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INTRODUCTION: It is well-known that the way physicians are remunerated can affect delivery of health care services to the population. Fee-for-service (FFS) generally leads to oversupply of services, while capitation leads to undersupply of services. However, little evidence exists on the link between remuneration and emergency department (ED) visits. We fill this gap using two popular blended models introduced in Ontario, Canada: the Family Health Group (FHG), an enhanced/blended FFS model, and Family Health Organization (FHO), a blended capitation model. We compare primary care services and rates of emergency department ED visits between these two models. We also evaluate whether these outcomes vary by regular- and after-hours, and patient morbidity status. METHODS: Physicians practicing in an FHG or FHO between April 2012 and March 2017 and their enrolled adult patients were included for analyses. The covariate-balancing propensity score weighting method was used to remove the influence of observable confounding and negative-binomial and linear regression models were used to evaluate the rates of primary care services, ED visits, and the dollar value of primary care services delivered between FHGs and FHOs. Visits were stratified as regular- and after-hours. Patients were stratified into three morbidity groups: non-morbid, single-morbid, and multimorbid (two or more chronic conditions). RESULTS: 6184 physicians and their patients were available for analysis. Compared to FHG physicians, FHO physicians delivered 14% (95% CI 13%, 15%) fewer primary care services per patient per year, with 27% fewer services during after-hours (95% CI 25%, 29%). Patients enrolled to FHO physicians made 27% more less-urgent (95% CI 23%, 31%) and 10% more urgent (95% CI 7%, 13%) ED visits per patient per year, with no difference in very-urgent ED visits. Differences in the pattern of ED visits were similar during regular- and after-hours. Although FHO physicians provided fewer services, multimorbid patients in FHOs made fewer very-urgent and urgent ED visits, with no difference in less-urgent ED visits. CONCLUSION: Primary care physicians practicing in Ontario's blended capitation model provide fewer primary care services compared to those practicing in a blended FFS model. Although the overall rate of ED visits was higher among patients enrolled to FHO physicians, multimorbid patients of FHO physicians make fewer urgent and very-urgent ED visits.

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Conventional wisdom suggests that in almost every profession, the most experienced and educated employees are remunerated at a higher rate than the less experienced ones. For example, new-graduate hires most commonly start at the bottom of the pay scale. No profession could reflect the importance of experience and the need for mastery of skills more than emergency medicine (EM), where a split-second decision could mean the difference between life and death. In Canada, however, EM physicians are remunerated as per a common pay scale that does not consider the length of their education, training, or years of practice. Such an unfair experience-remuneration mismatch (E-R mismatch) could lead to job dissatisfaction, burnout, and switching to other specialties. Given the current EM physician shortage in Canada, the E-R mismatch among such physicians could negatively impact patient care and the health system as a whole and prolong the already long wait times. The aim of this editorial is to shed light on this flaw in the Canadian healthcare system and lead to change toward a fair pay system. The creation of a professional and experience-based hierarchy among Canadian EM physicians should be considered a matter of urgency for those developing health-related legislation.

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Treating mental illnesses in primary care is increasingly emphasized to improve access to mental health services. Although family physicians (FPs) or general practitioners are in an ideal position to provide the bulk of mental health care, it is unclear how best to remunerate FPs for the adequate provision of mental health services. We examined the quantity of mental health services provided in Ontario's blended fee-for-service and blended capitation models. We evaluated the impact of FPs switching from blended fee-for-service to blended capitation on the provision of mental health services in primary care and emergency department using longitudinal health administrative data from 2007 to 2016. We accounted for the differences between those who switched to blended capitation and non-switchers in the baseline using propensity score weighted fixed-effects regressions to compare remuneration models. We found that switching from blended fee-for-service to blended capitation was associated with a 14% decrease (95% CI 12-14%) in the number of mental health services and an 18% decrease (95% CI 15-20%) in the corresponding value of services. This result was driven by the decrease in services during regular-hours. During after-hours, the number of services increased by 20% (95% CI 10-32%) and the corresponding value increased by 35% (95% CI 17-54%). Switching was associated with a 4% (95% CI 1-8%) decrease in emergency department visits for mental health reasons. Blended capitation reduced provision of mental health services without increasing emergency department visits, suggesting potential efficiency gain in the blended capitation model in Ontario.

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Psychiatric hospitalizations could be reduced if mental illnesses were detected and treated earlier in the primary care setting, leading to the World Health Organization recommendation that mental health services be integrated into primary care. The mental health services provided in primary care settings may vary based on how physicians are incentivized. Little is known about the link between physician remuneration and psychiatric hospitalizations. We contribute to this literature by studying the relationship between physician remuneration and psychiatric hospitalizations in Canada's most populous province, Ontario. Specifically, we study family physicians (FPs) who switched from blended fee-for-service (FFS) to blended capitation remuneration model, relative to those who remained in the blended FFS model, on psychiatric hospitalizations. Outcomes included psychiatric hospitalizations by enrolled patients and the proportion of hospitalized patients who had a follow-up visit with the FP within 14 days of discharge. We used longitudinal health administrative data from a cohort of practicing physicians from 2006 through 2016. Because physicians practicing in these two models are likely to be different, we employed inverse probability weighting based on estimated propensity scores to ensure that switchers and non-switchers were comparable at the baseline. Using inverse probability weighted fixed-effects regressions controlling for relevant confounders, we found that switching from blended FFS to blended capitation was associated with a 6.2% decrease in the number of psychiatric hospitalizations and a 4.7% decrease in the number of patients with a psychiatric hospitalization. No significant effect of remuneration on follow-up visits within 14 days of discharge was observed. Our results suggest that the blended capitation model is associated with fewer psychiatric hospitalizations relative to blended FFS.

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OBJECTIVES: In the middle to late 2000s, many family physicians switched from a Family Health Group (FHG; a blended fee-for-service model) to a Family Health Organization (FHO; a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model. METHODS: Using longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on 8 quality indicators related to diabetes care. Because FHO physicians are likely to be systematically different from FHGs, we employed propensity-score-based inverse probability-weighted fixed-effects regression models. All analyses were conducted at the physician level. RESULTS: We found that FHO physicians were more likely to provide glycated hemoglobin testing by 2.75% (95% confidence interval [CI], 1.89% to 3.60%), lipid assessment by 2.76% (CI, 1.95% to 3.57%), nephropathy screening by 1.08% (95% CI, 0.51% to 1.66%) and statin prescription by 1.08% (95% CI, 0.51% to 1.66%). Patients under FHOs had a lower estimated risk of mortality by 0.0124% (95% CI, 0.0123% to 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting enzyme inhibitors (or angiotensin II receptor blockers) and patients' risk of avoidable diabetes-related hospitalizations. CONCLUSIONS: Compared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care.

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We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.

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OBJECTIVE: The study examines the relationship between the primary care model that a physician belongs to and the efficiency of the primary care physician in Ontario, Canada. METHODS: Survey data were collected from 183 self-selected physicians and linked to administrative databases to capture the provision of services to the patients served for the 12 month period ending June 30, 2013, and the characteristics of the patients at the beginning of the study period. Two stochastic frontier regression models were used to estimate efficiency scores and parameters for two separate outputs: the number of distinct patients seen and the number of visits. RESULTS: Because of missing data, only 165 physicians were included in the analyses. The average efficiency was 0.72 for both outputs with scores varying from 4 % to 93 % for the visits and 5 % to 94 % for the number of patients seen. We observed that there were both very low and very high efficiency scores within each model. These variations were larger than variations in average scores across models.

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We develop a stylized principal-agent model with moral hazard and adverse selection to provide a unified framework for understanding some of the most salient features of the recent physician payment reform in Ontario and its impact on physician behavior. These features include the following: (i) physicians can choose a payment contract from a menu that includes an enhanced fee-for-service contract and a blended capitation contract; (ii) the capitation rate is higher, and the cost-reimbursement rate is lower in the blended capitation contract; (iii) physicians sort selectively into the contracts based on their preferences; and (iv) physicians in the blended capitation model provide fewer services than physicians in the enhanced fee-for-service model. Copyright © 2015 John Wiley & Sons, Ltd.

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We study the risk-selection and cost-shifting behavior of physicians in a unique capitation payment model in Ontario, using the incentive to enroll and care for complex and vulnerable patients as a case study. This incentive, which is incremental to the regular capitation payment, ceases after the first year of patient enrollment and may therefore impact on the physician's decision to continue to enroll the patient. Furthermore, because the enrolled patients in Ontario can seek care from any provider, the enrolling physician may shift some treatment costs to other providers. Using longitudinal administrative data and a control group of physicians in the fee-for-service model who were eligible for the same incentive, we find no evidence of either patient 'dumping' or cost shifting. These results highlight the need to re-examine the conventional wisdom about risk selection for physician payment models that significantly deviate from the stylized capitation model.

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PURPOSE: To examine treatment trends and costs associated with Dupuytren's disease (DD) in Canada. METHODS: Data regarding fasciectomies, fasciotomies and digit amputations performed for DD from 2005 to 2010 were extracted from the Canadian Institute for Health Information database. The data were analyzed according to year, sex and five-year age groups. The estimated annual physician reimbursement costs for DD in Ontario were calculated using Ontario Health Insurance Plan billing information and the 2010 Physician Schedule of Benefits. RESULTS: The number and rate of fasciectomies remained stable from 2005 to 2009 (mean of 4067 and 1.24 per 10,000, respectively), but increased in the 2009/2010 fiscal year (to 4458 and 1.32 per 10,000). The number of fasciotomies increased from 133 in 2005/2006 to 201 in 2008/2009, but dropped to 183 in 2009/2010. The mean number of amputations remained stable (12 procedures).The ratio of males to females undergoing fasciectomies remained stable (4:1). The highest rate of fasciectomies was performed for the age groups 65 to 69 years and 70 to 74 years. Estimated mean physician remuneration for DD in Ontario remained stable ($3.2 million per annum). DISCUSSION: The results regarding patient demographics are comparable with results from previous literature. There was a trend toward an increasing number of fasciectomies and fasciotomies annually, with fasciotomies increasing faster than fasciectomies, which is reflective of the aging population and the recent attention to fasciotomies in the literature. The present study was the first to investigate treatment trends and physician reimbursement costs for the management of DD in Canada.

OBJECTIF: Examiner les tendances thérapeutiques et les coûts associés à la maladie de Dupuytren (MD) au Canada. MÉTHODOLOGIE: Les chercheurs ont extrait des bases de données de l'Institut canadien d'information sur la santé les données relatives aux fasciectomies, aux fasciotomies et aux amputations de doigts effectuées en raison de la MD entre 2005 et 2010. Ils ont analysé les données selon l'âge, le sexe et les groupes d'âge par tranches de cinq ans. Ils ont calculé les coûts estimatifs annuels du remboursement des médecins attribuables à la MD en Ontario, au moyen de l'information de facturation tirée du Régime d'assurance-maladie de l'Ontario et du barème des prestations des médecins pour 2010. RÉSULTATS: Le nombre et le taux de fasciectomies sont demeurés stables de 2005 à 2009 (moyenne de 4 067 et de 1,24 sur 10 000, respectivement), mais ont augmenté pendant l'exercice 2009­2010 (à 4 458 et 1,32 sur 10 000). Le nombre de fasciotomies est passé de 133 à 2005­2006 à 201 en 2008­2009, mais a reculé à 183 en 2009­2010. Le nombre moyen d'amputations est demeuré stable (12 interventions). Le ratio d'hommes qui ont subi une fasciectomie par rapport aux femmes est également demeuré stable (4:1). Le plus fort taux de fasciectomies s'observait dans les groupes de 65 à 69 ans et de 70 à 74 ans. Enfin, la rémunération estimative moyenne des médecins pour soigner la MD en Ontario est demeurée stable (3,2 millions de dollars par année). EXPOSÉ: Les résultats relatifs à la démographie des patients sont comparables à ceux des publications antérieures. On a constaté une tendance vers une augmentation annuelle du nombre de fasciectomies et de fasciotomies. L'augmentation des fasciotomies était plus marquée que celle des fasciectomies, ce qui reflète le vieillissement de la population et l'intérêt récent pour les fasciotomies dans les publications. La présente étude était la première à examiner les tendances en matière de traitement et les coûts du remboursement des médecins pour la prise en charge de la MD au Canada.

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Pay for performance (P4P) incentives for physicians are generally designed as additional payments that can be paired with any existing payment mechanism such as a salary, fee-for-services and capitation. However, the link between the physician response to performance incentives and the existing payment mechanisms is still not well understood. In this article, we study this link using the recent primary care physician payment reform in Ontario as a natural experiment and the Diabetes Management Incentive as a case study. Using a comprehensive administrative data strategy and a difference-in-differences matching strategy, we find that physicians in a blended capitation model are more responsive to the Diabetes Management Incentive than physicians in an enhanced fee-for-service model. We show that this result implies that the optimal size of P4P incentives vary negatively with the degree of supply-side cost-sharing. These results have important implications for the design of P4P programs and the cost of their implementation.

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