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- Page navigation anchor for Authors' Response to E-Letter: “RE: Clarifying the Interpretation of PBR Effects: Objective Policy or Subjective Perception?”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:
- 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.
- 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.”
- 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...
Show MoreCompeting Interests: None declared. - Page navigation anchor for Performance Incentives and Their Unintended Consequences for Family PhysiciansPerformance Incentives and Their Unintended Consequences for Family Physicians
Dear Editor,
We read with interest the article by Brulin and Teoh, “Performance-Based Reimbursement, Illegitimate Tasks, Moral Distress, and Quality Care in Primary Care: A Mediation Model of Longitudinal Data” (1). We believe this study offers pertinent insights into the interplay between performance-based reimbursement (PBR) schemes, administrative overload, and the perception of care quality. We are writing from the perspective of Spanish family researchers working in a public health center. Our intention is to highlight how their findings resonate with challenges faced in Spain’s national health system, where health care competencies are decentralized to the regions (comunidades autónomas) and where multiple incentive models coexist. While the Swedish context in the study is shaped by its particular application of New Public Management principles (2), there are parallels in the Spanish primary care environment that help us appreciate the article’s conclusions and their relevance in broader European settings.
We note, first, that the authors convincingly show how PBR can inadvertently increase illegitimate tasks and moral distress. Such tasks, identified in previous literature as activities beyond or tangential to the core professional roles of physicians (3), include administrative duties or the completion of bureaucratic requirements seen as “unnecessary” or “unreasonable.” Indeed, Semmer and colleagues (4) found that work perceived as illegitimate can u...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Clarifying the Interpretation of PBR Effects: Objective Policy or Subjective Perception?RE: Clarifying the Interpretation of PBR Effects: Objective Policy or Subjective Perception?
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 fa...
Show MoreCompeting Interests: None declared.