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

PURPOSE We tested for direct and indirect effects that performance-based reimbursement (PBR) in primary care has on perceived individual and organizational quality of care, and the role of illegitimate tasks and moral distress as potential mediators.

METHOD We used results from the Longitudinal Occupational Health survey in Healthcare Sweden with data collected in 2021, 2022, and 2023. The sample of primary care physicians who answered at all 3 years and were aged 68 or more was 433. Performance-based reimbursement was measured using a single item. The Bern Illegitimate Tasks Scale measured illegitimate tasks, and moral distress was measured with a 10-item scale. Six items from the English National Health Staff Survey were used to measure the quality of individual and organizational care.

RESULT Of the 433 participants, 70% reported that PBR negatively impacted their work. Performance-based reimbursement was negatively associated with illegitimate tasks (b = −0.160; 95% CI, −0.240 to −0.080) and moral distress (b = −0.134; 95% CI, −0.210 to −0.058). These work factors were in turn associated with both individual and organizational quality of care. Using mediation models, we found an indirect effect (b = 0.011; 95% CI, 0.004 to 0.021) but no direct effect (b = 0.062; 95% CI, −0.019 to 0.143) between PBR on the quality of individual care.

CONCLUSION Performance-based reimbursement systems should account for the experience of individual primary care physicians to ensure effective, safe, and quality care, as this study shows how the level of illegitimate tasks and moral distress due to a PBR system can undermine care delivery. Consequently, it is imperative for stakeholders to consider how health care systems relate to the health care staff’s experience, well-being, and the care being provided.