Special Issue: General Practice Incentives
The incentivation for primary health workers is vital for the realization of two goals of the new healthcare reform in China, namely strengthening primary healthcare and achieving hierarchical diagnosis and treatment. Most previous studies put more emphasis on extrinsic incentive measures and their effect on job outcomes, ignoring the intrinsic motivation effect of job itself.
To perform an analysis of the job characteristics of primary health workers using the framework of Job Characteristics Model, assess their intrinsic motivation effect on job outcomes of these workers, and compare the strength of impact of the five dimensions of job characteristics and income and other extrinsic motivators on job outcomes, and put forward policy recommendations for improving work motivation and performance of primary health workers.
A survey using a self-developed questionnaire was conducted with primary health workers who were on duty on the day of the survey selected from a multistage sample of healthcare settings (including 18 community health centers and 20 township health centers) in three cities of Shandong Province from February to June 2021. Then, from those who effectively completed the survey, 167 cases were selected using convenience sampling to attend semi-structured interviews to understand their views of the characteristics of job as a primary health worker. Pearson correlation was used to analyze the correlations of the five dimensions of job characteristics and extrinsic motivators with autonomous motivation, performance, burnout, and turnover intention. Hierarchical multiple linear regression was used to analyze the strength of impact of the five dimensions of job characteristics and extrinsic motivators on job outcomes. Thematic analysis was used to analyze the interview data.
A total of 870 cases who handed in effective questionnaires were included for analysis. Among the five dimensions of job characteristics, respondents scored highest and lowest on skill variety (4.09±0.71) and task identity (3.18±1.04) , respectively, and their scores on task significance, feedback from job and autonomy were (3.91±0.76) (3.46±0.83) and (3.43±0.79) , respectively. Pearson correlation analysis showed that the level of each of the five dimensions of job characteristics had a positive correlation with autonomous motivation and performance (P<0.05) , and had a significant negative correlation with burnout and turnover intention (P<0.05) . Hierarchical multiple linear regression revealed that the five dimensions of job characteristics had significant impacts on job outcomes, specifically, autonomous motivation (R2=18.8%) , performance (R2=11.3%) , job burnout (R2=16.5%) and turnover intention (R2=21.9%) , whose explanatory power was stronger than that of five extrinsic motivators (The R2 values of the five extrinsic motivators' contributions to the four job outcomes were 1.7%, 3.4%, 5.8%, and 11.8%, respectively) . The interview results reflected the problems of task fragmentation, limited autonomy and insufficient feedback from job.
In primary health workers, the intrinsic motivation effect of job characteristics outweighs the extrinsic motivation effect in terms of explanatory power for job outcomes. And there is a gap between actual and theoretical job characteristics. Attention should be paid to the intrinsic motivation effect of job itself. Some measures should be taken, such as increasing training opportunities and quality, reducing work-related burden of these workers and empowering them, increasing resource investment and reducing policy constraints, improving the performance management system, to reshape job perceptions to improve work motivation and performance of primary health workers.
During the promotion of category-based management for community healthcare institutions (class 1 institutions obtain the financial security, and class 2 institutions implement a performance management system), how to appropriately determine the security level and scientifically evaluate the performance is a difficulty to tackle for health administrative departments.
To assess the operational efficiency of community healthcare institutions with the data envelopment analysis (DEA) using the information of costs of these institutions calculated using the equivalent method, then attempt to develop an input and management model of integrating cost accounting and performance management for these institutions, providing a theoretical basis for accurate and scientific input of various resources into the community through cost measurement with equivalent method, and a data basis for performance assessment in communities with different characteristics through efficiency evaluation.
The real data (financial status and staffing) of 14 community healthcare institutions during 2019 to 2020 were collected from their financial reports, hospital information system, maternal and child healthcare information system, chronic disease management information system, as well as focus group interviews. The equivalent method was used to calculate the total costs of medical services and public health services. The super-efficiency DEA was used to evaluate and analyze the operational efficiency of the 14 sample institutions.
(1) The average cost of one equivalent service (a general medical outpatient service lasting for 15 minutes was defined as one standard service equivalent unit) was 67.64 yuan in 2019 and 69.80 yuan in 2020 for the 14 institutions. The average cost of one equivalent essential medical service was higher than that of one equivalent public health service in both 2019 (167.14 yuan vs 18.86 yuan) and 2020 (215.43 yuan vs 19.78 yuan). The institutions demonstrated significant differences in the average cost of one equivalent essential medical service and the average cost of one equivalent public health service. (2) Each institution had its own peculiar characteristics. For example, S1 institution mainly provided essential medical services, and had higher total equivalent essential medical services and efficiency than other institutions, while S9 institution focused on providing public health services, and had the highest efficiency in delivering public health services. (3) In 2020, the 14 institutions provided 134 800 equivalent COVID-19-related services, with a cost of 1.037 8 million yuan. (4) In 2019 and 2020, only two institutions were relatively overall efficient, and ≥50.0% institutions were pure technically efficient. The institutions with overall operational inefficiency were mainly caused by scale inefficiency primarily due to increasing returns to scale.
The equivalent method provides a relatively unified "scale" to standardize the service efficiency of different types of community healthcare institutions, provides support for health administrative departments implementing category-based compensation for the institutions, benefiting the featured and high-level development of community healthcare institutions. Either institutions delivering essential medical services or those delivering public health services, mainly present increasing returns to scale, suggesting that the efficiency of these institutions can be improved by increasing the human/financial/material input into the institutions and providing precise compensation for them.
General practitioners are the gatekeepers when it comes to residents' healthcare. This means that the quality and quantity of their services will play a key role in improving basic medical services. The most appropriate incentive mechanism for general practitioners can improve their ability, minimize the desire to leave, and promote the stability of teams. Currently, China lacks a comprehensive and flawless practice system, and the exploration of incentives for general practitioners is still in its infancy, and there is a lack of a complete and effective practice system. This study highlights the critical importance of incentives and incentive mechanisms. It summarizes the experience of the United Kingdom, Australia, the United States, Shenzhen, Xiamen, and Shanghai with relatively mature incentive mechanisms in China and abroad. Additionally, to summarise the current problems that still exist in the incentive mechanism for general practitioners in China (single incentive approach, lack of career attraction due to the lack of obvious incentive effect, poor science of incentives leads to uneven allocation across regions, different incentive policies across regions and slow implementation) . As part of this strategy, together with the strategy of "Healthy China", innovative ideas are put forward in terms of enrolling general practice in national key clinical specialty, establishing authoritative professional academic institutions and regulatory institutions, developing a unified performance appraisal system, improving the diversified material and non-material incentive mechanisms, improving the competition and punishment mechanisms by means of information, and forming an efficient general practitioner service teams. In order to provide new research methods for investigating the incentive system of primary general practitioners in China.
As main health service providers in primary care, general practitioners (GPs) undertake the responsibility of gatekeepers for residents' health. Vigorously training GPs will contribute to the transformation of the healthcare delivery model, and the addressing of the issue related to difficult and high cost of getting medical treatment in China. However, the number of qualified GPs is insufficient in China, and low income is a major factor associated with the willingness of medical students to work as a GP. How to take actions to recruit, retain and appropriately employ GPs in primary care is a problem that needs to be addressed urgently in the development of China's primary care workforce. To provide evidence for the improvement of China's payment system for GPs, we collected the information related to the payment for GPs in the United Kingdom, the United States, Australia, and China by reviewing relevant studies and relevant official websites of the four countries, and performed an inter-county comparative analysis of the information in terms of income source, income level, payment methods, payment composition, and performance appraisal. We found that the four countries have the following aspects in common: all of them own a payment system for GPs and an assessment system for service quality and effectiveness of GPs, adopt a mixed payment method for GPs, and use financial incentives to promote GPs to improve the quality of their performance. In addition, the United States and China have explored methods to decentralize the management of medical insurance funds, so that the primary healthcare institutions can independently redistribute the surplus funds which has improved the proactivity of GPs at work. And Australia has set up the "coefficient of difference" and scholarships/subsidies for GPs, and carried out free trainings for improving the service capacities of GPs working in remote areas, to increase the attractiveness of working as a GP.
Development of an Incentive Model for General Practitioners in Fengxian District of Shanghai Based on Herzberg's Motivation-hygiene Theory
In view of the shortage of general practitioners (GPs) and limited community healthcare resources, it is urgently necessary for community health institutions to find accurate and scientific incentive methods to retain GPs and help them to realize their full potential, as well as promote the development of both community health institutions and GPs, thereby benefiting the health promotion of community residents.
To develop an incentive model for GPs to test the performance and effectiveness of current incentives for GPs, so as to put forward suggestions to improve the mechanisms of employing and retaining GPs.
In August 2019, we recruited 204 GPs from 11 community health centers (CHCs) in Shanghai's Fengxian District using stratified random sampling to attend an online survey using a questionnaire named General Practitioners' Perception and Evaluation of Incentive Measures developed based on our previous research results and Herzberg's motivation-hygiene theory. Then from August to September 2019, we invited directors responsible for medical care or public health issues, and medical quality control department heads from the above-mentioned 11 CHCs to attend an online survey using a questionnaire named Workload for General Practitioners in Community Health Centers of Fengxian District developed by usbased on a literature review. Then under the guidance of Herzberg's motivation-hygiene theory, we constructed a structural equation to develop an incentive model for GPs within Fengxian District with representative incentive policies, systems and initiatives related to GPs selected from the survey results as latent independent variables to measure GPs' (responders') perception and assessment of incentives, and with willingness to work, service radius, and workload of GPs as dependent variables.
The average scores for the implementation of incentive measures, and its associated influence on GPs' work status assessed by the 204 GPs were (0.77±0.14) , and (0.73±0.19) , respectively. The assessment score for implementation of incentive measures for GPs differed significantly by personal health condition and administrative position in the respondents (P<0.05) . The assessment score for the influence of implementing incentive measures on GPs' work status differed significantly by personal health condition in the respondents (P<0.05) . Spearman correlation analysis showed that GPs' work status was associated with the implementation of 25 incentive measures (one incentive measure at the subdistrict level was not included for analysis) (P<0.05) . The top three most highly correlated incentive measures were performance distribution (rs=0.652) , performance-based salary calculation (rs=0.621) , and wages and benefits (rs=0.614) . Partial correlation analysis indicated that, after controlling for variables such as the regional policy environment, the street and town government, and the work unit, the assessment score for implementation of either regional, or subdistrict or institutional incentive measures for GPs, was positively correlated with the assessment score for the influence of implementation of incentive measures for GPs on GPs' work status (r=0.381, 0.387, 0.528, P<0.001) . Theaverage assessment score for willingness to work by the respondents was (0.76±0.18) points. Theassessment scores of willingness to work by the respondents differed significantly by work unit (P<0.05) . Structural equation modeling revealed that the implementation of policy incentive measures influenced GPs' workload via GPs' willingness to work. Specifically, the implementation of policy incentive measures increased GPs' willingness to work (w1=0.43) , while GPs' willingness to work decreased with the increase of weighted workload (w2=-0.156) .
The GPs in Fengxian District showed higher level of willingness to work, namely, relatively high job stability, but they had not been incentivized by policy incentives to be competitive in obtaining improved performance, indicating that although policy incentives have produced partial effects on incentivizing GPs, the effects are still unsatisfactory. In the long run, it is necessary to consider whether there will be changes in GPs' retention status due to the lack of work initiative. For GPs, besides a guarantee of stable income, incentives to get more by doing more are also needed, which may be achieved by increasing the incentive authority and proportion of community health institutions when the total amount of incentives is limited.
Background A diabetes pay-for-performance（P4P） program has been implemented in Haimen District since January 2018，to incentivize family physicians to improve the quality of family physician care for type 2 diabetics.Objective To investigate the impact of P4P program for family physicians on type 2 diabetics' blood glucose control，medication compliance，health service utilization and medical expenses. Methods From March to June 2019，we selected type 2 diabetics from the name list of confirmed type 2 diabetics receiving the management from village health clinics（one was extracted every 10 cases） in Nantongli Tongzhou and Haimen Districts，including 496 with care delivered by family physicians incentivized by the P4P program（incentive group），and 589 with care delivered by family physicians without the program as an incentive（control group），and surveyed them using a questionnaire for collecting their information involving demographics，healthcare utilization，medical expenses，fasting blood glucose and medication compliance. Negative binomial regression，Logistic regression and OLS regression were used to analyze the influencing factors of annual outpatient visits，annual inpatient service utilization and medical costs. Results There were statistically significant differences between the two groups in terms of the distribution of education level and mean number of coexisted chronic diseases，and annual household income（P<0.05）. The incentive group had statistically lower mean fasting blood glucose level，less mean number of annual outpatient visits，lower annual inpatient service utilization rate and lower mean annual total medical costs than the control group（P<0.05）. The incentive group also showed statistically higher medication compliance（P<0.05）. After adjustment for demographic characteristics and fasting blood glucose，multivariate regression analysis found that compared with the control group，the incentive group demonstrated a reduction of 34.6% in mean annual outpatient visits（IRR=0.654，P<0.05），an increase of 54.96%（eb-1=0.549 6，P<0.05） in mean annual medication cost，and a decrease of 34.43%（eb-1=-0.344 3，P<0.05） in mean annual total medical costs. Further age-based subgroup analysis found that compared with the patients aged <60 and >70 in the control group，the number of outpatient visits of the same age patients in the incentive group decreased by 63.2%（IRR=0.368，P<0.05） and 54.2%（IRR=0.458，P<0.05） respectively；compared with the patients aged >70 in the control group，the utilization rate of inpatient services of the patients aged >70 in the incentive group decreased by 48.0%（OR=0.520，P<0.05）. Conclusion The diabetes P4P program for family physicians may partially contribute to reducing the outpatient care utilization in type 2 diabetics，and reducing the annual inpatient service utilization rate and annual total medical costs in over 70-year-old type 2 diabetics.
Special Issue: General Practice Incentives
