Table 4.

Qualitative themes and illustrative examples^a

Theme	N	%	Example
Reasons for switching to the independent contractor model
Financial difficulties of the salaried model	6	67	Outpatient was so horribly underpaid so we made that transition [to independent contractors], and so now outpatient is not the huge loss leader. I ran outpatient when it was salaried and I cannot tell you the financial stress of running that because your financial goals were literally impossible, and you knew no matter what would do, you were going to be extremely under budget and looking at the faces of folks that are working so very hard.
Contractor model transfers financial risk to the clinician	2	22	If a patient doesn’t come, the agency doesn’t pay the clinician. The organization wants to pass that fee on to a contractor and say, ‘You know, we’ll support you going, but we can’t pay for it.’ So, you’re talking about travel expenses and all that, plus the not being paid while they’re going to the training.
Consequences of the independent contractor model (general)
Turnover	3	33	[The contractor model] does lend itself to that kind of instability, kind of wondering. And you know, and I have yet to have a contractor give me proper notice.
Time = money	3	33	Contractor therapists are paid a piece rate, which means that they see somebody for an hour, and their rate is about 25.50 an hour. And, if the person doesn’t show up, they get nothing. Understood. They know that coming in. They work full time hours, and they are making a lot of money, but in the back of their mind they are thinking about the other stuff they are doing that they are not getting paid for (e.g., note writing, team meeting). I recruited people who I can sense have a desire to learn things because I figured that would work best. But, it’s difficult, even if you have a desire to learn things, you still have to eat.
Lack of recognition/connection to the organization	2	22	The [agency] sometimes forget about contractors in a sense that they do a lot of nice things for employees. Employees just got a raise or they are getting ready to get a raise. We have a day that we all get together and celebrate and when we have that day, contractors go home generally. You know, so they are kind of left out, but at this point, you’re looking at that being almost half the agency. People that are contractors are not connected to the agency. So if you have a mission and vision driven work, you’re going to have a hard time making that connection, They don’t go to all staff meetings, they don’t go to group meetings; they come do the work, they go.
Uncertainty	1	11	You know, so that also limits the kind of people that I can recruit because I have to find someone who is able to maintain themselves with no insurance and be able to consider that they might not get all the money every week.
Reduced quality of services	2	22	You lose a quality element as well. I’m not saying that independent contractors do poor work, what I’m saying is that my ability to develop and enhance and train individuals is also very limited.
Consequences of the independent contractor model (EBP-specific)
Impacts staff selection	3	33	We only have contractors. So, the agency, even if they do have money, because we do have money for training, is not willing to invest money to send a contractor to an expensive training…that they may or may not get a return on.
Contractors can not meet initiative requirements	4	44	But where the challenge has been is that we have people who are contractors, and therefore, their ability to commit time to the project is limited.
Contractors have to be committed to learning EBP because they are not paid for extra time	1	11	I have to find contracts who are willing to do [EBP], which I am not paying them for, including training and consultation, which means ultimately they would just have to be committed to the fact that they want to learn a skill.
Incentive for contractors to use EBP	1	11	Per diem staff [i.e., independent contractors] are only paid if they’re doing a session. So, they are going to do what works with the people they see. There is an incentive there to do that.
Alternatives or ways to improve the independent contractor model
Treating contractor clinicians with respect/providing opportunities for professional development	5	56	We feel strongly enough about the initiative and we want them to participate. We are paying for their training time as per their hourly fee-for-service rate. And they’re not salaried employees. So the agency takes on a certain amount of cost for that as well as some reduced productivity because people spend more time in supervision and beyond the actual face-to-face session with the consumer. What we have tried to do, the only thing we changed [when we transitioned to the contractor model] is how the staff are paid. Other than that, we behave as a department with staff who receives supervision.
Shared risk model	1	11	For employees we have tuition reimbursement. When you sign up for tuition reimbursement, you also sign off that you will be at the agency for 2 years or you have to pay the money back. So similarly, I think they could include this in the contract of independent contractor clinicians.
Primary care integration	1	11	I think we’re going to keep the [salaried] model because we believe in it and in addition to that, it is going to be integrated in primary care and behavioral health. We’re going to try to go as far as we can with the health home models.

^aEBP = evidence-based practices