Krasnik A, Groenewegen P P, Pedersen P A, von Scholten P, Mooney G, Gottschau A, Flierman H A, Damsgaard M T
Institute of Social Medicine, University of Copenhagen, Panum Institute, Denmark.
BMJ. 1990 Jun 30;300(6741):1698-701. doi: 10.1136/bmj.300.6741.1698.
To investigate the effects on general practitioners' activities of a change in their remuneration from a capitation based system to a mixed fee per item and capitation based system.
Follow up study with data collected from contact sheets completed by general practitioners in one period before (March 1987) a change in their remuneration system and two periods after (March 1988, November 1988), with a control group of general practitioners with a mixed fee per item and capitation based system throughout.
General practices in Copenhagen city (index group) and Copenhagen county (control group).
265 General practitioners in Copenhagen city, of whom 100 were selected randomly from the 130 who agreed to participate (10 exclusions) and 326 general practitioners in Copenhagen county.
Number of consultations (face to face and by telephone) and renewals of prescriptions, diagnostic and curative services, and specialist and hospital referrals per 1000 enlisted patients in one week.
Of the 75 general practitioners who completed all three sheets, four were excluded for incomplete data. Total contact rates per 1000 patients listed rose significantly compared with the rates before the change index in the city (100.0 before the change v 111.7 (95% confidence interval 106.4 to 117.4 after the change) and over the same time in the control group (100.0 v 106.0), but within a year these rates fell (to 104.2(99.1 to 109.6) and 104.0 respectively). There was an increase in consultations by telephone initially but not thereafter. Rates of examinations and treatments that attracted specific additional remuneration after the change rose significantly compared with those before (diagnostic services, 138.1 (118.7 to 160.5) and 159.5 (137.8 to 184.7) and curative services 194.6 (152.2 to 248.9) and 194.8(152.3 to 249.2) for second and third data collections respectively) and with the control group (diagnostic services 105.3, 107.6 and curative services 106.0, 115.0) whereas referral rates to secondary care fell (specialist referrals 90.1 (80.7 to 100.6) and 77.0 (68.6 to 86.4) and hospital referrals 87.4 (71.1 to 107.5) and 68.4 (54.7 to 85.4] in doctors in the city.
Introducing a partial fee for service system seemed to stimulate the provision of services by general practitioners, resulting in reduced referral rates. The concept of a "target income" which doctors aim at, rather than maximising their income seemed to play a part in adjustment to changing the system of remuneration.
探讨从人头费支付系统转变为按项目收费与人头费相结合的支付系统对全科医生工作的影响。
随访研究，数据收集自全科医生在薪酬系统改变前一个时期（1987年3月）以及改变后的两个时期（1988年3月、1988年11月）填写的联系表，对照组为自始至终采用按项目收费与人头费相结合支付系统的全科医生。
哥本哈根市（索引组）和哥本哈根郡（对照组）的全科医疗诊所。
哥本哈根市的265名全科医生，其中100名从同意参与的130名医生中随机选取（排除10名），以及哥本哈根郡的326名全科医生。
每1000名登记患者在一周内的会诊次数（面对面和电话会诊）、处方续签次数、诊断和治疗服务次数以及专科和医院转诊次数。
在完成所有三张表格的75名全科医生中，4名因数据不完整被排除。与城市索引组改变前相比（改变前为100.0，改变后为111.7（95%置信区间为106.4至117.4））以及同期对照组（100.0对106.0）相比，每1000名列出患者的总接触率显著上升，但在一年内这些比率下降（分别降至104.2（99.1至109.6）和104.0）。最初电话会诊次数增加，但之后没有。改变后吸引特定额外报酬的检查和治疗比率与之前相比显著上升（诊断服务，第二次和第三次数据收集分别为138.1（118.7至160.）和159.5（137.8至184.7），治疗服务为194.6（152.2至248.9）和194.8（152.3至249.2）），与对照组相比（诊断服务为105.3、107.6，治疗服务为106.0、115.0），而二级医疗转诊率下降（城市医生的专科转诊率为90.1（80.7至100.6）和77.0（68.6至86.4），医院转诊率为87.4（71.1至107.5）和68.4（54.7至85.4））。
引入部分服务收费系统似乎刺激了全科医生提供服务，导致转诊率降低。医生所追求的“目标收入”概念，而非收入最大化，似乎在薪酬系统变化的调整中起到了作用。
