Performance-Based Reimbursement, Illegitimate Tasks, Moral Distress, and Quality Care in Primary Care: A Mediation Model of Longitudinal Data

We read with great interest the article by Brulin and Teoh, which used a longitudinal design to examine the impact of performance-based reimbursement (PBR) systems on physicians’ perceptions of quality of care through the mediating roles of illegitimate tasks and moral distress. Their findings highlight important psychosocial mechanisms that may undermine the perceived quality of care in primary care settings, and we commend the authors for addressing this timely and complex issue.

However, we would like to offer a clarification that we believe is crucial for the appropriate interpretation of the study’s findings. In the analysis, the key independent variable—“impact of the PBR system”—was measured using a single item capturing the subjective evaluation of PBR by individual physicians, not the objective presence or structure of a PBR system itself. The item asked, “To what extent has the PBR system affected your work?”, with response options ranging from “very negative” to “very positive.”

This means that the significant indirect effects reported in the study—namely, the associations of PBR with illegitimate tasks, moral distress, and eventually perceived quality of care—should be interpreted as reflecting how physicians’ perceptions of PBR relate to these downstream experiences and outcomes, rather than the causal impact of the PBR system per se.

The distinction is more than semantic. Subjective appraisal of a policy is likely influenced by various factors including local implementation, workload, leadership style, and prior expectations. Therefore, conclusions that refer to “the effect of PBR” should more precisely refer to “the effect of perceiving PBR as negative.” Without objective variation in PBR exposure or structure, causal inferences about the policy itself should be made cautiously.

We believe this clarification enhances, rather than detracts from, the significance of the authors’ findings. The results suggest that how a performance system is perceived by frontline clinicians may be as important as the system’s formal design, and this opens avenues for improving implementation through participatory processes, communication strategies, and attention to clinicians’ sense of fairness and coherence.

Thank you for the opportunity to comment on this important work.