Skip to main content
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 undermine physicians’ sense of professional identity and generate frustration. In Spanish primary care clinics, something quite similar occurs whenever new incentive-based indicators require exhaustive reporting or coding that bears scant relationship to the complexity of actual clinical care. Although the specific tasks may differ from those in Sweden, the structural challenge remains: PBR, when it is narrowly designed, can pull physicians away from patient-centered work, thus creating the seeds of moral distress described by Ulrich (5). He conceptualized moral distress as the feeling of knowing the morally correct action but being constrained from executing it. That sense of constraint easily arises when short consultations are implicitly encouraged by pay-for-performance criteria that reward process metrics more than in-depth care—this is especially marked in some autonomous communities in Spain that use targets focused on rapid turnover of patients or high volumes of routine check-ups.
The article also underscores how moral distress, heightened by tasks deemed illegitimate, can ultimately compromise the quality of care at the individual level. The authors’ methodology is clear and focuses on longitudinal data, which is valuable when exploring phenomena that unfold over time, such as job dissatisfaction and, eventually, negative impacts on patient care (6). In Spain, we have observed that primary care physicians, especially those with heavy administrative requirements tied to local performance metrics, report a similar erosion of perceived care quality. These perceptions frequently surface in staff meetings, where doctors speak of the tension between meeting quantitative indicators—often part of negotiated agreements for extra remuneration or resource allocation—and ensuring the comprehensive, holistic visits that family medicine fundamentally values. The key takeaway, also highlighted by Brulin and Teoh, is that policies designed to improve care through performance evaluation may, in practice, deprive clinicians of the time and freedom they need to apply best practices, ultimately impeding their professional fulfillment and sense of ethical alignment (7,8).
One core dimension of the article that we find especially pertinent is the authors’ discussion of collateral effects arising from performance-based systems. In Spain, where each autonomous community can set its own performance targets, this can lead to a patchwork of approaches, some more administrative than others. Indeed, as the authors explain in other article, PBR systems may be introduced to streamline or rationalize health services, yet they can end up producing an “obsession with metrics” (9). Certain regions in Spain have aligned financial incentives with prescribing rates, referral patterns, or the achievement of disease management goals that might not always capture clinical complexity. The cumulative effect is that physicians, feeling pressure to achieve externally set objectives, spend a significant portion of their appointment time inputting data, coding strictly for managerial requirements, or meeting with practice supervisors to review performance dashboards. Such bureaucratization can become, in itself, an illegitimate burden (4), sidetracking physicians from their therapeutic focus and further fueling the kind of moral distress the study describes. In some cases, this distress may worsen if the physician becomes convinced that rushed consultations or fragmented visits compromise the ethical standards of practice that guide family medicine (10,11).
Another valuable contribution in the study is the attention given to the balance between efficiency and humanity in clinical care. The authors rightly describe how New Public Management doctrines emphasize cost control, quantification of results, and constant monitoring (2). If poorly designed, however, these incentives might propel clinicians to prioritize measurable targets over a more holistic concept of patient-centeredness. In the Spanish context, family physicians often voice concern about the erosion of the therapeutic alliance because of tight scheduling and the relentless pursuit of numeric indicators—sometimes framed as “vital to securing additional resources” for the health center, yet not fully aligned with the needs of a region’s aging population, for example. A more prudent approach, as Brulin and Teoh’s findings imply, involves listening to the experiences of clinicians who are directly affected by the system. Their article illustrates that any incentive strategy must incorporate continuous feedback loops with frontline professionals, or risk creating misaligned priorities and dissatisfaction (12).
Alongside this, we appreciate how the authors address the issue of fragmentation. Although the article focuses on Sweden, they point out that PBR is often introduced under a broader umbrella of governance reforms that vary from region to region. A parallel phenomenon in Spain’s decentralized system is that performance incentives differ in design and intensity, leading to unequal resource distribution and creating tension among neighboring communities. Physicians in one region may struggle under heavier administrative workloads compared to others with fewer metrics to fulfill or alternative evaluation systems. This divergence may perpetuate a sense of professional injustice and intensify moral distress, as described in earlier studies on the interaction between governance models and staff well-being (13,14).
Furthermore, the authors address the cyclical nature of burnout and absenteeism. One of the most striking concerns for us is how the extra workload from PBR—particularly in tasks that many clinicians perceive as superfluous—contributes to a gradual sense of being overwhelmed, ultimately leading to higher rates of sick leave or staff turnover. Research indicates that poor working conditions, including high psychological demands with low perceived control, can significantly increase the risk of burnout in primary care (15). When some physicians leave or go on extended absences, those who remain must shoulder an even larger workload, thus fueling a vicious circle of resource strain. We have seen a similar pattern in Spain, especially in deprived or underserved areas where physician shortages are already severe, and administrative burdens compound existing difficulties in recruitment and retention.
Finally, and perhaps most integrally, we commend Brulin and Teoh’s suggestion that incentive schemes should be expanded beyond narrow process indicators to capture a wider range of clinical and professional values. Their results indicate that performance-based mechanisms should be mindful of physicians’ daily realities, or risk alienating those professionals whose motivation is not primarily financial. Similar arguments have been made by Bodenheimer and Sinsky (16) in the context of moving from the Triple Aim to the Quadruple Aim, highlighting the need to protect provider well-being and a sense of professional fulfillment. In Spanish family medicine, we frequently propose interventions such as reducing the administrative burden (for instance, simplifying sick leave regulations or delegation of certain tasks to trained administrative staff) and focusing on team-based incentives that strengthen continuity of care rather than single performance metrics. Such restructuring might mitigate moral distress by allowing more time for in-depth consultations, integrated care for multimorbid patients, and better alignment with the core values of our profession. These strategies align well with Brulin and Teoh’s findings, suggesting that incentives should support, not undermine, the work of primary care physicians.
In our opinion, the article by Brulin and Teoh provides a nuanced exploration of how PBR, illegitimate tasks, and moral distress interplay to affect both individual and organizational quality of care in Swedish primary care. We find their longitudinal design and clear conceptual framework especially compelling in light of the similar challenges facing Spanish family physicians. Their rigorous use of validated scales and broad sample of participants supports the credibility of the results, which may be particularly relevant in other settings where performance-based models are also entrenched. We share the authors’ view that carefully designed policies should consider the experiences of clinicians to avoid generating unnecessary burdens and emotional strain. In Spain, the structural complexity of 17 autonomous communities, each with its own set of incentives, only amplifies these concerns. We see this article as a call for policy makers and health administrators—both in Sweden and here at home—to consult the frontline workforce when shaping or revising reimbursement frameworks. In our view, performance management should be a tool to enhance care rather than a hurdle that restricts the professional ethos of family medicine.
REFERENCES:
1. Brulin E, Teoh K. Performance-Based Reimbursement, Illegitimate Tasks, Moral Distress, and Quality Care in Primary Care: A Mediation Model of Longitudinal Data. Ann Fam Med. 2025 Mar 1;23(2):145–50.
2. Hood C. A Public Management for All Seasons? Public Adm. 1991;69(1):3–19.
3. Berwick DM. The Science of Improvement. JAMA. 2008 Mar 12;299(10):1182–4.
4. Semmer NK, Jacobshagen N, Meier LL, Elfering A, Beehr TA, Kälin W, et al. Illegitimate tasks as a source of work stress. Work Stress. 2015;29(1):32–56.
5. Ravitsky V, Fiester A, Caplan AL. The Penn Center Guide to Bioethics. Springer Publishing Company; 2009. 857 p.
6. Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLOS ONE. 2016 Jul 8;11(7):e0159015.
7. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Ann Intern Med. 2006;145(4):265–72.
8. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, And Cost. Health Aff (Millwood). 2008 May;27(3):759–69.
9. Brulin E, Ekberg K, Landstad BJ, Lidwall U, Sjöström M, Wilczek A. Money talks: performance-based reimbursement systems impact on perceived work, health and patient care for physicians in Sweden. Front Psychol [Internet]. 2023 Jul 7 [cited 2025 Apr 18];14. Available from: https://www.frontiersin.orghttps://www.frontiersin.org/journals/psycholo...
10. Bejerot E, Hasselbladh H. Forms of Intervention in Public Sector Organizations: Generic Traits in Public Sector Reforms. Organ Stud. 2013 Sep 1;34(9):1357–80.
11. Fredriksson M, Blomqvist P, Winblad U. Conflict and Compliance in Swedish Health Care Governance: Soft Law in the ‘Shadow of Hierarchy’. Scand Polit Stud. 2012;35(1):48–70.
12. Checkland K, Harrison S, Snow S, Mcdermott I, Coleman A. Commissioning in the English National Health Service: What’s the Problem? J Soc Policy. 2012 Jul;41(3):533–50.
13. Morley G, Bradbury-Jones C, Ives J. What is ‘moral distress’ in nursing? A feminist empirical bioethics study. Nurs Ethics. 2020 Aug 1;27(5):1297–314.
14. Morley G, Grady C, McCarthy J, Ulrich CM. Covid-19: Ethical Challenges for Nurses. Hastings Cent Rep. 2020;50(3):35–9.
15. Quick TL. Healthy work: Stress, productivity, and the reconstruction of working life. Natl Product Rev. 1990;9(4):475–9.
16. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med. 2014 Nov 1;12(6):573–6.