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Working Under a Clinic-Level Quality Incentive: Primary Care Clinicians’ Perceptions

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Pay-for-performance programs that reward physicians for achieving quality and cost goals often tie incentive payments to individual, rather than group-level, performance. To understand the strengths and weaknesses of the latter approach, the authors of this Commonwealth Fund–supported study surveyed primary care physicians at Fairview Health Services, a Minnesota-based integrated delivery system that based 40 percent of compensation on clinic-level quality metrics.

Key Findings

  • Many physicians said the new approach encouraged collaboration among physicians and led to quality improvement and less “patient dumping” by clinicians who might otherwise steer medically complex patients to colleagues to improve their individual performance. In some instances the program also prompted physicians to seek out and learn from higher-performing doctors.
  • Some physicians expressed frustration that they could not change the way lower-performing physicians practiced medicine, which decreased their own compensation. They also had concerns that physicians who were not contributing as much could ride the coattails of higher performers.
  • Almost three-quarters of the physicians surveyed felt a hybrid approach—one that offered group-level incentives when team action was essential and individual incentives when behavior changes were dependent on individual action—would be superior. 


Payers seeking to promote system-level changes may benefit from using both approaches at once, but this may require additional research to determine whether a hybrid approach would preserve the strengths of the team-based approach while mitigating its weaknesses.

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Publication Details



Jessica Greene, Professor and Associate Dean for Research, George Washington University School of Nursing

[email protected]


J. Greene, E. T. Kurtzman, J. H. Hibbard et al., "Working Under a Clinic-Level Quality Incentive: Primary Care Clinicians' Perceptions," Annals of Family Medicine, May/June 2015 13(3):235–41.