Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures

INTRODUCTION

Given ongoing nationwide shortcomings in clinical services to improve population health,¹ primary care practices are under increasing financial and regulatory pressure to efficiently deliver high-quality health care.^2,3 Team-based primary care models, with each team member functioning at the top of his or her scope of practice, have been an effective solution.^4-6

Medical assistants (MAs) make up a substantial portion of the medical workforce and have played a key role because of their multifunctionality, short training period, racial and socioeconomic backgrounds often reflective of the patient communities served, and high relative value as the lowest-paid members of the care team.^7-12 In many jurisdictions, their scope has expanded to include health coaching, scribing, translating, and phlebotomy, which has enabled MAs to deliver increased value to team-based primary care.^7,12 Notably, high-performing MAs can improve standardized quality measures in their patient population, including those related to screening, immunization status, medication adherence, and tobacco cessation.^7,13,14 MAs have further demonstrated value in team-based care settings by problem solving in real time to remove barriers to care.¹⁵ Despite the growing value provided by MAs, performance-based financial incentives, which have been widely used and evaluated in the physician population,¹⁶ are typically not part of their compensation.^12,17

Strategies for efficiently and effectively incentivizing the primary care team to promote high-quality care are debated.^7,12 Physician financial incentives have been linked to better patient care,¹⁶ but less is known about incentives for other staff. Financial incentives for MAs have been shown to be appropriate¹² and effective¹⁸ in the context of expanded MA roles and responsibilities. Incentives could improve performance by providing recognition and clarifying goals, as demonstrated among MAs outside of the United States.¹⁹ These studies suggest that MA incentives may be useful in health systems’ efforts to improve quality of care, but optimizing incentive design is important. Too small of an incentive relative to salary is ineffective at changing physician behavior.^20,21 Modest incentives, however, may result in greater productivity gains when aimed at MAs, given their relatively low annual median pay of $34,800 in 2019, one-half the median annual pay of registered nurses ($73,300) and one-sixth that of physicians ($208,000).²²

Incentives may come with some risk. Financial motivators make up a relatively narrow band of human motivational domains, which also include mastery, autonomy/power, relatedness, social purpose, and hygiene factors (avoiding demotivation).²³ Research has shown that extrinsic motivators (eg, financial rewards) can “crowd out” intrinsic motivators (eg, autonomy), leading to a reduction in performance long term.^23-27 These unintended effects may be mitigated to a certain degree by the structuring of a financial incentive: sustainability, a performance focus on quantity rather than quality, and the copresence of nonfinancial incentives may attenuate these adverse effects.^23,26,27

Furthermore, effective incentive design requires workers to have both the capability to perform the desired task and control over the desired outcome²⁸; these aspects depend on which area of performance is being incentivized. Even when MAs have the capability for expanded roles,^7,12 they may not always exercise control over outcomes commonly incentivized in primary care, including health measures (eg, adequate diabetes control) that are used by national pay-for-performance programs.²⁹ Similar to professional organizations for physicians, the American Association of Medial Assistants has voiced concern that MAs are being asked to deliver outcomes they cannot control.³⁰ Worker control over an incentivized performance area is an essential component of effective incentive programs in other health settings.¹⁶ Further research is needed to understand MA perceptions of control over various population health quality measures in order to select appropriate targets for financial incentive. This exploratory study therefore aims to understand MA acceptability of financial incentives and perceived control over common population health measures.

METHODS

Using mixed methods to explore MA perspectives on financial incentives (past and theoretical), we assessed variation in work processes that may be influenced by a financial incentive and perceived control over common population health measures with semistructured focus groups that incorporated a short survey. Key incentive frameworks described above^23,31 were used to guide the design, interpretation, and presentation of findings.

RESULTS

Across the 3 institutions, we conducted 10 focus groups with 4 to 9 participants each, for a total of 59 MA participants. As shown in Table 1, the large majority of MAs (78.0%) worked in urban/suburban settings, 44% were aged 30 to 39 years, 92% were female, 37% were White, and 54% were non-Hispanic. Nearly one-half had worked as an MA for 10 years or more. Findings were consistent across institutions as well as urban/suburban vs partially rural areas, and are therefore reported for the cohort as a whole.

The mixed-methods analysis suggested 3 emergent themes around MA incentives: (1) limited MA experience with financial incentives but overall acceptability, (2) potential for increased performance through increased effort, and (3) strongest perceived control over same-day population health measures. We discuss findings below with illustrative comments denoted by participant number and focus group number (MA, FG).

DISCUSSION

This study underscores the potential opportunity and risk posed by MA financial incentives to improve the quality of care, particularly given MAs’ expanding roles. MAs reported that the idea of a financial incentive, even a relatively small one, was acceptable overall. They showed positive interest in a bonus representing 2% to 3% of their average annual base pay ($34,000 to $40,000 in their geographic localities³⁰). Although past literature suggests that a 10% to 20% bonus is needed to create meaningful behavior change among higher-paid professionals,³⁸ our findings point to potential benefit from directing limited health system resources to lower-paid system members.

Participating MAs reported nearly no direct experience with financial incentives but indicated that they might encourage increased consistency in their day-today performance related to population health measures. Behavior change might include not forgetting steps during patient rooming workflow, repeated follow-up to obtain outside records, and completing population health workflow for all patients, rather than solely for their physician’s empaneled patients. These disclosures suggest at least some room for improvement in MA performance that might be influenced by a financial incentive and lead to improved patient outcomes.

MAs also expressed that although they have the skills necessary to close population health gaps, they control only a subset of population health measures, particularly those with workflow processes that can be completed during a single patient encounter. These measures included body mass index screening, tobacco use, and depression screening, as well as influenza and pneumococcal vaccinations, from the subset of 11 measures studied. The principle of linking incentives to same-day measures, however, may be expanded to other existing and novel population health measures. The quantity of simultaneous target measures also matters, and care should be taken to avoid overburdening MAs with too many “meticulous little pieces,” as suggested by cognitive load theory.³⁹ Furthermore, empiric investigations of potential adverse behavioral and relational consequences resulting from the introduction of financial incentives, alongside strategies to mitigate such effects, are needed to inform where and how financial incentives might optimally be applied in the MA population.

A dominant undercurrent throughout these conversations validates prior findings¹² that large structural challenges within each health system—capacity constraints, work hour restrictions, inefficient electronic health records, and patient behavioral health issues, among others—make it challenging for MAs to complete their daily tasks. External barriers such as an inability to retrieve records from outside sources or a patient declining recommended care dominated themes of resistance to incentive workability. Health systems considering introducing an MA financial incentive must therefore consider all aspects of the MA work environment and workflow to remove existing barriers to optimal performance. Additional research is needed to understand how to best use MAs in health care systems to improve quality of care and staff experience.

Patients of diverse backgrounds may also benefit from increased MA involvement in their care activities, given their increased diversity relative to other members of the health care team.^40,41 Racially concordant care between patients and physicians has been associated with greater patient satisfaction, higher-quality communication, and better patient health outcomes,^42-44 but how MA diversity might impact clinical care is uncertain. We note participant demographics in our sample were even more racially and ethnically diverse than those of national MA samples, with an overrepresentation of Hispanic participants (45.8% sample, 26.1% national) and Asian participants (15.3% sample, 4.2% national), though the sex balance was equivalent.⁴⁰ Our sample more closely approximated local California health worker demographics where 6 of the 10 focus groups took place.⁴¹

This work is exploratory in nature and focused on the impact of incentives on quality of care, yet findings suggest a possible secondary effect on employee satisfaction. MA financial incentives are thought to improve satisfaction and reduce staff turnover.⁴³ Some MAs remarked that because physicians received financial incentives for the work completed in collaboration with the MA, a personal financial incentive would increase fairness and, potentially, job satisfaction. Such “organizational justice,” defined as employees’ perceptions of fairness in the workplace, has also been associated with improved performance and decreased turnover.^17,46 Use of MA financial incentives to improve staff satisfaction therefore merits further research.

We note that this research was also conducted before the COVID-19 pandemic and the corresponding shift to telemedicine in many health systems.^47,48 MAs’ ability to close population health care gaps may be severely limited if they are not well integrated into the video visit workflow and thus have limited contact with the patient.^49,50 Additional investigation is needed to assess this concern.

This study has several limitations. Our focus groups were drawn from 3 institutions in 2 geographic areas and may not be representative of MAs in other institutions or regions. Our use of focus groups rather than individual interviews fostered important dialog but may also have limited certain disclosures. Additionally, participant demographic data were captured anonymously and not directly tied to individual qualitative comments given the potential vulnerability MAs faced in participating in a focus groups in their place of work. This choice limited an analysis comparing subgroups of varying demographics, although this may be an area for future investigation. Further, our conclusions—based on 11 population health measures—may have varied had other measures been chosen. Additional study is needed to understand MA perceptions of control across the multitude of existing population health measures. Also, there is a need to evaluate the return on investment for incentive programs that address population health metrics, particularly the increase in performance for every dollar spent.

In conclusion, within 3 health care organizations, primary care MAs perceived that relatively small performance-based financial incentives would increase their motivation and the quality of care in their clinic. Furthermore, MAs reported feeling responsible for and able to control population health outcomes that could be completed within a single encounter, such as body mass index screening, depression and tobacco screening, and vaccinations. As health care systems nationwide aim to improve population health measures, it may be a savvy use of limited resources to focus incentives more on MAs. With MAs playing an increasingly essential role within primary care teams, future investigation is needed to develop effective and fair financial incentives.