Two sides to every coin

There is a growing trend of physicians becoming employees of hospital systems and employment is viewed as a mechanism to help achieve health system goals. Yet, the research is mixed on the effects of moving physicians to employment models. While the literature has traditionally placed such forms of employment relationships in opposition to professional autonomy, it has often overlooked the effects on other professional values and there is little empirical work that actually assesses how such a shift affects and is perceived by clinicians themselves. To address these gaps, we conducted a mixed method study at one hospital that recently moved all formerly self-employed physicians to employment contracts. We interviewed physicians to understand how the shift into employment was perceived to influence their work in three domains: the patient domain, the individual domain and the organizational domain. We then conducted a follow-up survey across both formerly employed and self-employed physicians to test our initial findings. We find both positive and negative effects in different domains, offering insights into the mixed results found in the current literature.


Introduction
Healthcare systems across Europe and North America are pursuing tighter forms of integration between physicians and hospitals (Leleu et al., 2018).In particular there is an increasing trend of hospitals gaining ownership of physician practices (Baker et al., 2018) and a growing number of doctors becoming employees of hospital systems (Casalino et al., 2008;OECD, 2020;Post et al., 2017) rather than self-employed practitioners (Adler and Kwon, 2013).These arrangements are pursued for numerous reasons, including controlling costs and physician resource use, pressure from insurance companies, increasing hospital-physician alignment, and improving care quality (Burns and Muller, 2008).However, despite the purported organizational benefits of employment, physicians have historically resisted such 'bureaucratic modes of work' (Scott 1982) or employment relations (Robinson, 2001) and the effects of employment remain unclear in the literature (see Baker et al., 2018).
While some healthcare systems have historically employed hospitalbased physicians (e.g., the UK, Denmark) there are also many healthcare systems (e.g., Canada, the Netherlands, USA) where a large proportion of physicians remain self-employed (Quentin et al., 2018), organizing their own private practices at the group level (Freidson, 1988) and contracting their services with hospitals and healthcare providers.In the sociological literature, direct employment has traditionally been viewed as in direct opposition with professional values (Freidson 1988;Racko, 2017) and physician opposition to increased bureaucratic control has been well documented (Toth, 2015).Former research has suggested that direct employment reduces physicians' autonomy by limiting their discretion and authority in deciding how to treat and care for patients based on their clinical expertise, for example providing 'customized care' (Mishra et al., 2020).Conversely, other scholars have argued that physicians may actually benefit from employment (Lin, 2014) and that salaried employment models preserve or may even increase autonomy (Hoff et al., 2020).
Given the mixed evidence found in the current literature of the move to employment contracts, and a lack of empirical data that understands how physicians respond to and are affected by these shifts, we conducted a case study in a Dutch hospital that recently moved all physicians to self-employment.We question: how does moving to salaried employment directly affect physicians?In particular, we investigate the effects of employment on physicians in three domains: in their approach to patient care, in the individual domain (professional values, job satisfaction) and the organizational domain (hospital-physician relationships including organizational identification and trust).Considering effects in all three domains allows us to offer insight into the multidimensional ways in which such a shift affects physicians.We began with an in-depth interview study with a diverse sample of medical specialists within the hospital.To expand our sample and validate some of our emergent qualitative findings, we developed a brief online survey that was distributed to all specialists within the organization.
With this research we want to make the following contributions.First, our study examines the effects of employment on physicians in several domains, which provides insights into the mixed results that plague the current literature.There remains a scarcity of empirical studies that address the effects of employment on physicians and outcomes in multiple domains (Burns et al., 2020).In particular, we take up the call by other scholars to investigate the effects of specific employment relationships (Lin, 2014), particularly on medical professionals' values (Racko, 2017) and hospital-physician relations (HPR) (Burns and Muller, 2008).Second, our findings indicate the importance of teasing out the methods of payment from the type of employment relationship when redesigning physician incentives.While there has been much attention given to the form of payment physicians receive (e.g., fee-for-service) in both the academic literature and in policy circles, the organizational structure and position of physicians is often ignored.As Robinson asserts, 'the economic relationship of the individual to the organization constitutes in its own right a powerful incentive mechanism ' (2001; 171).This is an important point to examine further as physician satisfaction 'may be more influenced by the arrangement of work [e.g., employment relations] than by the arrangement of payment' (Freidson, 1988: 103).

Physician employment
The employment relationship between physicians and hospitals can best be described on a spectrum from loosely integrated (self-employed physicians operating their own group practice) to tightly integrated (physicians are directly employed by the hospital) (Casalino and Robinson, 2003).Physicians' employment relationship with the hospital varies based on several factors, including the cultural and historical context, specialism, and individual characteristics (Hoff, 1998).In practice, physicians' employment model may sometimes be linked to the form of payment they receive.For example, in tightly integrated models where physicians are directly employed by the hospital and are paid an annual salary based on hours worked (Bazzoli, 2021;Burns et al., 2020).
Research also shows that in practice, self-employed physicians tend to be paid in some form of fee-for-service or activity-based payment (e.g., diagnostic-related groups, DRGs) (OECD, 2020).However, when assessing the effects of employment reform it is important to note that physicians employment status and payment type remain conceptually distinct.While a change in employment status may correlate with a change in payment in practice, as seen in the present case, moving to employment does not always indicate a change in payment method.Employed physicians may be paid based on time (e.g.salaried), performance (e.g.pay-for-performance), or volume (achieving certain hospital volumes) (Bazzoli, 2021) and self-employed physicians may choose to utilize a variety of payment methods to incentivize their practice.

A shift towards employment
While in some contexts (e.g., National Healthcare Systems like the UK) physicians have historically been employees, other healthcare systems now take seriously the promise that further integrating physicians into healthcare systems will deliver a ream of benefits.This is evidenced by the push towards tighter forms of [economic] integration (Baker et al., 2014;Leleu et al., 2018) with an increasing number of physicians becoming employees of hospitals across Europe and the United States (Baker et al., 2014;Burns and Pauly, 2018), including medical specialists (Bazzoli, 2021).Physicians too are increasingly choosing these arrangements, evidenced by the trend of new graduates preferring employment contracts as well as the switch of tenured physicians from private practice to employment (Darves, 2014).This is also indicative of a larger trend of professionals across all sectors working as salaried employees (Bunderson, 2001;Wallace, 1995).As Scott et al. (2017) point out, physician employment rose from 29% to 42% in the USA between the period of 2003 and 2012.This trend is evidenced across the majority of EU member states, with the number of physicians employed in the hospital increasing significantly in the last decade (2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018), even in countries where a majority of specialists were already employed (OECD, 2020).

Effects of employment
The employment relationship between physicians and the organization functions as a powerful incentive mechanism with consequences for physicians' behavior (Robinson, 2001).Scholars have argued in particular that physicians' employment relationships can have an influence on the expression of professional values (Racko, 2017) and especially physicians' autonomy (Friedson 1988;Lin, 2014).For physicians, core professional values include autonomy (the freedom to make decisions regarding what work is done and how work is conducted without external interference) (Adler and Kwon, 2013;Raelin, 1985), which includes high levels of discretion in clinical work (the ability to use judgement in how to carry out tasks) and what has been described by Racko (2017) as 'the common good'.The common good refers to physicians' commitment to a code of ethics (e.g., the Hippocratic Oath) and to put patients and the good of society above self-interest (Larson, 1977).
Based on their commitment to the common good, physicians have long been afforded high levels of autonomy in multiple domains.However, the employment relationship physicians have may have consequences for the type of autonomy that physicians experience and consequently the autonomy they perceive to lose or gain when entering into a new employment relationship.While all physicians likely experience high levels of clinical autonomy (i.e., individual discretion in clinical decision-making) (Lin, 2014) in their daily work due to their high levels of expertise knowledge and skill (Brivot, 2011), physicians in self-employment are likely to experience higher levels of organizational autonomy (freedom to make organizational decisions without managerial influence (Wiedner and Mantere, 2019)) based on their control over their own businesses, resources and self-governance.This includes discretion over hiring and firing colleagues, rosters and schedules, and the group's resource distribution (e.g.investing in clinical materials).

Effects in the patient domain
The economic integration arrangements of physicians and hospitals is pursued due to its supposed effect on the ability of hospitals to achieve organizational goals, such as cost control, efficiency and better care quality (Leleu et al., 2018).Employment arrangements are viewed as a way to ensure better adherence to guidelines by increasing organizational control (Scott et al., 2017).However, despite these purported benefits, the effects on patient outcomes and hospital performance remain particularly mixed (Burns and Muller, 2008;Post et al., 2017).For example, Scott et al. (2017) found no association with the switch to employment on performance or patient care outcomes, including patient satisfaction, length of stay, mortality, and readmissions.Yet, in a recent meta-analysis of the effects of vertically integrated systems, it appears that integrated systems show some benefit in quality of care but no difference, or negative results, in terms of efficiency (Matcha et al., 2019).

Effects in the individual domain
Tighter forms of integration have historically been resisted and theorized to clash with professionals' expression of values by the nature of increasing managerial control and oversight, clashing with professionals' desire for autonomy (Hoff, 1998;Raelin, 1985).While autonomy is never 'absolute' (Larson, 1977) the notion of autonomy continues to underlie professionalism (Freidson, 1988) and perceived threats to professional values can have negative effects for the organization, patients, and professionals themselves, influencing physician job satisfaction, care quality and issues of stress and burnout (Lin, 2014).Evidence from the US indicates that with the increasing trend toward employment, physicians report treatment and referral interference (Darves, 2014).The perceived effect of employment on professional values is also likely to influence physicians' assessment of outcomes at other levels, such as in patient care.Physicians surveyed about the effect of being on salaried contracts had negative perceptions about being salaried on their clinical autonomy (66.8%) quality of care (62.7%) and relation with patients (56.8%) (Deom et al., 2010).This aligns with the traditional notion that work within bureaucratic organizations threatens professionals' power and autonomy (Casalino et al., 2008).However, the so-called incompatibility between professionals and bureaucracy writ large has been criticized for being overly simplistic and ignoring important structural characteristics (Wallace, 1995).Instead, scholars have argued that physicians' intentions for economic integration with organizations may derive from quality standards and values (e.g., the common good), including a commitment to society, such as improving care quality while reducing costs and making care patient-centered (Burns and Muller, 2008).

Effects in the organizational domain
The move to employment is viewed as a mechanism to better align physicians and organizations, allowing organizations to ensure better adherence to guidelines, and patient quality (Mishra et al., 2020;Scott et al., 2017).While there remain scarce empirical studies that explore the impact of moving physicians to employment contracts (Burns et al., 2020), existing studies indicate a primarily positive relationship.In prior studies, employment has been found to increase hospital-physician alignment and commitment (McGowan and MacNulty, 2006).Burns et al. (2001) found that employed physicians have higher levels of commitment to the organization, but reveal that the difference in commitment between physicians in tightly integrated versus more loose systems are not very large.They argue that it remains unclear if higher commitment will actually lead physicians to engage in behaviors that support system goals.As professionals' transition into employment, Bunderson (2001) warns that perceived breaches in the psychological contract may increase if professionals view the organization as reducing their organizational autonomy or not providing adequate financial resources.Such breaches were found to result in lowered organizational commitment, job satisfaction, physician productivity and patient satisfaction (Bunderson, 2001).Given the mixed reviews and a lack of empirical research that assesses effects in multiple domains, more empirical research is needed to further assess these effects (Burns et al., 2020).

Physicians position in the Netherlands
Hospitals in the Netherlands are private, not-for-profit institutions.General hospitals in the Netherlands operate a hybrid model, working with both employed and contracted specialists.Employed specialists make up about 40% while a majority maintain in private practice, similar to North American models such as Canada and the USA (Quentin et al., 2018).In general hospitals, medical specialists traditionally operate in private practice at the specialty group level, operating businesses within the hospital and contracting for services.In the Netherlands, specialists are paid based on a DRG system.However, partially as a result of the pressure to move physicians away from production-based payments, there is an increasing trend towards tighter forms of integration, such as moving physicians to salaried employment contracts (Baker et al., 2018;Casalino et al., 2008;OECD, 2020).

Reforming hospital payment and governance: integrated funding
In 2015, hospitals and medical specialists across the Netherlands had to reorganize themselves as a result of a government reform which integrated the hospital budget (In Dutch 'integrale bekostiging').Samson (name has been changed to preserve anonymity) was one of the only organizations nationwide where all self-employed physicians moved into employment.This decision was also influenced by financial issues that meant Samson would need to reduce costs and secure contracts from insurers in order to sustain the organization.The move to employment was envisioned as part of a longer-term transition to a 'participation model' whereby physicians could invest and become shareholders in the hospital (e.g., co-ownership).However, participation remains legally contentious, blocking coownership.Therefore, our study captures this transition of physicians to employment.We were particularly interested in assessing the outcomes of this transition for the professionals at the center of that change (i.e., self-employed specialists).

Methods
We conducted a mixed-method case study to assess the effect of moving to salaried employment for physicians.Samson is a medium sized general hospital that moved all self-employed physicians (roughly 70%) to salaried employment contracts in the beginning of 2015.Because literature offers little insights into how the process of switching from autonomous modes of work to employment actually unfolds, and the effects remain unclear (Baker et al., 2018), we employed an exploratory sequential design (Fetters et al., 2013).We began with exploratory in-depth interviews (N = 21) to gain detailed insights from physicians on the ground.Interviews allowed us to map the transition and its perceived outcomes in detail, and allowed us to develop emergent themes directly from participants.Using insights gathered from the interviews, we designed a short survey that sampled a wider pool of respondents and accounted for underrepresented populations.Using a survey provided participants more anonymity to speak openly about the change and its effects and allowed us to further validate our initial findings regarding the effects of switching physician employment models in both the individual (measuring job satisfaction) and organizational domain (measuring organizational trust, identification).Additionally, the survey included an open question to allow a wider pool of respondents to comment about the move to employment.

Sample
Beginning with an exploratory in-depth interview study, medical specialists were contacted to participate and share their opinions about the current organizational climate, recent changes, and ongoing challenges in their work.We asked participants to reflect upon perceived outcomes of the changes and to contrast the effects of salaried employment and self-employment.Interviews were conducted onsite, and the first author had access to an internal server and email to directly contact professionals with interview requests.Hospital management granted access to the site, rosters and respondents, and informed staff via email of our research and presence onsite.Hospital management was consulted to purposefully select a starting list of respondents across all specialties and ensure multiple perspectives were represented.We then engaged in snowball sampling to address further gaps, such as including participants who were advocates for and against the change.In total 21 medical specialists were interviewed (see Table 1) in June 2018, 42 months post change.Interviews were concluded when the researchers reached saturation, evidenced by the lack of new insights in interviews.Interviews lasted between 30 and 60 min and were recorded with permission.Interviews were transcribed verbatim and a copy of each transcript was made available for participants to ensure accuracy.

Analysis
Interview analysis was conducted in line with an interpretive approach (Strauss and Corbin, 1998).A process of iterative analysis was conducted throughout the research period and thematic coding was performed to derive salient themes and concepts.Initial codes were emergent from the data and were largely descriptive, focusing on feelings about the change, perceived outcomes, and documenting physicians' feelings about employment versus self-employment.Moving from the first stage of open coding to a second level of axial coding (Strauss and Corbin, 1998) original codes were grouped into themes, for example, quality focus, doctor knows best, interdependence and trust.During analysis themes were fed back into the research team, and discussed at length to ensure accuracy.In a last stage, theoretical coding was used to group themes into concepts, for example we saw that there were two distinct types of autonomy that emerged as central (clinical and organizational), and other axial codes could be grouped into an emphasis on common good (putting patients first) and HPR more generally (including trust and interdependence).In a final step we further clustered these concepts based on their correspondence to relevant domains, as we present here.This includes perceived effects in patient care, the individual domain, and organizational domain (See Table 2).

Sample
The survey was distributed to the entire population of medical specialists (N = 188) via internal email in December 2018 (47 months post change).Prior research has highlighted poor response rates among  physicians (Cunningham et al., 2015), however in our case, we received a positive response of 52 percent (n = 98), which is rather high for this population.After accounting for missing values and incomplete responses the number of useable observations totaled 44 percent (n = 82).Within our resulting sample, the mean age is 46.4 years, mean tenure is 12.1 years, average tenure at Samson is 9.9.years and 35 are female (42.2%).Ten of these specialists have a managerial role, 49 (59.7%) were self-employed before the move, 10 were salaried employees and 23 came in after the move.24 belong to a surgical specialty, 41 to a non-surgical specialty, 10 to a supporting specialty and 8 to another category (e.g., emergency physician).

Measures
Interviews highlighted three key outcomes: that hospital-physician relations had been significantly affected as a result of the change, and that the shift to employment had substantial effects on physicians' behavior (e.g., collaboration, approach to care) and satisfaction with their work environment (e.g., via a loss of autonomy).Therefore, we used the survey to verify if there was a substantial difference between those who experienced the change (formerly self-employed) and those who did not (previously employed or new to the organization) in effects in the organizational domain (organizational identification, organizational trust) and in the individual domain (job satisfaction).We used the organizational identification measure from Mael and Ashforth (1992), dropping the item 'I am very interested in what others think about Samson' due to low reliability found in other studies with similar target populations (Hekman et al., 2009).The Cronbach's alpha for this scale was 0.92.We included a 5-item measure of intergroup trust adapted for the organizational level (de Jong and Elfring, 2010), where sample items include 'I am confident the organization will take my interests into account when making work related decisions' and 'I trust the organization'.The Alpha for this scale was 0.95.The chosen job-satisfaction measure included 7 items that assess both intrinsic and extrinsic aspects of work ('the amount of worthwhile accomplishment I get from doing my job', 'the amount of pay and benefits I receive') and one 'global' item ('Overall, how satisfied are you currently?').The Alpha for this scale was 0.82.This measure included items that address critical issues that arose in interviews and that pertain to professional values including satisfaction with autonomy and discretion (The amount of autonomy I have in my job, the amount of independent thought and action I can exercise in my job).
All items were rated on a 7-point scale.Organizational identification and organizational trust were measured on a scale between strongly disagree and strongly agree, and job satisfaction was measured on a scale between extremely dissatisfied and extremely satisfied.The survey included a two-item question for respondents to score their current (How would you describe your relationship with the organization currently (after to moving to the employment model?) and previous relationship (How would you describe your relationship with the organization prior to the changes (prior to moving to the employment model?)Respondents ranked their relationship on a sliding scale of 1(terrible)-100(excellent).Additionally, we included an open question for respondents as follows: please use the space below to provide your personal opinions about the following: What is your personal opinion about doctors moving to employment?Our open survey questions yielded 38 responses (45.7%) and text was subsequently coded and categorized.This text was reviewed to highlight emergent themes, and comments were categorized into four primary categories: patient care, individual domain, organizational domain, and change process.Overall, the open-text supported the general findings from the qualitative analysis (most positive statements in patient care, most negative responses regarding individual and organizational domain).

Statistical analysis and results
To calculate our independent variable, we computed an initial categorical variable ('employ status') with two categories: (1) physicians who were previously self-employed (experienced the change) or (2) physicians who were previously employed or joined Samson after the change (did not experience the change).We tested for correlations (see Table 3) and then ran independent ANOVA's to check the relationship with our independent variable and outcome measures of organizational identification (OI), job satisfaction (JS), and organizational trust (OT), which yielded significant results for all three variables (p < .05).

Findings
In the following sections, we introduce and detail the [perceived] effects of physicians becoming employees of a hospital organization.We group these effects into three domains and present them in the following order: (1) effects on patient care (treatment behaviors, approach to care and care delivery) (2) individual effects (impact on professional values, clinical autonomy and job satisfaction) and (3) effects on organizational relations (perceived influence on HPR, organizational autonomy, organizational trust, and identification).

Effects on patient care
When discussing the change and its effects within the organization, it became clear that the perceived effects on physician behavior and on patient care were overwhelmingly positive.However, respondents' positive assessment of this effect centered largely on the shift away from a production-based incentive rather than on the employment status of physicians.

From a production focus to a patient focus
Across the organization, there was a positive response to removing the former production incentive.For doctors in and outside of selfemployment, the production incentive was perceived to have created a system that did not necessarily align with 'best' patient care, and kept money as a focus and barrier to changing care for the better.This undermined physicians' ability to focus on the common good.In interviews, physicians positioned production-based pay in opposition to quality care.While many doctors distinguished that they had not consciously operated based on financial considerations, they recognized considerable flaws in the system.Doctors explained how the system had previously incentivized the wrong behaviors, leading to over-treatment and preventing patients from receiving the best care.
We had to change the way we worked because we wanted to decrease production, we don't want to operate on just anyone … [before] everybody who has a sore throat gets their tonsils out because that makes great money for me but everybody who has a sore throat doesnt have to get their tonsils out … but if I get paid by production I will say 'well, I have to take them out'.So I am thinking with my wallet and not with my medical sense.I don't want to point the finger at every doctor, but I think that happens a lot … the system does create some intent to operate because if I do more I get more … you are not being paid based upon what is the best for the patient -Anesthesiologist.
In the opinion of respondents, such perverse incentives led to activities such as patients being seen more often than needed (e.g., consultations for chronic patients), issues over patient ownership, overtreatment of patients (duplication of labs, aggressive treatments), unnecessary visits (due to the DBC system which incentivized each specialty to perform their own consults) and gaming of the system.Physicians associated a move away from the old system with a significant improvement in patient care processes, including physicians' behavior, and patient centeredness.Physicians felt that their pressure to see many patients and perform many services in a short time decreased, improving their ability to focus on the right things.
The transition to salaried employment is causing a significant shift from focus on money to focus on patient care and collaboration-open survey question.
In responses to the open survey question, physicians indicated that time with patients and patient quality has improved by moving towards employment.Physicians indicated that the positive outcomes were primarily about the removal of a money and production focus that led to an increased focus on quality of care and improved clinical collaboration.

Improved collaboration for patient care
Physicians detailed how the old system incentivized a competition mentality between specialty groups and discouraged doctors to innovate or rearrange clinical work as needed for changing patient demographics and healthcare demands.
No, the collaboration wasn't there [before], it was a competitionorthopedic surgeon.
In the new system, respondents indicated that collaboration had become much easier.For example, patients would now simply get the best physician for the job whereas before there may be discussions over ownership and about task sharing due to the money attached to procedures.
The good thing is, is that all the different departments and specialties you have in the hospital work more together and I think for the patient that's the best.-Internist.
While the majority of respondents agreed that professional collaboration between doctors had always been on a good level, collaboration was made easier in the new system.In particular, issues over patient ownership and quarrels between groups (mostly on financial issues) were now removed, making it easier to rearrange tasks and share patients as needed without fear of lowering the group's performance and income.

Upholding the common good
One benefit of the change was that physicians were better aligned with the value of the common good.This was clearly connected to the push to become more patient centered and shift away from a money focus.In addition, being involved in an innovative change and taking strides to improve and shift the sector was a motivator for physicians who wanted to be part of making healthcare better, more affordable and sustainable for patients.
In the end like I said, I am completely content with the change we made, for my personal situation and my personal work happiness and in the long run I think its super exciting to be part of this landslide transformation, which is going to have huge effects on the entire sector, in the country and maybe even beyond.If you see the results they are unprecedented, so I am really curious what is going to happen.-Anestheisiologist.
When physicians no longer had to produce to secure their groups income, it lowered the pressure and allowed physicians to step out of the 'rat race' and get back to focusing on things that matter in their work.By moving away from their former competitive business models, and having the freedom to make improvements in care at a larger scale (reorganizing care delivery, improving costs and sustainability), the move to employment upheld the value of the common good and allowed physicians to reduce work pressures.This positive effect was recognized even by those who felt negatively about the change in other areas, and was used as a main focal point for change leaders.However, respondents noted that pressures did not disappear completely, but that discussions became less about money and 'more about hours' worked, demonstrating the existence of continued system level pressures on production.

Losing autonomy
When we asked physicians to consider the effect of moving to employment on their position within the organization and their work more generally, many respondents began to express negative effects of the change.This was also for doctors who were generally positive about the effects at the patient level.For many doctors who were formerly selfemployed, moving to employment resulted in a loss of autonomy and 'grip' in the hospital.Effects at the individual level were captured in the survey by measuring physicians' job satisfaction, which included items that assess individuals' satisfaction with the amount of autonomy they have.The survey confirms that those who were self-employed before the change score lower on job satisfaction (m = 5.05) than those that were previously employed or came after the change (m = 5.68) (F[1,76] = 5.19, p < .05).(See Fig. 1).
The issue of autonomy traditionally regards physicians' clinical autonomy but was expressed by physicians in interviews to include the loss of organizational autonomy within specialty groups.Doctors felt that because they were no longer self-governing, they were now at the mercy of the bureaucratic process, which felt slow and unresponsive.This occurred at the same time where doctors lost their ability to self-regulate and organize their roster, resources, and practice, delivering a negative effect and undermining positive effects.
We didn't have a lot of discussion [about going to employment] because we thought well if this is the right way to go with the hospital then we do it and we try it.But, what we notice now is we are more stressed than before … because we have less autonomy.Before, when you think 'well we are too busy we need another person to join the group' you have it in your own hands, the autonomy [to decide].So you can also decide for yourself how will you work and what time will you spend per patient on the outpatient clinic ….And now you don't have that much influence anymore.So there are changes in a lot of things, a lot of things are happening around us and we think that is not the way we want to treat our patients.-Internist.
Doctors, as professionals, felt that they should remain in control of their own organization and take a leading role in organizational decisions and the organization and delivery of care.Doctors who did not hold formal leadership positions expressed dissatisfaction with the governance structure and felt that by losing their independent status, physicians' power and influence was limited or merely symbolic.Physicians felt that their discretion about how to treat patients, what materials they needed, and resources including hiring and firing of staff was undermined and that requests were subject to a slow and uncaring bureaucratic structure.Physicians felt they had little formal recourse or voice to stand up in the case that they were opposed to certain [proposed] actions, had issues to address or wanted to initiate change.
The directors think they know what is best for the patient, nobody asks the doctor who actually sees the patient.-Open survey questions.
Doctors ultimately felt that by giving up their self-employment they lost both clinical and organizational autonomy and influence while the banks, insurers, government and the board gained increased power over them.For some doctors, this tipping of power and control was perceived to directly limit physicians' ability to protect the common good.These physicians did not trust care decisions in the hands of the board or other stakeholders, and felt that taking away physicians' central role introduced the risk that future decisions regarding care delivery will be based on cost-cutting rather than on what is best for the patient.

Effects in the organizational domain
It was clear that while some physicians were avid supporters of the change, and that most physicians recognized the benefits at the patient level, overall the transition was a difficult and emotive time.Interview data indicates that the change ultimately led to a lack of cohesion in the organization, particularly between physicians and the organization.

Hospital-physician relations (HPR)
In interviews respondents reflected upon key challenges they faced in the years following the reform.A key issue that emerged was the negative impact of the change to employment on physician and hospital relations (HPR).For the organization to move forward in a positive manner, physicians asserted that the organization and doctors would need to 'find their way back to each other'.During interviews, nearly four years post change, the organization was still described as 'lost'.Doctors within the organization described lacking a strong sense of connection to Samson and expressed low levels of trust and affinity toward management and board.
The dust is [now] laying down.So, there is time now to find a purpose.The difficulty is that we are so vulnerable at this moment, having lost souls and not having the purpose really sharp, that there are cracks in the loyalty.And people are finding the ways that they are not comfortable with the situation they're in and they're looking out for other jobs.So, the main challenge is to keep them motivated and keep them loyal.-Orthopedic surgeon.
For many individuals and groups, the change process was challenging and emotional consequences clearly lingered.While the brunt of the negative emotions was directed towards the former leadership team (board transitioned after the change), some of the effects carried over to create a more general divide between physicians and organizational leadership.While those involved with the change were primarily positive, they expressed an understanding that the change process could have been managed better, and that it had significant consequences on HPR and organizational dynamics.Despite what they describe as a 'facade of choice', some physicians felt they had ultimately been forced into salaried employment.
The way managerially that it was done, it was not good.It was topdown it was manipulative, there was not a lot of choice.There was a choice but it was a choice of ''what do you want to lose; your arm, or both your legs?' That's how it felt.And so it was very manipulative, and that, for some groups, that caused it a lot of pain.-Cardiologist.
Overall, for a core group of physicians, the decisions felt forced, topdown, and individuals did not feel involved.Some felt tricked into employment, realizing after the fact that it wasn't 'necessary' although even groups that 'held out' longer eventually came around.Even those who were involved in the change process, or were more positive, recognized the prevalence of this view amongst their colleagues.
They had a choice, but they didn't feel so.I think most of them didn't feel like it was a choice.I also think then that the board of directors didn't make it feel like a choice because in the end they were very keen on all of us going into employment and I think that is the best for the organization.So, there is anger and sadness there [because] some people felt they were pushed into it or tricked.-Pediatrician.
Despite the differences between physicians in interviews and their opinions about the process of moving to employment, we saw in the survey that overall the relationship between doctors and the organization had worsened.We asked respondents to indicate how they perceived the quality of their relationship with the organization before and after they moved into employment contracts.Those who were at Samson before the change and responded to this question (n = 48), qualified their relationship before the change as 68 (on a scale from 0 to 100) and after the change as 52.This is a significant decrease (t = 3.71, df = 47, p < .01).Before the change this relationship was on average rather good, and after the change it is moderate.This relationship is critical for an organization, and may decrease organizational identification and impact performance and citizenship behaviors within the organization.The survey data indicate that medical specialists who were previously self-employed identify significantly less with the organization (m = 4.39) than medical specialists who already were employed before the change or came in after the change (m = 5.10) (F[1,80] = 4.10, p < .05).Those who were previously self-employed also trust the organization less (m = 3.64) than medical specialists who were employed before the change or came in after (m = 4.34) (F[1,80] = 4.00).

Discussion
We wanted to better understand, from the perspective of physicians themselves, how moving to employment effects outcomes in multiple domains.We questioned how physicians perceived the move to employment affected the domain of patient care, the individual domain (expression of professional values, job satisfaction) and the organizational domain (hospital-physician relations).Through our empirical analysis, it becomes apparent that physicians have divergent attitudes towards the process of moving to employment, and that during change processes values may become refracted (Wright et al., 2017) and reprioritized, even within the same individuals.Individual physicians expressed both positive and negative effects that related to different outcome domains and expression of values.We find that most positive effects were attributed to the patient care domain and related to the shift away from a production focus, which supported physicians' expression of the common good.More negative effects were attributed to losing self-employment status and were found in the individual and organizational domains, where physicians perceived a loss of autonomy.We thus believe our findings shed light into the mixed results that continue to plague the literature on physician employment reform (Burns and Muller, 2008) and offer insights into the overlooked issue of employment status and payment entanglement, as well as the potential refraction of values in the face of change.In the following sections, we detail these contributions.

Shining light on mixed results: disentangling the effects of payment reform
A salient point that emerges from our study and is often overlooked in the literature is the entanglement of employment status and payment structure (see Robinson, 2001 for a notable exception).While payment reform advocates focus on moving away from fee-for-service (FFS), they often gloss over the issue of employment relations between physicians and organizations.As the push towards tighter forms of (economic) integration increases across healthcare systems in the West (Adler and Kwon, 2013;Post et al., 2017), it is important to consider the goals and impact of integrating physicians into healthcare systems.In the literature, goals include reducing production (e.g., eliminating FFS) and better aligning providers (Burns and Muller, 2008).However, as Burns et al. (2020) suggest, we must begin to more critically question if the negative effects outweigh the benefits gained.
The positive effects in our case were produced primarily from eliminating a production-based system, appealing to physicians' sense of common good (Racko, 2017) and removing the financial pressures of production in daily work.Negative effects were primarily attributed to becoming employees of the hospital, triggering a perceived loss of autonomy and independence.Some physicians felt that by becoming employees they lost the ability to organize their own work in a way that allowed them to provide the best patient care, such as replacing and hiring staff and the ability to make decisions about resources and materials needed and to use for patient care.They felt that by being subject to organizational control and losing organizational autonomy, they had little recourse to fight against the increasing organizational focus on cost cutting, which some physicians felt took precedence over providing high quality patient care and undermined the common good.
When changes threaten core professional values, conflict is likely to emerge between professionals and the organization (Wright et al., 2017).To minimize the emergence of conflict, our study highlights the importance of invoking shared values, (e.g., the common good) when leading and implementing change efforts.However, even when change processes go well, negative effects may result, highlighting the importance for management and policymakers to weigh the effects of change at multiple levels.As both our interview and survey data show, almost four years post change (47 months), job satisfaction and organizational relations were significantly lower for physicians who moved from self-employment to employment.This is a key issue as physicians remain central actors in the system, and their engagement is essential for patient quality and system performance.We believe therefore, in line with other scholars (Abdulsalam et al., 2018) that while eliminating production incentives is still an important and timely goal, moving physicians to employment may not deliver the expected benefits in practice (Burns et al., 2020).Contrarily, the shift to employment may undermine values that are essential for continuation of high-quality care.

Two sides to every coin: weighing up the benefits of employment
Our findings highlight that policies need to account for and ensure that professionals are able to uphold their full set of values in new organizational arrangements.Otherwise, potential [negative] countereffects, such as the undermining of positive effects in one domain as we see in our case, may lead to change resistance and poorer hospitalphysician relations.While previous studies have found employment to be effective at increasing hospital-physician alignment (McGowan and MacNulty, 2006), we find that for those who transitioned into employment from self-employment, the opposite effect occurred.It is therefore worth considering alternative models that allow physicians to transition away from production-based reimbursement while still maintaining control over the organization of their work and independence, particularly from managerial oversight.Given the current difficulties in physician payment reform, Burns and Pauly (2018) suggest that it may be better to revise our policy strategies, focusing instead on physician behavioral change and technological innovation.Systems that integrate physicians (e.g., by creating dual governance structures or connecting pay to performance goals) but allow them to maintain organizational autonomy and keep a safe distance from bureaucratic control, may help to achieve the goals of hospital-physician alignment and efficiency without triggering institutional tensions and threatening professional values.

Limitations and directions for future research
We believe that our case has several strengths, such as the in-depth nature and mixed method design that allow us to examine previously overlooked effects at the micro-level.Our study adds to the literature by considering effects in multiple domains and emphasizes the importance of studying the relationship between organizations and professions (Burns et al., 2020) particularly in regards to physician employment reform.However, our study has some notable limitations that warrant opportunities for future research.First, while we were able to examine effects post-change, it would be insightful for future research to incorporate a design that examines both pre and post change measures.Second, we believe that our insights about the effect of moving to employment on HPR warrants further investigation given its contradiction with the previous literature (Burns et al., 2001;McGowan and MacNulty, 2006).It is possible that the effects we find, particularly in the organizational domain, are closely related to the organizational context and change process.Studies of other organizational contexts and that incorporate a longitudinal design may help to illuminate how attitudes and behaviors evolve over time, and identify salient contextual factors.Due to the small sample of the survey study, our findings are tentative and a good first step for further research.Lastly, comparative cross-cultural studies that account for system differences (such as private and public sectors) would add important nuance to the existing empirical evidence.

Conclusion
With this research, we offer a granular perspective into the effects of changing physicians employment status and illuminate the complexities that accompany the shift to employment for physicians.While the current case is limited to one country, we have helped to build a muchneeded empirical base of evidence regarding the effects of different governance and employment models (Burns et al., 2020).The Netherlands is illustrative of other countries where employment arrangements are increasingly being pursued for and by hospital-based specialists (Baker et al., 2014).Our findings have helped to unearth and shed light on some important elements of employment reform that have previously been ignored.For example, the importance of disentangling employment status and mode of payment may lead us to consider alternative models that focus on the central issue of removing production incentives while allowing professionals to retain independence.The question therefore remains if employing physicians is the best way forward (Abdulsalam et al., 2018), not only for patients, but for healthcare organizations and professionals more generally.We hope that future scholars will expand upon the findings here in order to continue to build a much-needed empirical base of evidence that can better inform us about the effects of new and evolving governance and employment models.

Table 1
Interview list.