Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
JAMA Netw Open. 2019 Nov 1;2(11):e1914861. doi: 10.1001/jamanetworkopen.2019.14861.
Specialist physicians are key members of chronic care management teams; to date, however, little is known about the association between specialist payment models and outcomes for patients with chronic diseases.
To examine the association of payment model with visit frequency, quality of care, and costs for patients with chronic diseases seen by specialists.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study using propensity-score matching in patients seen by a specialist physician was conducted between April 1, 2011, and September 31, 2014. The study was completed on March 31, 2015, and data analysis was conducted from June 2017 to February 2018 and finalized in August 2019. In a population-based design, 109 839 adults with diabetes or chronic kidney disease newly referred to specialists were included. Because patients seen by independent salary-based and fee-for-service (FFS) specialists were significantly different in observed baseline characteristics, patients were matched 1:1 on demographic, illness, and physician characteristics.
Specialist physician payment model (salary-based or FFS).
Follow-up outpatient visits, guideline-recommended care delivery, adverse events, and costs.
A total of 90 605 patients received care from FFS physicians and 19 234 received care from salary-based physicians. Before matching, the patients seen by salary-based physicians had more advanced chronic kidney disease (2630 of 14 414 [18.2%] vs 6627 of 54 489 [12.2%]), and a higher proportion had 5 or more comorbidities (5989 of 19 234 [31.3%] vs 23 326 of 90 605 [25.7%]). Propensity-score matching resulted in a cohort of 31 898 patients (15 949 FFS, 15 949 salary-based) seeing 489 specialists. In the matched cohort, patients were similar (mean [SD] age, 61.3 [18.2] years; 17 632 women [55.3%]; 29 251 residing in urban settings [91.7%]). Patients seen by salary-based specialists had a higher follow-up visit rate compared with those seen by FFS specialists (1.74 visits; 95% CI, 1.58-1.92 visits vs 1.54 visits; 95% CI, 1.41-1.68 visits), but the difference was not significant (rate ratio, 1.13; 95% CI, 0.99-1.28; P = .06). There was no statistical difference in guideline-recommended care delivery, hospital or emergency department visits for ambulatory care-sensitive conditions, or costs between patients seeing FFS and salary-based specialists. The median association of physician clustering with health care use and quality outcomes was consistently greater than the association with the physician payment, suggesting variation between physicians (eg, median rate ratio for follow-up outpatient visit rate was 1.74, which is greater than the rate ratio of 1.13).
Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; however, there is variation in outcomes between physicians. This finding suggests the need to consider other strategies to reduce physician variation to improve the value of care and outcomes for people with chronic diseases.
专科医生是慢性病管理团队的重要成员；然而，迄今为止，人们对慢性病患者的专科医生支付模式与结果之间的关系知之甚少。
研究支付模式与慢性病专科医生就诊患者的就诊频率、护理质量和成本之间的关系。
设计、设置和参与者：在 2011 年 4 月 1 日至 2014 年 9 月 31 日期间，采用倾向评分匹配对专科医生就诊的患者进行了回顾性队列研究。研究于 2015 年 3 月 31 日完成，数据分析于 2017 年 6 月至 2018 年 2 月进行，并于 2019 年 8 月最终确定。在基于人群的设计中，纳入了 109839 名新转诊至专科医生的患有糖尿病或慢性肾脏病的成年人。由于独立薪酬制和按服务收费（FFS）的专科医生在观察到的基线特征上存在显著差异，因此患者按照人口统计学、疾病和医生特征进行 1:1 匹配。
专科医生支付模式（薪酬制或 FFS）。
随访门诊就诊、指南推荐的护理提供、不良事件和成本。
共有 90605 名患者接受了 FFS 医生的治疗，19234 名患者接受了薪酬制医生的治疗。在匹配之前，薪酬制医生就诊的患者慢性肾脏病更为严重（14414 例中有 2630 例[18.2%] vs 54489 例中有 6627 例[12.2%]），并且有更多的患者存在 5 种或更多合并症（19234 例中有 5989 例[31.3%] vs 90605 例中有 23326 例[25.7%]）。倾向评分匹配产生了一个由 31898 名患者（15949 名 FFS，15949 名薪酬制）组成的队列，他们共接受了 489 名专科医生的治疗。在匹配队列中，患者相似（平均[标准差]年龄，61.3[18.2]岁；17632 名女性[55.3%]；29251 名居住在城市地区[91.7%]）。薪酬制专科医生就诊的患者就诊次数多于 FFS 专科医生就诊的患者（1.74 次就诊；95%CI，1.58-1.92 次就诊 vs 1.54 次就诊；95%CI，1.41-1.68 次就诊），但差异无统计学意义（就诊率比，1.13；95%CI，0.99-1.28；P=0.06）。FFS 和薪酬制专科医生就诊的患者在指南推荐的护理提供、因急性病而到门诊就诊、以及医疗费用方面没有统计学差异。医生聚类与医疗保健使用和质量结果之间的关联中位数始终大于与医生支付之间的关联，这表明医生之间存在差异（例如，门诊就诊率的中位数就诊率比为 1.74，大于 1.13 的就诊率比）。
专科医生的支付方式似乎与慢性病门诊患者的就诊次数、质量和成本没有关联；然而，医生之间存在结果差异。这一发现表明，有必要考虑其他策略来减少医生的差异，以提高慢性病患者的护理价值和结果。
