Coping with autonomy: Managers’ responses to the pendulum between activity-based and fixed reimbursement systems in Swedish hospital care

Abstract

Governance and management in publicly funded services includes the processes that governments use to ensure that the activities of organizations involved in the delivery of public services are in line with those expected. In hospital care, the reimbursement model is viewed as an important tool to motivate providers to act in the interest of the funding body. The purpose of this study was to analyse consequences of a change from activity-based funding (ABF) to global budgeting for the governance and management of hospitals in a Swedish county council. The paper furthers previous research by illustrating how managers at different levels and in different hospital types adopt different strategies to cope with the increased autonomy inherent to the budget model. A single case study with an explorative onset was used to study different levels of management and cover different specialties in the county council Region Skåne (RS). The main source of data is semi-structured interviews with managers at different levels of the health care organisation. A key result is that shifting reimbursement system had potentially large consequences for the processes of management and governance. The results suggest that a reform aimed at increased professional autonomy may have different effects depending on the way that managers handle the change and that such differences may be attributable to type of hospital. i.e. university versus non-university hospitals. Two potential strategies for managers to cope with a change from variable ABF to fixed global budgets have been identified: One is to compensate for the low level of detail in assignments by continuing or even increasing the use of other coercive controls. Another is to adapt and align other controls with the new reimbursement model and focus on more enabling types of governance and management overall.