Abstract
BackgroundPrimary care has been reformed in recent years in Ontario, Canada, with a move away from traditional fee-for-service to enhanced fee-for-service and capitation-based models. It is unclear how new models have affected disparities in cancer screening. We evaluated whether Ontario’s enhanced fee-for-service model was associated with a change in the gaps in cancer screening for people living with low income and people who are foreign-born.MethodsWe conducted a population-based longitudinal analysis from 2002 to 2013 of Ontario family physicians who transitioned from traditional fee-for-service to enhanced fee-for-service. The binary outcomes of interest were adherence to cervical, breast and colorectal cancer screening recommendations. Outcomes were analyzed using mixed-effects logistic regression. Analyses produced annual odds ratios comparing the odds of being up-to-date for screening among patients in enhanced fee-for-service versus patients in traditional fee-for-service for each social stratum separately. We calculated the ratios of stratum-specific odds ratios to assess whether the transition from traditional to enhanced fee-for-service was associated with a change in screening gaps between immigrants and long-term residents, and between people in the lowest and highest neighbourhood income quintiles.ResultsThroughout the study period, cancer screening was consistently lower among immigrants and among people in the lowest income quintile. Transition to enhanced fee-for-service was generally associated with increased screening uptake for all, however for most years, ratios of ratios were significantly less than 1 for all three cancer screening types, indicating that there was a widening of the screening gap between immigrants and long-term residents and between people living in the lowest vs. highest income quintile associated with transitions.ConclusionThe transition to enhanced fee-for-service in Ontario was generally associated with a widening of screening inequities for foreign-born and low-income patients.
Highlights
Primary care has been reformed in recent years in Ontario, Canada, with a move away from traditional fee-for-service to enhanced fee-for-service and capitation-based models
During the study period, 7336 family physicians transitioned from the traditional FFS primary care model to a Patient enrolment model (PEM)
Ratios of odds ratios are presented, with Q5 and traditional fee-for-service serving as referent groups after transition, screening inequities were worse for patients of these physicians after adjusting for certain patient and physician characteristics
Summary
Primary care has been reformed in recent years in Ontario, Canada, with a move away from traditional fee-for-service to enhanced fee-for-service and capitation-based models It is unclear how new models have affected disparities in cancer screening. Practices could transition from traditional fee-for-service to capitation-based payment models, wherein the majority of physician remuneration is based on the number and profile of patients under their care, or maintain their fee-for-service (FFS) payment structure but transition to an enhanced model of care, often referred to as enhanced fee-for-service (Table 1) Key elements of these new models were formalized patient enrolment ( their name attribution “Patient Enrolment Model” or PEM) and financial incentives and bonuses, including for screening for cervical, breast and colorectal cancer for enrolled patients [29, 31, 32]. It is unclear whether and how the new PEMs models affected existing gaps in care across social strata
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