Performance-Based Reimbursement Increases Administrative Burden and Moral Distress, Lowers Perceived Quality of Care
Background and Goal: Performance-based reimbursement (PBR) is a payment system in which clinics receive compensation based on the quality and outcomes of care they deliver, rather than the volume of services provided. Although designed to improve efficiency and effectiveness, the growth of PBR systems has been linked to increased administrative work for physicians. This study examined how PBR affects doctors' perceived ability to provide quality care at both the individual and organizational levels.
Study Approach: Researchers conducted a longitudinal study using a three-wave survey of primary care physicians, drawing data from the Longitudinal Occupational Health Survey in Health Care Sweden. The first wave, conducted from March to May 2021, involved a survey sent to a nationally representative sample of physicians (N=6,699), asking respondents to rate the impact of the PBR system on a scale ranging from very negative to very positive. The second wave, conducted from March to May 2022, measured illegitimate tasks (tasks that fall beyond the scope of an employee's primary responsibilities and professional role or tasks not anticipated for a particular position) using the Bern Illegitimate Tasks Scale. Moral distress was assessed using an instrument originally developed for Norwegian physicians and later translated into Swedish. The third wave, conducted from October to December 2023, evaluated perceived quality of care at both the individual and organizational levels using the English National Health Staff Survey.
Main Results: A total of 433 primary care physicians responded to the survey at all three time points. Overall, 70.2% of respondents reported that PBR negatively impacted their work (58.9% negative, 12.3% very negative).
Quality of Individual Care
PBR was associated with increased illegitimate work tasks and greater moral distress
Illegitimate work tasks and moral distress were both associated with lower perceived individual quality of care
Quality of Organizational Care
PBR was associated with an increase in illegitimate work tasks and lower perceived organizational quality of care
Moral distress did not have a significant association with perceived organizational quality of care
Why It Matters: The identification of illegitimate tasks and moral distress as factors associated with perceived care quality suggests that reducing tasks which are seen as irrelevant could support physician well-being and health care delivery.
The Annals of Family Medicine