Abstract
Canada is a leader in experimenting with alternative, non fee for service provider remuneration methods; all jurisdictions have implemented salaries and payment models that blend fee for service with salary or capitation components. A series of qualitative interviews were held with 27 stakeholders in the Canadian health care system to assess the reasons and expectations behind the implementation of these payment methods for family physicians, as well as the extent to which objectives have been achieved. Results indicate that the main reasons are a need to recruit and retain primary care physicians to rural and remote regions of the country, and the desire to increase collaboration, care continuity, prevention and health promotion. The general perception is that positive results have been observed, but problems are not alleviated. Blended payments have had some positive effects on preventive care delivery, collaboration, and care continuity. Salaries have provided a stable, predictable, and high source of income for physicians, thereby improving recruitment and retention. The implementation of salaries, however, led to concerns with declining physician productivity, and has brought to light a need for improved measurement and monitoring systems.
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We were able to interview an MOH/DOH representative from each jurisdiction. Other types of stakeholders were not available from each jurisdiction. For example, not every jurisdiction has a medical school, and some provinces have more than one medical school.
Not all jurisdictions commented on the observed outcomes. The number of reported observed outcomes falls short of the number of expected outcomes on several occasions.
In parentheses we have indicated the regions from which representatives have agreed with a particular view or statement.
References
Ariizumi, H. (2004) Physician competition, and managed care organizations’ contract choice. Department of Economics. The University of Western Ontario.
Barro, J., & Beaulieu, N. (2003). Selection and improvement: Physician responses to financial incentives. National Bureau of Economic Research, Inc., NBER working papers: 10017.
Bliemel, M., & Hassanein, K. (2004). E-health: Applying business process reengineering principles to healthcare in Canada. International Journal of E-Business, 2(6), 625–643. doi:10.1504/IJEB.2004.006129.
Blomqvist, A. (1991). The doctor as double agent: Information asymmetry, health insurance and medical care. Journal of Health Economics, 10(4), 411–422. doi:10.1016/0167-6296(91)90023-G.
Bolduc, D., Fortin, B., & Fournier, M. A. (1996). The effects of incentive policies on the practice location of doctors: A multinomial probit analysis. Journal of Labor Economics, 14(4), 703–732. doi:10.1086/209828.
Canadian Institute of Health Information. (2005). Alternative Payments and the National Physician Database, The Status of Alternative Payment Programs for Physicians in Canada 2002–2003; Information for 2003–2004. Ottawa, Ontario.
Carlsen, F., & Grytten, J. (1998). More physicians: Improved availability or induced demand? Health Economics, 7, 495–508. doi:10.1002/(SICI)1099-1050(199809)7:6<495::AID-HEC368>3.0.CO;2-S.
Carlsen, F., & Grytten, J. (2000). Consumer satisfaction and supplier induced demand. Journal of Health Economics, 19(5), 731–753. doi:10.1016/S0167-6296(00)00044-8.
Chaix-Couturier, C., Durand-Zalenski, I., Jolly, D., & Durieux, P. (2000). Effects of financial incentives on medical practice: Results from a systematic review of the literature and methodological issues. International Journal for Quality in Health Care, 12(2), 133–142. doi:10.1093/intqhc/12.2.133.
Chalkley, M., & Tilley, C. (2005). The existence and nature of physician agency: Evidence of stinting in the British National Health Service. Journal of Economics & Management Strategy, 14(3), 647–664. doi:10.1111/j.1530-9134.2005.00077.x.
Christensen, A. J., & Johnson, J. A. (2002). Patient adherence with medical treatment regiments: An interactive approach. Current Directions in Psychological Science, 11(3), 94–97. doi:10.1111/1467-8721.00176.
Cuffel, B. J., Bloom, J. R., Wallace, N., Hausman, J. W., & Hu, T. W. (2002). Two year outcomes of fee-for-service and capitated Medicaid programs for people with severe mental illness. HSR: Health Services Research, 37(2), 341–359. doi:10.1111/1475-6773.026.
Delattre, E., & Dormont, B. (2003). Fixed fees and physician-induced demand: A panel data study of French physicians. Health Economics, 12, 741–754. doi:10.1002/hec.823.
Denzii, C. (2000). Medication noncompliance: What is the problem? Managed Care Supplement, 9(9), 7–12.
Ellickson, P., Stern, S., & Trajtenberg, M. (2000). Patient welfare and compliance: An empirical framework for measuring the benefits from pharmaceutical innovation, NBER Working Paper No. W6890.
Ellis, R. P., & McGuire, T. G. (1996). Optimal payment systems for health services. Journal of Health Economics, 9, 375–396. doi:10.1016/0167-6296(90)90001-J.
Evans, R. (1984). Strained mercy: The economics of Canadian medical care. Toronto: Butterworths.
Farley, P. (1986). Theories of the price and quantity of physcian services. Journal of Health Economics, 5, 315–333. doi:10.1016/0167-6296(86)90007-X.
Forsberg, E., Axelsson, R., & Arnetz, B. (2001). Financial incentives in health care. The impact of performance-based reimbursement. Health Policy (Amsterdam), 58, 243–262. doi:10.1016/S0168-8510(01)00163-4.
Fuchs, V. (1996). Economics, values, and health care reform. The American Economic Review, 86, 1–24.
Gafni, A., Charles, C., & Whelan, T. (1998). The physician-patient encounter: The physician as a perfect agent for the patient versus the informed treatment decision-making model. Social Science and Medicine, 47(3), 347–354. doi:10.1016/S0277-9536(98)00091-4.
Gagne, R., & Leger, P. T. (2005). Determinants of physicians’ decisions to specialize. Health Economics, 14, 721–735. doi:10.1002/hec.970.
Gene-Badia, J., Escaramis-Babiano, G., Sans-Corrales, M., Sampietro-Colom, L., Aguado-Menguy, F., Cabezas-Pena, C., et al. (2007). Impact of economic incentives on quality of professional life and on end-user satisfaction in primary care. Health Policy (Amsterdam), 80(1), 2–10. doi:10.1016/j.healthpol.2006.02.008.
Gosden, T., Forland, F., Kristiansen, I. S., Sutton, M., Leese, B., Guifidda, A., et al. (2001). Impact of payment method on behaviour of primary care physicians: A systematic review. Journal of Health Services Research & Policy, 6(1), 44–55. doi:10.1258/1355819011927198.
Gosden, T., Sibbald, B., Williams, J., Petchey, R., & Leese, B. (2003). Paying doctors by salary: A controlled study of general practitioner behaviour in England. Health Policy (Amsterdam), 64, 415–423. doi:10.1016/S0168-8510(02)00204-X.
Greenfield, S., Rogers, W., Mangotich, M., Carney, M., & Tarlow, A. R. (1995). Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Journal of the American Medical Association, 274(18), 1436–1444. doi:10.1001/jama.274.18.1436.
Gruber, J., & Owings, M. (1996). Physician financial incentives and cesarean section delivery. The Rand Journal of Economics, 27, 99–123. doi:10.2307/2555794.
Grytten, J., & Sorensen, R. (2001). Type of contract and supplier-induced demand for primary physicians in Norway. Journal of Health Economics, 20, 379–393. doi:10.1016/S0167-6296(00)00087-4.
Grytten, J., & Sorensen, R. (2003). Practice variation and physician specific effects. Journal of Health Economics, 22(3), 403–418. doi:10.1016/S0167-6296(02)00105-4.
Jegers, M., Kesteloot, K., De Graeve, D., & Gilles, W. (2002). A typology for provider payment systems in health care. Health Policy (Amsterdam), 60, 255–273. doi:10.1016/S0168-8510(01)00216-0.
Jelovac, I. (2001). Physicians’ payment contracts, treatment decisions and diagnosis accuracy. Health Economics, 10, 9–25. doi:10.1002/1099-1050(200101)10:1<9::AID-HEC560>3.0.CO;2-Y.
Kyngas, H., Duffy, M. E., & Kroll, J. (2000). Conceptual framework of compliance. Journal of Clinical Nursing, 9, 5–12. doi:10.1046/j.1365-2702.2000.00309.x.
Lee, C. (1995). Optimal medical treatment under asymmetric information. Journal of Health Economics, 14, 419–441. doi:10.1016/0167-6296(95)00012-7.
Lomas, J. (1996). Reluctant rationer: Public input to health care priorities. Hamilton, ON: Centre for Health Economic and Policy Analysis.
Lurie, N., Christianson, J., Finch, M., & Moscovice, M. (1994). The effects of capitation on health and functional status of the Medicaid elderly: A randomized trail. Annals of Internal Medicine, 120(6), 506–511.
Ma, A. (1994). Health care payment systems: Cost and quality incentives. Journal of Economics & Management Strategy, 3, 93–112. doi:10.1111/j.1430-9134.1994.00093.x.
Ma, A., & McGuire, T. (1997). Optimal health insurance and provider payment. The American Economic Review, 87, 685–704.
McGuire, T. G. (2000). Physician agency. In A. J. Culyer, & J. P. Newhouse (Eds.), Handbook of health economics (pp. 461–536). Elsevier Science.
McGuire, T. G., & Pauly, M. V. (1991). Physician response to fee changes with multiple payers. Journal of Health Economics, 10, 385–410. doi:10.1016/0167-6296(91)90022-F.
Menec, V., Black, C., Roos, N., & Bogdanovic, B. (2001). What is the potential for formal patient registration in Canadian primary care? The scale of ‘informal registration’ in Manitoba. Journal of Health Services Research & Policy, 6(4), 202–206. doi:10.1258/1355819011927495.
Nassiri, A., & Rochaix, L. (2006). Revisiting physicians’ financial incentives in Québec: A panel system approach. Health Economics, 15(1), 49–64. doi:10.1002/hec.1012.
Newhouse, J. (1996). Reimbursing health plans and health providers: Efficiency in production versus selection. Journal of Economic Literature, 34, 1236–1263.
North South Group Inc. (2005). Critical inventory of family physician alternative remuneration models. The Nova Scotia Department of Health, Halifax, Canada, submitted.
Quast, T., Sappington, D. E., & Shenkman, E. (2008). Does the quality of care in medicaid MCOs vary with the form of physician compensation? Health Economics, 17(4), 545–550. doi:10.1002/hec.1264.
Retchin, S. M., Brown, B., Yeh, S. C., Chu, D., & Moreno, L. (1997). Outcomes of stroke patients in Medicare fee for service and managed care. Journal of the American Medical Association, 278(2), 119–124. doi:10.1001/jama.278.2.119.
Robinson, J. C. (2001). Theory and practice in the design of physician payment incentives. The Milbank Quarterly, 79(2), 149–177. doi:10.1111/1468-0009.00202.
Rochaix, L. (1989). Information asymmetry and search in the market for physicians’ services. Journal of Health Economics, 8, 53–84. doi:10.1016/0167-6296(89)90009-X.
Rogerson, W. (1994). Choice of treatment intensities by a non-profit hospital under perspective coverage. Journal of Economics & Management Strategy, 7, 51.
Rosenthal, M. B., Frank, R. G., Li, Z., & Epstein, A. M. (2005). Early experience with pay-for-performance: From concept to practice. Journal of the American Medical Association, 294(14), 1788–1793. doi:10.1001/jama.294.14.1788.
Scott, A. (2001). Eliciting GPs’ preferences for pecuniary and non-pecuniary job characteristics. Journal of Health Economics, 20, 329–347. doi:10.1016/S0167-6296(00)00083-7.
Sloan, F. A., & Feldman, R. (1978). Competition among physicians. In W. Greenberg (Ed.) (pp. 45–102).
Sobrero, M. E. S., Dick, A. W., Zwanziger, J., Mukamel, D., & Weyl, N. (2003). Effects of capitation on switching primary care physicians. HSR: Health Services Research, 31(1), 191–209.
Sorensen, R. J., & Grytten, J. (1999). Competition and supplier-induced demand in a health care system with fixed fees. Health Economics, 8(6), 497–508. doi:10.1002/(SICI)1099-1050(199909)8:6<497::AID-HEC439>3.0.CO;2-D.
Sorensen, R. J., & Grytten, J. (2003). Service production and contract choice in primary physician services. Health Policy (Amsterdam), 66, 73–93. doi:10.1016/S0168-8510(03)00026-5.
Stano, M. (1987). A further analysis of the physician inducement controversy. Journal of Health Economics, 6, 227–238. doi:10.1016/0167-6296(87)90010-5.
Vernon, S. W., Hughes, J. I., Heckel, V. M., & Jackson, G. L. (1992). Quality of care for colorectal cancer in a fee-for-service and health maintenance organization practice. Cancer, 69(10), 2418–2425. doi:10.1002/1097-0142(19920515)69:10<2418::AID-CNCR2820691006>3.0.CO;2-1.
Vick, S., & Scott, A. (1998). Agency in health care. examining patients’ preferences for attributes of the doctor-patient relationship. Journal of Health Economics, 17(5), 587–605. doi:10.1016/S0167-6296(97)00035-0.
Ware, J. E., Bayliss, M. S., Rogers, W. H., Kosinski, M., & Tarlow, A. R. (1996). Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. Journal of the American Medical Association, 276(13), 1039–1047. doi:10.1001/jama.276.13.1039b.
Whynes, D. K., & Baines, D. L. (1998). Income-based incentives in UK general practice. Health Policy (Amsterdam), 43, 15–31. doi:10.1016/S0168-8510(97)00078-X.
Woodward, R. S., & Warren-Boulton, F. (1984). Considering the effects of financial incentives and professional ethics on ‘appropriate’ medical care. Journal of Health Economics, 3, 223–237.
Wranik, D. (2008). A Taxonomy of Quality Based Incentive Payments, Faculty of Management, Dalhousie University, Working Paper.
Wranik, D. (2008). Are doctors lazy? Inappropriate and ineffective treatment recommendations. Faculty of Management, Dalhousie University, Working Paper.
Wranik, D. (2008). Health Human Resource Planning in Canada: A Typology and application. Health Policy (Amsterdam), 86, 27–41. doi:10.1016/j.healthpol.2007.08.004.
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Wranik, D.W., Durier-Copp, M. Physician Remuneration Methods for Family Physicians in Canada: Expected Outcomes and Lessons Learned. Health Care Anal 18, 35–59 (2010). https://doi.org/10.1007/s10728-008-0105-9
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DOI: https://doi.org/10.1007/s10728-008-0105-9