Blended Capitation Model Research Articles

Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada.

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. 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). 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. 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.

Mental Health Services Provision in Primary Care and Emergency Department Settings: Analysis of Blended Fee-for-Service and Blended Capitation Models in Ontario, Canada.

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.

Physician remuneration schemes, psychiatric hospitalizations and follow-up care: Evidence from blended fee-for-service and capitation models.

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.

Quality of Diabetes Care in Blended Fee-for-Service and Blended Capitation Payment Systems

ObjectivesIn 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. MethodsUsing 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. ResultsWe 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. ConclusionsCompared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care.

Team-based primary care practice and physician's services: Evidence from Family Health Teams in Ontario, Canada.

Team-based primary care offers a wide range of health services to patients by using interdisciplinary health care providers committed to delivering comprehensive, coordinated and high-quality care through team collaboration. Ontario's Family Health Team (FHT), the largest team-based practice model in Canada, was introduced to improve access to and effectiveness of primary health care services, and was available primarily for physicians paid under blended capitation models (Family Health Organizations and Family Health Networks). Using health administrative data on physicians practicing under blended capitation models in Ontario between 2006 and 2015, we study the impact of switching from non-FHT to FHTs on the production of capitated comprehensive care services, after-hours services, non-incentivized services, and services provided to non-enrolled patients by family physicians. We find that when in FHTs, physicians increase the production of total services and non-incentivized services by 26% and 5% per annum and reduce capitated comprehensive care services by 3.2% per annum. When in FHTs, physicians also see and enroll more patients relative to those practicing in non-FHTs. We find evidence of improved access to physician's services under team-based primary care, but switching to FHTs has no effect on the production of after-hours services and services provided to non-enrolled patients.

Stirring the pot: Switching from blended fee‐for‐service to blended capitation models of physician remuneration

In Canada's most populous province, Ontario, family physicians may choose between the blended fee-for-service (Family Health Group [FHG]) and blended capitation (Family Health Organization [FHO] payment models). Both models incentivize physicians to provide after-hours (AH) and comprehensive care, but FHO physicians receive a capitation payment per enrolled patient adjusted for age and sex, plus a reduced fee-for-service while FHG physicians are paid by fee-for-service. We develop a theoretical model of physician labor supply with multitasking to predict their behavior under FHG and FHO, and estimable equations are derived to test the predictions empirically. Using health administrative data from 2006 to 2014 and a two-stage estimation strategy, we study the impact of switching from FHG to FHO on the production of a capitated basket of services, after-hours services and nonincentivized services. Our results reveal that switching from the FHG to FHO reduces the production of capitated services to enrolled patients and services to nonenrolled patients by 15% and 5% per annum and increases the production of after-hours and nonincentivized services by 8% and 15% per annum.

Physician group, physician and patient characteristics associated with joining interprofessional team-based primary care in Ontario, Canada

PurposeCountries throughout the world have been experimenting with new models to deliver primary care. We investigated physician group, physician and patient characteristics associated with voluntarily joining team-based primary care in Ontario. MethodsThis cross-sectional study linked provincial administrative datasets to form data extractions of interest over time with the earliest in 2005 and the latest in 2013. We generated mixed, generalized chi-square and multivariate models to compare the characteristics of teams and non-teams, both with blended capitation reimbursement, and to examine characteristics associated with joining a team. ResultsHaving more physicians per group, being a female physician, having more years under the blended capitation model, having more patients in the lowest income quintile and more patients residing in rural areas were positively associated with joining a team. Being a female physician and having more patients who are males, recent immigrants and living in rural areas were positively associated with the outcome of joining teams in the late phase. ConclusionsOur study findings indicate that there are differences in physician group, physician and patient characteristics when comparing teams to non-teams. Other jurisdictions aiming to expand physician participation in interprofessional care should note those factors. Researchers looking to understand the impact of team-based care should be aware of pre-existing differences and the need to address selection bias associated with participation in team-based care.

Family physician remuneration schemes and specialist referrals: Quasi-experimental evidence from Ontario, Canada.

Understanding how family physicians respond to incentives from remuneration schemes is a central theme in the literature. One understudied aspect is referrals to specialists. Although the theoretical literature has suggested that capitation increases referrals to specialists, the empirical evidence is mixed. We push forward the empirical research on this question by studying family physicians who switched from blended fee-for-service to blended capitation in Ontario, Canada. Using several health administrative databases from 2005 to 2013, we rely on inverse probability weighting with fixed-effects regression models to account for observed and unobserved differences between the switchers and nonswitchers. Switching from blended fee-for-service to blended capitation increases referrals to specialists by about 5% to 7% per annum. The cost of specialist referrals is about 7 to 9% higher in the blended capitation model relative to the blended fee-for-service. These results are generally robust to a variety of alternative model specifications and matching techniques, suggesting that they are driven partly by the incentive effect of remuneration. Policy makers need to consider the benefits of capitation payment scheme against the unintended consequences of higher referrals to specialists.

Costs of health care across primary care models in Ontario

BackgroundThe purpose of this study is to analyze the relationship between newly introduced primary care models in Ontario, Canada, and patients’ primary care and total health care costs. A specific focus is on the payment mechanisms for primary care physicians, i.e. fee-for-service (FFS), enhanced-FFS, and blended capitation, and whether providers practiced as part of a multidisciplinary team.MethodsUtilization data for a one year period was measured using administrative databases for a 10% sample selected at random from the Ontario adult population. Primary care and total health care costs were calculated at the individual level and included costs from physician services, hospital visits and admissions, long term care, drugs, home care, lab tests, and visits to non-medical health care providers. Generalized linear model regressions were conducted to assess the differences in costs between primary care models.ResultsPatients not enrolled with a primary care physicians were younger, more likely to be males and of lower socio-economic status. Patients in blended capitation models were healthier and wealthier than FFS and enhanced-FFS patients. Primary care and total health care costs were significantly different across Ontario primary care models. Using the traditional FFS as the reference, we found that patients in the enhanced-FFS models had the lowest total health care costs, and also the lowest primary care costs. Patients in the blended capitation models had higher primary care costs but lower total health care costs. Patients that were in multidisciplinary teams (FHT), where physicians are also paid on a blended capitation basis, had higher total health care costs than non-FHT patients but still lower than the FFS reference group. Primary care and total health care costs increased with patients’ age, morbidity, and lower income quintile across all primary care payment types.ConclusionsThe new primary care models were associated with lower total health care costs for patients compared to the traditional FFS model, despite higher primary care costs in some models.

The impact of primary care reform on health system performance in Canada: a systematic review.

BackgroundWe aimed to synthesize the evidence of a causal effect and draw inferences about whether Canadian primary care reforms improved health system performance based on measures of health service utilization, processes of care, and physician productivity.MethodsWe searched the Embase, PubMed and Web of Science databases for records from 2000 to September 2015. We based our risk of bias assessment on the Grading of Recommendations Assessment, Development and Evaluation guidelines. Full-text studies were synthesized and organized according to the three outcome categories: health service utilization, processes of care, and physician costs and productivity.ResultsWe found moderate quality evidence that team-based models of care led to reductions in emergency department use, but the evidence was mixed for hospital admissions. We also found low quality evidence that team-based models, blended capitation models and pay-for-performance incentives led to small and sometimes non-significant improvements in processes of care. Studies examining new payment models on physician costs and productivity were of high methodological quality and provided a coherent body of evidence assessing enhanced fee-for-service and blended capitation payment models.ConclusionA small number of studies suggested that team-based models contributed to reductions in emergency department use in Quebec and Alberta. Regarding processes of diabetes care, studies found higher rates of testing for blood glucose levels, retinopathy and cholesterol in Alberta’s team-based primary care model and in practices eligible for pay-for-performance incentives in Ontario. However pay-for-performance in Ontario was found to have null to moderate effects on other prevention and screening activities. Although blended capitation payment in Ontario contributed to decreases in the number of services delivered and patients seen per day, the number of enrolled patients and number of days worked in a year was similar to that of enhanced fee-for-service practices.

Physician Payment Contracts in the Presence of Moral Hazard and Adverse Selection: The Theory and Its Application in Ontario.

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.

Cardiology and accountable care.

Cardiovascular disease is the leading cause of death in the United States and accounts for ≈17% of national health expenditures and 30% of Medicare spending.1 Among physician groups and professional societies, cardiologists have been among those leading efforts to create evidence-based guidelines and to measure quality of care. In the post-health reform era, national efforts have expanded beyond quality to include innovative delivery models, such as the patient-centered medical home (PCMH), the medical neighborhood, and accountable care organizations (ACOs). This next generation of care models and the payment strategies that support them incentivize efficiency, patient-centeredness, and care coordination with an emphasis on primary care. We propose strategies for cardiologists to create collaborative opportunities within these new models drawing from examples from around the country within the context of a framework developed by the American College of Physicians.2 Pursuing these approaches or others along similar lines will enable cardiologists to lead and to be active participants in shaping delivery system transformation. These innovative delivery models share similar features. The PCMH is a model of care that emphasizes additional support for primary care providers within a patient-centered team, whereas a medical neighborhood represents a broader collection of primary care doctors, specialists such as cardiologists, hospitals, and other stakeholders within a region that seek to reduce fragmented care by sharing accountability.2,3 The ACO, too, is a broader care delivery arrangement, but in this case, groups of providers are accountable for the quality, cost, and overall care of a particular population, typically defined by the payer. In the Medicare Shared Savings Program (MSSP), an ACO model for Medicare beneficiaries, the ACO can capture shared savings if it reduces its healthcare expenditures and meets certain quality performance standards, nearly half of which are related to cardiovascular disease.4 Within the …

Quality of asthma care under different primary care models in Canada: a population-based study.

BackgroundPrevious research has shown variations in quality of care and patient outcomes under different primary care models. The objective of this study was to use previously validated, evidence-based performance indicators to measure quality of asthma care over time and to compare quality of care between different primary care models.MethodsData were obtained for years 2006 to 2010 from the Ontario Asthma Surveillance Information System, which uses health administrative databases to track individuals with asthma living in the province of Ontario, Canada. Individuals with asthma (n=1,813,922) were divided into groups based on the practice model of their primary care provider (i.e., fee-for-service, blended fee-for-service, blended capitation). Quality of asthma care was measured using six validated, evidence-based asthma care performance indicators.ResultsAll of the asthma performance indicators improved over time within each of the primary care models. Compared to the traditional fee-for-service model, the blended fee-for-service and blended capitation models had higher use of spirometry for asthma diagnosis and monitoring, higher rates of inhaled corticosteroid prescription, and lower outpatient claims. Emergency department visits were lowest in the blended fee-for-service group.ConclusionsQuality of asthma care improved over time within each of the primary care models. However, the amount by which they improved differed between the models. The newer primary care models (i.e., blended fee-for-service, blended capitation) appear to provide better quality of asthma care compared to the traditional fee-for-service model.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0232-y) contains supplementary material, which is available to authorized users.

Physician Payment Contracts in the Presence of Moral Hazard and Adverse Selection: The Theory and its Application to Ontario

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: (1) physicians can choose a payment contract from a menu that includes an enhanced fee-for-service contract and a blended capitation contract; (2) the capitation rate is higher and the cost-reimbursement rate is lower in the blended capitation contract; (3) physicians sort selectively into the contracts based on their preferences; and (4) physicians in the blended capitation model provide fewer services than physicians in the enhanced fee-for-service model.

The relationship between primary care models and processes of diabetes care in Ontario.

This study examined the association between Ontario's differing primary care models and receipt of recommended testing for people with diabetes. We analyzed available administrative data for 757 928 people with diabetes aged 40 years and older. We assigned them to a primary care physician and assessed whether they had received 3 key monitoring tests between 2006 and 2008. We used multivariable generalized estimating equation models to test the associations among various primary care models and receipt of recommended testing. Ontarians with diabetes who were enrolled in a non-team blended capitation model (OR 1.18, 95% CI 1.09 to 1.27) and those enrolled in a team-based blended capitation model (OR 1.20, 95% CI 1.13 to 1.28) were more likely than those enrolled in a blended fee-for-service model to receive the optimal number of 3 recommended monitoring tests. Patients who were not enrolled in any model and who were assigned to a traditional fee-for-service physician were least likely to receive optimal monitoring compared to those enrolled in a blended fee-for-service model (OR 0.60, 95% CI 0.57 to 0.62). The biggest gap in diabetes care was for patients not enrolled in any primary care model. Research and policy work is needed to understand and reduce this care gap, especially which provider and patient-level factors are involved. Options may include intensive outreach to patients, knowledge translation to physicians, encouraging enrollment and efforts to remove barriers to care.

LINK BETWEEN PAY FOR PERFORMANCE INCENTIVES AND PHYSICIAN PAYMENT MECHANISMS: EVIDENCE FROM THE DIABETES MANAGEMENT INCENTIVE IN ONTARIO

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.

Link between Pay for Performance Incentives and Physician Payment Mechanisms: Evidence from the Diabetes Management Incentive in Ontario

Pay for performance (P4P) incentives for physicians are generally designed as additional payments that can be paired with any existing payment mechanism such as salary, fee-for-service, and capitation. However, the link between the physician response to performance incentives and the existing payment mechanisms is still not well understood. In this paper, we study this link using the recent primary care reform in Ontario as a natural experiment and the Diabetes Management Incentive (DMI) as a case study. Using a comprehensive administrative data and a difference-indifferences matching strategy, we find that physicians in a blended capitation model are more responsive to the DMI than physicians in an enhanced fee-for-service model. We show that for a given payment mechanism this result implies that the optimal size of P4P incentives varies 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.

Quality assurance of sphincterotomy: A prospective single-centre survey

In Ontario, Canada, the patient-centred medical home is a model of primary care delivery that includes 3 model types of interest for this study: enhanced fee-for-service, blended capitation, and team-based blended capitation. All 3 models involve rostering of patients and have similar practice requirements but differ in method of physician reimbursement, with the blended capitation models incorporating adjustments for age and sex, but not case mix, of rostered patients. We evaluated the extent to which persons with mental illness were included in physicians' total practices (as rostered and non-rostered patients) and were included on physicians' rosters across types of medical homes in Ontario. Using population-based administrative data, we considered 3 groups of patients: those with psychotic or bipolar diagnoses, those with other mental health diagnoses, and those with no mental health diagnoses. We modelled the prevalence of mental health diagnoses and the proportion of patients with such diagnoses who were rostered across the 3 medical home model types, controlling for demographic characteristics and case mix. Compared with enhanced fee-for-service practices, and relative to patients without mental illness, the proportions of patients with psychosis or bipolar disorders were not different in blended capitation and team-based blended capitation practices (rate ratio [RR] 0.91, 95% confidence interval [CI] 0.82-1.01; RR 1.06, 95% CI 0.96-1.17, respectively). However, there were fewer patients with other mental illnesses (RR 0.94, 95% CI 0.90-0.99; RR 0.89, 95% CI 0.85-0.94, respectively). Compared with expected proportions, practices based on both capitation models were significantly less likely than enhanced fee-for-service practices to roster patients with psychosis or bipolar disorders (for blended capitation, RR 0.92, 95% CI 0.90-0.93; for team-based capitation, RR 0.92, 95% CI 0.88-0.93) and also patients with other mental illnesses (for blended capitation, RR 0.94, 95% CI 0.92-0.95; for team-based capitation, RR 0.93, 95% CI 0.92-0.94). Persons with mental illness were under-represented in the rosters of Ontario's capitation-based medical homes. These findings suggest a need to direct attention to the incentive structure for including patients with mental illness.

Comparison of primary care models in the prevention of cardiovascular disease - a cross sectional study

BackgroundPrimary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models.MethodsThis is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models.ResultsThe percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management.ConclusionsThis study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice.Trial RegistrationClinicalTrials.gov: NCT00574808

Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation

Primary care reform in Ontario, Canada, included the initiation of a blended capitation model in 2001-2002 and an enhanced fee-for-service model in 2003. Both models involve patient rostering, incentives for preventive care and requirements for after-hours care. We evaluated practice characteristics and patterns of care under both models. Using administrative data, we identified physicians belonging to either the capitation or the enhanced fee-for-service group throughout the period from Sept. 1, 2005, to Aug. 31, 2006, and their enrolled patients. Practices were stratified by location (urban v. rural). We compared the groups in terms of practice characteristics and patterns of care, including comprehensiveness of care, continuity of care, after-hours care, visits to the emergency department and uptake of new patients. Patients in the capitation and enhanced fee-for-service practices had similar demographic characteristics. Patients in capitation practices had lower morbidity and comorbidity indices. Comprehensiveness and continuity of care were similar between the 2 groups. Compared with patients in enhanced fee-for-service practices, those in capitation practices had less after-hours care (adjusted rate ratio [RR] 0.68, 95% confidence interval [CI] 0.61-0.75) and more visits to emergency departments (adjusted RR 1.20, 95% CI 1.15-1.25). Overall, physicians in the capitation group enrolled fewer new patients than did physicians in the enhanced fee-for-service group (37.0 v. 52.0 per physician); the same was true of new graduates (60.3 v. 72.1 per physician). Physicians enrolled in the capitation model had different practice characteristics than those in the enhanced fee-for-service model. These characteristics appeared to be pre-existing and not due to enrolment in a new model. Although the capitation model provides an alternative to fee-for-service practice, its characteristics should be the focus of future policy development and research.