Gosden T, Forland F, Kristiansen I S, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L
National Primary Care Research and Development Centre, 5th Floor Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
J Health Serv Res Policy. 2001 Jan;6(1):44-55. doi: 10.1258/1355819011927198.
To review the impact of payment systems on the behaviour of primary care physicians.
All randomised trials, controlled before and after studies, and interrupted time series studies that compared capitation, salary, fee-for-service or target payments (mixed or separately) that were identified by computerised searches of the literature. Methodological quality assessment and data extraction were undertaken independently by two reviewers using a data checklist. Study results were qualitatively analysed.
Six studies met the inclusion criteria. There was considerable variation in the quality of reporting, study setting and the range of outcomes measured. Fee-for-service resulted in a higher quantity of primary care services provided compared with capitation but the evidence of the impact on the quantity of secondary care services was mixed. Fee-for-service resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but lower patient satisfaction with access to a physician compared with salary payment. The evidence of the impact of target payment on immunisation rates was inconclusive.
There is some evidence to suggest that how a primary care physician is paid does affect his/her behaviour but the generalisability of these studies is unknown. Most policy changes in the area of payment systems are inadequately informed by research. Future changes to doctor payment systems need to be rigorously evaluated.
回顾支付系统对基层医疗医生行为的影响。
通过计算机检索文献，纳入所有比较按人头付费、薪资制、按服务收费或目标支付（混合或单独）的随机试验、前后对照研究以及中断时间序列研究。两名评审员使用数据清单独立进行方法学质量评估和数据提取。对研究结果进行定性分析。
六项研究符合纳入标准。报告质量、研究背景和所测量结果的范围存在很大差异。与按人头付费相比，按服务收费导致提供的基层医疗服务数量更多，但对二级医疗服务数量影响的证据不一。与薪资制相比，按服务收费导致患者就诊次数更多、护理连续性更好、对推荐就诊次数的依从性更高，但患者对看医生的满意度更低。目标支付对免疫接种率影响的证据尚无定论。
有证据表明基层医疗医生的支付方式确实会影响其行为，但这些研究的可推广性尚不清楚。支付系统领域的大多数政策变化缺乏充分的研究依据。未来医生支付系统的变革需要进行严格评估。
