Does an activity based remuneration system attract young doctors to general practice?

Birgit Abelsen,Jan Abel Olsen

doi:10.1186/1472-6963-12-68

Abstract

BackgroundThe use of increasingly complex payment schemes in primary care may represent a barrier to recruiting general practitioners (GP). The existing Norwegian remuneration system is fully activity based - 2/3 fee-for-service and 1/3 capitation. Given that the system has been designed and revised in close collaborations with the medical association, it is likely to correspond - at least to some degree - with the preferences of current GPs (men in majority). The objective of this paper was to study which preferences that young doctors (women in majority), who are the potential entrants to general practice have for activity based vs. salary based payment systems.MethodsIn November-December 2010 all last year medical students and all interns in Norway (n = 1.562) were invited to participate in an online survey. The respondents were asked their opinion on systems of remuneration for GPs; inclination to work as a GP; risk attitude; income preferences; work pace tolerance. The data was analysed using one-way ANOVA and multinomial logistic regression analysis.ResultsA total of 831 (53%) responded. Nearly half the sample (47%) did not consider the remuneration system to be important for their inclination to work as GP; 36% considered the current system to make general practice more attractive, while 17% considered it to make general practice less attractive. Those who are attracted by the existing system were men and those who think high income is important, while those who are deterred by the system are risk averse and less happy with a high work pace. On the question of preferred remuneration system, half the sample preferred a mix of salary and activity based remuneration (the median respondent would prefer a 50/50 mix). Only 20% preferred a fully activity based system like the existing one. A salary system was preferred by women, and those less concerned with high income, while a fully activity based system was preferred by men, and those happy with a high work pace.ConclusionsGiven a concern about low recruitment to general practice in Norway, and the fact that an increasing share of medical students is women, we were interested in the extent to which the current Norwegian remuneration system correspond with the preferences of potential GPs. This study suggests that an existing remuneration mechanism has a selection effect on who would like to become a GP. Those most attracted are income motivated men. Those deterred are risk averse, and less happy with a high work pace. More research is needed on the extent to which experienced GPs differ along the questions we asked potential GPs, as well as studying the relative importance of other attributes than payment schemes.

Highlights

The use of increasingly complex payment schemes in primary care may represent a barrier to recruiting general practitioners (GP)
The response rate differed across sub-groups: from 47% among hospital interns; 54% among last year medical students, and; 60% among GP interns
Given a concern about low recruitment to general practice in Norway, and the fact that an increasing share of medical students is women, we were interested in the extent to which the current Norwegian remuneration system correspond with the preferences of potential GPs

Summary

Introduction

The use of increasingly complex payment schemes in primary care may represent a barrier to recruiting general practitioners (GP). A public purchaser may pay a lump sum to cover some of the fixed costs of the practice depending on national cost variations, as well as bonuses if the GP achieves some pre-specified targets [2] Such complex payment mechanisms appear to be a common feature of many countries’ primary health care systems [3]. The FFS part is a mix of a fixed fee paid by patients, and variable fees paid by the federal government, depending on the duration of the consultation, on whether certain types of examinations and laboratory tests are initiated, and on whether or not the GP is a specialist in general medicine [4] These intricate activity based payment contracts stand in sharp contrast to the salary based payments of doctors in hospitals and other parts of the health sector

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