Effects of performance‐based reimbursement on the professional autonomy and power of physicians and the quality of care

Abstract

The key question addressed in this study is whether performance-based reimbursement in health care affects the professional power and autonomy of physicians, and if so, whether this has any consequences for the quality of care. This cohort study examines the period 1994-98 in 11 Swedish county councils. Four hundred and eighteen physicians were studied in Stockholm County Council, which has a performance-based reimbursement system, and in ten councils without such a system. The results show that professional power and autonomy are considered to be very limited in all councils, and that they have decreased during the period studied. Professional autonomy is, however, more limited in Stockholm. The limitations in Stockholm are more related to financial considerations, whereas the limitations in the other councils are more due to guidelines and lists of recommended drugs. Professional autonomy and power were found to be important determinants for quality of care, and the physicians in Stockholm estimated the quality of care lower than their colleagues in the ten other councils. Thus, our study suggests that the performance-based reimbursement system might fail to reach the desired results due to its negative impact on professional power and autonomy.

Activity‐based financing of health care––experiences from Sweden

“…In addition, many of the physicians experienced that the quality of care had been reduced between the years 1991 and 1998. The difference was hardly dramatic but statistically significant (Forsberg et al, 2001a).…”

The impact of financial constraints and incentives on professional autonomy

“…As the research presented here and elsewhere indicates, frontline GPs consider that increased financial constraints and accountability lead to a reduction in their ability to exercise professional judgement. Others have suggested the performance based reimbursement systems not only reduce professional autonomy, but that they lead to a lower quality of care (Forsberg et al, 2001).…”

“…Clinical decision-making, which has been regarded as the core of professional autonomy and a neutral zone based on expertise alone, becomes contested and the subject of legitimate scrutiny and intervention when government objectives shift the boundaries. For example, physicians in Sweden regard their professional power and autonomy as having been severely limited, through a performance-based reimbursement system (Forsberg et al, 2001). It seems that changing autonomy by increasing financial constraints and incentives is also likely to reduce clinical freedom.…”

The relative importance of leadership and payment system

“…Two questionnaires were used: incentive, efficiency, environment (IEE), constructed at the Centre for Health Services Development 1992-1994 [16,17] and quality, work, competence (QWC), constructed 1993 [18,19]. An index created in QWC was used to assess leadership.…”