Article Figures & Data
Figures
- Figure 1.
Study Model Measuring the Impact of the Performance-Based Reimbursement Systems on Quality of Care
Tables
Measurement Range No. Mean (SD) Impact of PBR system 1-5 423 2.24 (0.76) Illegitimate tasks 1-5 431 3.15 (0.66) Moral distress 0-3 425 1.58 (0.66) Quality of individual care 1-5 429 3.82 (0.63) Quality of organizational care 1-5 426 3.70 (0.73) Quantitative demands 1-5 427 3.39 (0.91) Age, y 28-67 433 45.16 (11.21) PBR = performance-based reimbursement.
Effect type Relationship Quality of individual care Quality of organizational care Effecta 95% CI t Effecta 95% CI t Direct effect PBR ➞ QoC −0.013 −0.091 to 0.066 −0.317 0.055 −0.039 to 0.149 1.144 Total effect PBR ➞ QoC 0.062 −0.019 to 0.143 1.522 0.121 0.026 to 0.216 2.512 Indirect effect PBR ➞ IWT ➞ MD ➞ QoC 0.011 0.004 to 0.021 … 0.006 −0.001 to 0.015 … Indirect effect PBR ➞ IWT ➞ QoC 0.075 0.041 to 0.112 … 0.046 0.019 to 0.077 … Indirect effect PBR ➞ MD ➞ QoC 0.027 0.001 to 0.049 … 0.015 −0.001 to 0.015 … IWT = illegitimate work tasks; MD = moral distress; PBR = performance-based reimbursement; QoC = quality of care.
↵a Adjusted for age, gender, quantitative workload.
VISUAL ABSTRACT IN PDF FILE BELOW
- VisualAbstractBrulin.pdf -
PDF file
- VisualAbstractBrulin.pdf -
PLAIN-LANGUAGE SUMMARY
Original Research
Performance-Based Reimbursement Linked to Increased Administrative Burden, Moral Distress, and Lower Perceived Care Quality
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. Researchers explored whether illegitimate tasks (tasks that fall beyond the scope of an employee's primary responsibilities and professional role or tasks that are not anticipated for a particular position) and moral distress—feelings of stress or guilt due to forced unethical decisions—played a role in these outcomes.
Study Approach: Researchers conducted a longitudinal study using a three-wave survey of primary care physicians. Data were drawn 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). Respondents rated 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 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
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PBR was associated with increased illegitimate work tasks, which in turn was linked to greater moral distress.
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Both illegitimate work tasks and moral distress were associated with lower perceived individual quality of care.
Quality of Organizational Care
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PBR was associated with an increase in illegitimate work tasks, which was linked to lower perceived organizational quality of care.
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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 that are seen as irrelevant could support physician well-being and health care delivery. Given these findings, policymakers should consider how health care systems, including PBR structures, impact the workforce’s well-being and ability to provide care.
Performance-Based Reimbursement, Illegitimate Tasks, Moral Distress, and Quality Care in Primary Care: A Mediation Model of Longitudinal Data
Emma Brulin, RD, PhD
Unit of Occupational Medicine, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
Kevin Teoh, PhD
Birkbeck Business School, Birkbeck, University of London, London, United Kingdom
Visual Abstract:
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