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Money matters – primary care providers' perceptions of payment incentives

Sofie Vengberg (Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden)
Mio Fredriksson (Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden)
Bo Burström (Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden)
Kristina Burström (Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden)
Ulrika Winblad (Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden)

Journal of Health Organization and Management

ISSN: 1477-7266

Article publication date: 2 February 2021

Issue publication date: 8 June 2021




Payments to healthcare providers create incentives that can influence provider behaviour. Research on unit-level incentives in primary care is, however, scarce. This paper examines how managers and salaried physicians at Swedish primary healthcare centres perceive that payment incentives directed towards the healthcare centre affect their work.


An interview study was conducted with 24 respondents at 13 primary healthcare centres in two cities, located in regions with different payment systems. One had a mixed system comprised of fee-for-service and risk-adjusted capitation payments, and the other a mainly risk-adjusted capitation system.


Findings suggested that both managers and salaried physicians were aware of and adapted to unit-level payment incentives, albeit the latter sometimes to a lesser extent. Respondents perceived fee-for-service payments to stimulate production of shorter visits, up-coding of visits and skimming of healthier patients. Results also suggested that differentiated rates for patient visits affected horizontal prioritisations between physician and nurse visits. Respondents perceived that risk-adjustments for diagnoses led to a focus on registering diagnosis codes, and to some extent, also up-coding of secondary diagnoses.

Practical implications

Policymakers and responsible authorities need to design payment systems carefully, balancing different incentives and considering how and from where data used to calculate payments are retrieved, not relying too heavily on data supplied by providers.


This study contributes evidence on unit-level payment incentives in primary care, a scarcely researched topic, especially using qualitative methods.



The authors are grateful to all the respondents for their valuable participation in this interview study. The authors would also like to thank Associate Editor Dr. Mitchell Sarkies and the two anonymous reviewers for their constructive comments and suggestions on how the paper could be developed. The research received financial support from the Forum for Health Policy, and the Swedish Research Council for Health, Working Life and Welfare [grant number 2014-4763].


Vengberg, S., Fredriksson, M., Burström, B., Burström, K. and Winblad, U. (2021), "Money matters – primary care providers' perceptions of payment incentives", Journal of Health Organization and Management, Vol. 35 No. 4, pp. 458-474.



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