The impact of reimbursement systems on equity in access and quality of primary care: A systematic literature review.

Wenjing Tao,Bo Burström,Janne Agerholm

doi:10.1186/s12913-016-1805-8

Wenjing Tao, Bo Burström + Show 1 more

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https://doi.org/10.1186/s12913-016-1805-8

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Abstract

BackgroundReimbursement systems provide incentives to health care providers and may drive physician behaviour. This review assesses the impact of reimbursement system on socioeconomic and racial inequalities in access, utilization and quality of primary care.MethodsA systematic search was performed in Web of Science and PubMed for English language studies published between 1980 and 2013, supplemented by reference tracking. Articles were selected based on inclusion criteria, and data extraction and critical appraisal were performed by two authors independently. Data were synthesized in a narrative manner and categorized according to study outcome and reimbursement system.ResultsTwenty seven articles, mostly from the United States and United Kingdom, were included in the data synthesis. Reimbursement systems seem to have limited effect on socioeconomic and racial inequity in access, utilization and quality of primary care. Capitation might have a more beneficial impact on inequity in access to primary care and number of ambulatory care sensitive admissions than fee-for-service, but did worse in patient satisfaction. Pay-for-performance had little or no impact on socioeconomic and racial inequity in the management of diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, and preventive services.ConclusionWe found little scientific evidence supporting an association between reimbursement system and socioeconomic or racial inequity in access, utilization and quality of primary care. Overall, few studies addressed this research question, and heterogeneity in context and outcomes complicates comparisons across studies. Further empirical studies are warranted.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1805-8) contains supplementary material, which is available to authorized users.

Highlights

Reimbursement systems provide incentives to health care providers and may drive physician behaviour
Inequity refers to systematic differences that is created by unjust social processes and avoidable, and is frequently distinguished from inequality [21]
After full-text review and critical appraisal, the most common reasons for exclusion were 1) socioeconomic and racial/ethnic inequities were not addressed (n = 19); 2) the study lacked a comparison group for the reimbursement system (n = 12); 3) reimbursement system could not be identified (n = 10); and 4) the research question did not match the aim of the systematic review (n = 10)

Summary

Introduction

Reimbursement systems provide incentives to health care providers and may drive physician behaviour. This review assesses the impact of reimbursement system on socioeconomic and racial inequalities in access, utilization and quality of primary care. According to a study of 22 European countries, low socioeconomic status implied higher rates of death and poorer selfassessed health [2]. Finding healthcare providers willing to accept them [7], and low-income individuals with chronic conditions are less likely to receive standard of care [8]. Fewer Hispanics and African Americans have a regular primary care provider and they are more likely to visit the emergency room. In Sweden, high income individuals aged 65+ have significantly more doctor’s visits than low income individuals after adjustment for health status, and nonattendance in breast cancer screening is associated with disadvantaged socioeconomic position [11, 12]

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