Greene Jessica, Kurtzman Ellen T, Hibbard Judith H, Overton Valerie
School of Nursing, The George Washington University, Washington, DC
School of Nursing, The George Washington University, Washington, DC.
Ann Fam Med. 2015 May-Jun;13(3):235-41. doi: 10.1370/afm.1779.
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.
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.
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.
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.
设计按绩效付费项目时的一个关键考虑因素是确定激励应授予的实体——个体临床医生还是团队工作的临床医生群体。一些人认为团队层面的激励最为有效，即团队中的临床医生根据团队绩效获得相同的激励；另一些人则主张临床医生层面激励的有效性。本研究考察了基层医疗临床医生对在诊所层面给予的基于团队的质量激励的看法。
本研究是与美景健康服务机构合作开展的，该机构40%的基层医疗薪酬模式基于诊所层面的质量绩效。我们进行了48次深度访谈，以探究临床医生对诊所层面激励的看法，还对150名临床医生进行了在线调查（回复率56%），以调查临床医生认为针对质量激励的最佳目标实体。
临床医生报告称，基于诊所的质量激励的优点是团队质量得到改善，患者“甩锅”情况减少，即把预后差的患者转给其他临床医生的情况减少。缺点是临床医生缺乏控制权，以及表现较好的同事让表现一般的同事搭便车。关于该模式对团队动态的影响，报告不一。虽然临床医生报告称与同事的互动增多，但一些人描述了紧张关系的加剧。大多数接受调查的临床医生（73%）认为，应该结合诊所层面和个人层面的激励措施，以维持协作并认可个人表现。
该研究突出了基于诊所层面绩效的激励措施的重要优缺点。未来的研究应测试混合群体和个人激励的混合激励措施是否能保留每种设计的一些最佳元素，同时减轻负面影响。
