generalizability. Issues Soc Environ Account. 2011;5(1):25-64. doi:22164/isea.v5i1.59
  81. Yin RK. Validity and generalization in future case study evaluations. Evaluation. 2013;19(3):321-332. doi:1177/1356389013497081
  82. Gummesson E. Access to reality: observations on observational methods. Qual Mark Res. 2007;10(2):130-134. doi:1108/13522750710740808
  83. Nederhof AJ. Methods of coping with social desirability bias: a review. Eur J Soc Psychol. 198515(3):263-80. doi:1002/ejsp.2420150303
  84. Riege AM. Validity and reliability tests in case study research: a literature review with “hands-on” applications for each research phase. Qual Mark Res. 2003;6(2):75-86. doi:1108/13522750310470055
  • Receive Date: 05 November 2021
  • Revise Date: 25 October 2022
  • Accept Date: 10 December 2022
  • First Publish Date: 11 December 2022