Experiences of general practices with a participatory pay-for-performance program: a qualitative study in primary care

The involvement of target users in the design choices of a pay-for-performance program may enhance its impact, but little is known about the views of participants in these programs. To explore general practices’ experiences with pay-for-performance in primary care we conducted a qualitative study in general practices in the Netherlands. Thirty out of 65 general practices participating in a pay-for-performance program, stratified for bonus, were invited for a semistructured interview on feasibility, feedback and the bonus, spending of the bonus, unintended consequences, and future developments. Content analysis was used to process the resulting transcripts. We included 29 practices. The feasibility of the pay-for-performance program was questioned due to the substantial time investment. The feedback on clinical care, practice management and patient experience was mostly discussed in the team, and used for improvement plans, but was also qualified as annoying for one GP and for another GP it brought feelings of insecurity. Most practices considered the bonus a stimulus to improve quality of care, in addition to compensation for their effort and time invested. Distinctive performance features were not displayed, for instance, on a website. The bonus was mainly spent on new equipment or team building. Practices referred to gaming and focusing on those aspects that were incentivised (‘tunnel vision’) as unintended consequences. Future developments should be directed to absolute thresholds, new indicators to keep the process going, and an independent audit. Linking a part of the bonus to innovation was also suggested. The participants thought the pay-for-performance program was a labour-intensive positive breakthrough to stimulate quality improvement, but warned of unintended consequences of the program and the sustainability of the indicator set.