title: Working under a clinic-level quality incentive: primary care clinicians' perceptions.
abstract: BACKGROUND
  A key consideration in designing pay-for-performance programs is determining what entity the incentive should be awarded to-individual clinicians or to groups of clinicians working in teams. Some argue that team-level incentives, in which clinicians who are part of a team receive the same incentive based on the team's performance, are most effective; others argue for the efficacy of clinician-level incentives. This study examines primary care clinicians' perceptions of a team-based quality incentive awarded at the clinic level.
  
  
  METHODS
  This research was conducted with Fairview Health Services, where 40% of the primary care compensation model was based on clinic-level quality performance. We conducted 48 in-depth interviews to explore clinicians' perceptions of the clinic-level incentive, as well as an online survey of 150 clinicians (response rate 56%) to investigate which entity the clinicians would consider optimal to target for quality incentives.
  
  
  RESULTS
  Clinicians reported the strengths of the clinic-based quality incentive were quality improvement for the team and less patient "dumping," or shifting patients with poor outcomes to other clinicians. The weaknesses were clinicians' lack of control and colleagues riding the coattails of higher performers. There were mixed reports on the model's impact on team dynamics. Although clinicians reported greater interaction with colleagues, some described an increase in tension. Most clinicians surveyed (73%) believed that there should be a mix of clinic and individual-level incentives to maintain collaboration and recognize individual performance.
  
  
  CONCLUSIONS
  The study highlights the important advantages and disadvantages of using incentives based upon clinic-level performance. Future research should test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.
authors.affiliation: School of Nursing, The George Washington University, Washington, DC jessgreene@gwu.edu.
authors.forename: Jessica
authors.initials: J
authors.lastname: Greene
authors.affiliation: School of Nursing, The George Washington University, Washington, DC.
authors.forename: Ellen T
authors.initials: ET
authors.lastname: Kurtzman
authors.affiliation: Department of Planning, Public Policy, and Management, Health Policy Research Group, University of Oregon.
authors.forename: Judith H
authors.initials: JH
authors.lastname: Hibbard
authors.affiliation: Vice President Quality and Innovation, Fairview Medical Group.
authors.forename: Valerie
authors.initials: V
authors.lastname: Overton
mesh_terms: D000328:Adult; D005260:Female; D006282:Health Personnel / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D010465:Perception; D010816:Physician Incentive Plans / Q000191:economics*; D011320:Primary Health Care / Q000592:standards*; D058996:Quality Improvement / Q000592:standards*; D012052:Reimbursement, Incentive / Q000191:economics*; D011795:Surveys and Questionnaires
keywords: physician incentive plans; quality improvement