The Influence Of Hospital Pay-for-Performance Satisfaction On Physician Professionalism

Objective: Physician professionalism has always been the cornerstone to improving quality of medical care.At its core,physician professionalism aims to put the interests of patients first—ahead of personal gain and financial rewards,to continuously improve upon personal professional knowledge and competency,and to ensure quality medical care while promoting the equitable distribution of medical resources.Professionalism encompasses altruism,self-monitoring,and commitment to improving the quality of medical care and clinical research.As health systems in more and more countries around the world establish performance-based compensation systems,there has been research from various countries on performance-based pay,also known as pay for performance(P4P).These mainly focused on different P4 P policies and incentive plans and their impact on health care quality.Clinicians are the objective targets of P4 P incentives and are also leaders of healthcare services.Therefore,increasing attention is directed toward improving professionalism and health care quality.Relevant research on the impact of P4 P on physician professionalism have two distinct characteristics.First,physician professionalism is always a complex convergence of concepts.It is defined differently under different cultural backgrounds,making it incomplete to study the effects of P4 P on certain aspects of physician professionalism from a single perspective.For example,physician professionalism cannot simply be attributed to altruism or ethical behavior.The second is the concept of the “economic man” in regards to P4 P.This describes doctors to be constantly guided by ways that maximize their own value or utility,which seems to contradict principles of physician professionalism such as altruism.The concept is evident but rarely questioned,and as a result,there is a lack of discussion on the specific influencing mechanisms of P4 P on physician professionalism.When comparing pay satisfaction with other factors of job satisfaction(such as satisfaction with coworkers or with the organizational structure of the workplace),P4 P systems can better control the precursors of pay satisfaction.The main purpose of this research was to study the theoretical mechanism of the impact of pay satisfaction on physician professionalism and carry out verification on the basis of empirical evidence.Methods: Through a structured search of relevant literature on physician professionalism and pay for performance(P4P)and the clustering of topics by keyword co-occurrence frequency,a visual knowledge map was created to review relevant theoretical mechanisms of physician professionalism and P4 P.This was done to understand the role and placement of satisfaction within the main theoretical mechanism that influences physician professionalism and P4 P.Interviews were held with directors or vice directors of internal medicine,surgery,obstetrics and gynecology(OBGYN),and pediatrics departments at tertiary hospitals in Liaoning Province,PR China.Interviewees were motivated to talk about factors and causes affecting physician professionalism in the hospital performance evaluation system.Interviews were recorded,and interview material were sorted and organized.Grounded theory was used for initial coding,focused coding,axial coding,and selective coding.The impact of P4 P on physician professionalism in tertiary hospitals of Liaoning Province was summarized according to physician positions in the hospital payment systems,including the role of pay satisfaction.Based on bibliometrics and qualitative research interviews,hypotheses were constructed regarding the impact of pay satisfaction on physician professionalism.Participants were drawn via stratified sampling of 37 tertiary hospitals in 14 prefecture-level cities in Liaoning Province.Clinicians from internal medicine,surgery,OBGYN,pediatrics,and emergency(including the ICU)departments of 8 tertiary hospitals in the cities of Shenyang,Dalian,Jinzhou,Tieling,and Fushun were surveyed using the Chinese Physician Professionalism Evaluation Scale and the Pay Satisfaction Questionnaire.Survey scales were tested for reliability and validity,and multiple linear regression was used to analyze the factors affecting the relationship of P4 P and pay satisfaction on physician professionalism.Multiple demographic variables were controlled for in order to determine any regulating effects.Results: Using co-occurrence clustering to analyze recent literature on physician professionalism and hospital P4 P,585 articles were retrieved from the Pub Med database and 892 articles were retrieved from the Web of Science core database.After excluding duplicates,a total of 1239 papers were identified for keyword co-occurrence analysis,and a keyword co-occurrence network was created based on the text theme from co-occurrence clustering.It was discovered that relevant research focused on the keywords “motivation” and “(physician’s)practice patterns”.Existing research often used motivation theory to discuss the relationship between clinician needs,behaviours,goals,and motivations.In motivation theory,satisfaction is an important process factor.Studies on physician professionalism primarily focused on popular topics such as altruism,professional autonomy and patient-centeredness,doctor-patient relationships,compassion,respect,understanding,ethics,cooperation,fair distribution of medical resources,adherence to ethical principles,and humanism.Other aspects included professional identity formation and professional dilemmas.Five rounds of interviews were conducted with 19 interviewees from Shengjing Hospital of China Medical University,the Fourth Affiliated Hospital of China Medical University,Dalian Central Hospital,the First Affiliated Hospital of Jinzhou Medical University,the Tieling Tiefa Coal Industry Group General Hospital.More than 70,000 words of interview material were sorted,and the collated interview data were coded sentence by sentence,forming 274 initial codes.According to the importance of the codes and the concepts they reflected,the initial codes were refined into 182 focused codes.After refining and organizing the generic relationship of the focused codes,70 axial codes were generated.Further integration of the codes formed the themes of “performance allocation”,“physician professionalism”,“individual factors”,“external factors”,and “health care quality”.The themes,based on grounded theory,showed that P4 P satisfaction was both a result of hospital P4 P at the clinician level and also an important factor for physician motivation.Interview results showed that clinicians believed that performance-orientation has a negative impact on "integrity and responsibility" and "compassion,respect,communication,and cooperation".Additionally,interviewees believed that welfare guarantee is the guaranteeing factor of the "pursuit of excellence" and that structural management has a positive effect on all dimensions of physician professionalism.Based on questionnaire surveying and multiple linear regression analysis of 802 clinicians in 8 tertiary hospitals in Liaoning Province,there was a significant positive correlation between P4 P satisfaction and physician professionalism(β = 0.18,SE = 0.04).For the professionalism dimension of physicians’ "compassion,respect,communication,and cooperation",P4 P satisfaction had a significantly negative correlation(β =-0.26,SE = 0.08),and structure and management satisfaction had a significantly positive correlation(β = 0.28,SE = 0.09).The dimension of "integrity and responsibility" had a significantly negative correlation with P4 P satisfaction(β =-0.23,SE = 0.08).For the dimension of “pursuing excellence”,satisfaction with welfare guarantee and satisfaction with structural management had significantly positive correlations(β = 0.20,SE = 0.08;β = 0.19,SE = 0.09,respectively).For the dimension of "fair distribution of medical resources,fulfillment of humanitarianism,and adherence to ethical standards",satisfaction with welfare guarantee and satisfaction with structural management had significantly positive correlations(β = 0.17,SE = 0.08;β = 0.20,SE = 0.09,respectively).After including the interaction terms for the variables into the regression model,there was a marginal effect of P4 P satisfaction on physician professionalism.Analyses were adjusted by age,job title,number of years of work,region,and average number of night shifts per month.Conclusions: Hospital pay for performance(P4P)satisfaction can promote physician professionalism,but the impact on each dimension of professionalism is different.Physician satisfaction with the structural management of P4 P was more conducive to the construction of physician professionalism.Results suggest that when designing and distributing P4 P systems,team-based allocation may be more conducive to teamwork and communication.Positive performance rewards based on role models may help foster physician integrity and responsibility.Involving clinicians in the development of performance indicators may be conducive to a learning atmosphere and the pursuit of excellence.And lastly,performance allocation by team may reduce the risk of financial penalties on physicians due to the fair allocation of medical resources.