Performance-based reimbursement linked to increased burden, lower perceived quality of care

A new study published in the Annals of Family Medicine raises concerns about the effects of performance-based reimbursement (PBR) on primary care physicians (PCPs), highlighting increased administrative burdens, rates of moral distress, and a decline in perceived quality of care.

Drawing data from the Longitudinal Occupational Health Survey in Health Care Sweden, researchers analyzed responses from 433 Swedish PCPs who participated in a three-wave survey between 2021 and 2023. The findings suggest that, while PBR models are intended to improve health care efficiency and outcomes, they may be contributing to physician dissatisfaction and potentially undermining quality of care.

PBR systems are payment models meant to compensate health care providers based on specific performance metrics, including patient outcomes, efficiency and adherence to quality standards. Unlike traditional fee-for-service models, PBR systems aim to incentivize high-value care by tying payments into measurable results.

PBR differs from value-based care (VBC) in that it often focuses on individual provider performance and specific quality metrics, whereas VBC takes a broader approach, emphasizing coordinated, preventative care to improve long-term health outcomes.

Findings

According to the study, 70.2% of responding physicians reported that PBR negatively impacted their work experience. Specifically:

• PBR was linked to an increase in illegitimate tasks — tasks beyond the scope of a PCP’s primary responsibilities — which could include excessive documentation/paperwork and administrative tasks.
• The rise in illegitimate tasks correlated with heightened moral distress — feelings of stress or guilt stemming from making ethically challenging decisions, often due to feeling constrained in providing the quality of care they deem necessary.
• Increased illegitimate tasks and moral distress were associated with a decline in perceived individual quality of care.
• At an organizational level, PBR was also associated with reduced perceived care quality, though moral distress did not play a statistically significant role in this aspect.

The study’s authors suggest that while PBR aims to enhance accountability and efficiency, it may inadvertently increase administrative demands that detract from clinical care.

“The level of illegitimate tasks and moral distress due to a PBR system can undermine care delivery,” the authors of the study wrote. “The clinical implication of this study is that quality of care is not limited to best practices and evidence-based medicine but also relies on [PCPs’] work systems.”

The study underscores the need for health care leaders and policymakers to reevaluate how performance metrics are implemented. “Quality of care must be viewed in the context of organizational demands and the conditions that primary care physicians’ need to carry out clinical work,” the authors wrote.

With ongoing workforce shortages and rising burnout rates, reducing illegitimate tasks and addressing PBR-related moral distress could be key to improving physician retention and patient outcomes.