Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
Department of Economics, University of Ottawa, Ottawa, ON, Canada.
Eur J Health Econ. 2024 Apr;25(3):363-377. doi: 10.1007/s10198-023-01591-w. Epub 2023 May 8.
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.
众所周知，医生的薪酬方式会影响向人群提供的医疗服务。按服务收费（FFS）通常会导致服务过度供应，而人头付费则会导致服务供应不足。然而，关于薪酬与急诊部（ED）就诊之间的联系，证据很少。我们使用在加拿大安大略省引入的两种流行的混合模型来填补这一空白：家庭健康小组（FHG），一种增强/混合 FFS 模型，和家庭健康组织（FHO），一种混合人头付费模型。我们比较了这两种模型的初级保健服务和急诊部 ED 就诊率。我们还评估了这些结果是否因常规和非工作时间以及患者发病状态而异。
在 2012 年 4 月至 2017 年 3 月期间，在 FHG 或 FHO 执业的医生及其登记的成年患者被纳入分析。使用协变量平衡倾向评分加权法消除可观察混杂因素的影响，并使用负二项式和线性回归模型评估 FHG 和 FHO 之间的初级保健服务、ED 就诊次数和初级保健服务的美元价值。就诊分为常规和非工作时间。患者分为三个发病状态组：非发病、单发病和多发病（两种或多种慢性疾病）。
共有 6184 名医生及其患者可用于分析。与 FHG 医生相比，FHO 医生每年为每位患者提供的初级保健服务减少了 14%（95% CI 13%，15%），非工作时间减少了 27%（95% CI 25%，29%）。登记到 FHO 医生的患者每年因不太紧急（95% CI 23%，31%）和更紧急（95% CI 7%，13%）的原因而进行的 ED 就诊次数分别增加了 27%和 10%，但非常紧急的 ED 就诊次数没有差异。常规和非工作时间就诊模式的差异相似。尽管 FHO 医生提供的服务较少，但 FHO 中的多发病患者进行的非常紧急和紧急 ED 就诊次数较少，而不太紧急的 ED 就诊次数则没有差异。
在安大略省混合人头付费模式下执业的初级保健医生提供的初级保健服务比在混合 FFS 模式下执业的医生要少。尽管登记到 FHO 医生的患者的 ED 就诊总次数较高，但 FHO 医生的多发病患者进行的紧急和非常紧急的 ED 就诊次数较少。
