Authors' Response to E-Letter: “RE: Clarifying the Interpretation of PBR Effects: Objective Policy or Subjective Perception?”

Thank you for reading and acknowledging our work. 

The question about the impact of performance-based reimbursement (PBR) is complex. In our previous study (Brulin et al., 2023), we explored PBR using mixed methods. This included open-ended questions where physicians could describe how PBR impacts them with their own words, and three closed questions: 

1. To what extent did the physicians' experience of PBR impact their work, with answers on a 4-point scale ranging from “to a large extent” to “not at all.
2. Physicians who answered that PBR impacted their work were then asked to rate, on a 4-point scale, whether the experience of how PBR impacted their work was “very positive,” “positive,” “negative,” or “very negative.” 
3. Physicians were asked to what extent they experienced PBR affecting their ability to act on patients’ medical needs. Answers ranged on a 4-point scale: “to a very large extent,” “to a large extent,” to “to some extent,” and “not at all.”

 Based on the result from the study mentioned above, we decided to use the second question and included all participants who responded that they did not think PBR impacted them as a fifth middle category, “neutral”.

 We agree that a more suitable term to use would have been the perceived effect of PBR and not just the effect of PBR. As we use survey data, all our measures were self-perceived and self-rated, and we therefore did not specify it throughout the text (due to word limits). We did make this point in other parts of the paper, including the model in Figure 1, and as the final limitation discussed. However, as our exposure ranged from perceiving the impact of PBR as negative to perceiving it as positive, the exposure is not only that their perception of PBR is negative or not.

As PBR is part of the performance management and measurement system, it represents a core governing factor of organizational structures. We believe the main contribution of this article is that we cannot view organizational structures separately from job quality, and in turn, quality of care; rather, they are interlinked. We are grateful for your clarification, which helps further unpack the nuances and complexity in this area, and offers some further avenues in which to examine, understand, and involve the perceptions of physicians when it comes to managing organizational structures and processes.