Performance-based reimbursement increases administrative burden and moral distress, lowers perceived quality of care
Performance-based reimbursement, illegitimate tasks, moral distress, and quality care in primary care: a mediation model of longitudinal data
American Academy of Family Physicians
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All Quality Metrics Are Wrong; Some Quality Metrics Could Become Useful
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Performance-Based Reimbursement Increases Administrative Burden and Moral Distress, Lowers Perceived Quality of Care
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.
Study Approach: Researchers conducted a longitudinal study using a three-wave survey of primary care physicians, drawing data 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), asking respondents to rate 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 (tasks that fall beyond the scope of an employee's primary responsibilities and professional role or tasks not anticipated for a particular position) 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
PBR was associated with increased illegitimate work tasks and greater moral distress
Illegitimate work tasks and moral distress were both associated with lower perceived individual quality of care
Quality of Organizational Care
PBR was associated with an increase in illegitimate work tasks and lower perceived organizational quality of care
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 which are seen as irrelevant could support physician well-being and health care delivery.
Journal
The Annals of Family Medicine
Pay-for-performance metrics must be more impactful and physician-controlled
All quality metrics are wrong; Some quality metrics could become useful
Pay-for-Performance Metrics Must Be More Impactful and Physician-Controlled
Background: This editorial builds on a study by Brulin and Teoh, released ahead of the March/April 2025 issue of Annals of Family Medicine, which found that performance-based reimbursement is associated with lower perceived quality of care by increasing illegitimate tasks and moral distress for primary care physicians.
Editorial Stance: Quality metrics and pay-for-performance initiatives are far more expensive than many patients, clinicians, or administrators realize. The authors call for more rigorous review through cluster randomized controlled trials both before and after implementation—and recommend against implementing metrics with little impact or those that detract from care. They recommend refocusing incentives on targets that are impactful, time-limited, low-cost, and physician-controlled.
Why It Matters: While no single metric is perfect, some can support better care if applied thoughtfully and tested in real-world settings. All Quality Metrics Are Wrong; Some Quality Metrics Could Become Useful
Michael E. Johansen, MD, MS, et al
Grant Family Medicine, OhioHealth, Columbus, Ohio
Journal
The Annals of Family Medicine
Survey finds many Americans greatly overestimate primary care spending
The general public vastly overestimates primary care spending in the united states
American Academy of Family Physicians
Survey Finds Many Americans Greatly Overestimate Primary Care Spending
Background and Goal: This study, based on an online survey of 1,135 adults demographically representative of the U.S. population, aimed to measure public perceptions of primary care spending.
Key Insights: Respondents believed that 51.8% of overall health care spending goes to primary care—more than 10 times the documented share of 4.7%. Additionally, respondents believed that primary care addresses 58.7% of health care needs, very close to actual primary care utilization as a percentage of all ambulatory physician visits in the United States (50.3%).
Why It Matters: Chronic underinvestment in primary care has resulted in workforce shortages, physician burnout, reduced access, and suboptimal care. Access to high-quality primary care has been associated with better population health and more equitable outcomes.
The General Public Vastly Overestimates Primary Care Spending in the United States
Melissa Ma, BS, et al
School of Medicine, University of California, San Francisco, San Francisco, California
Journal
The Annals of Family Medicine
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