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

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Abstract

Introduction

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.

Methods

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).

Results

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.

Conclusion

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.

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Data availability

The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The underlying statistical analysis plan are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

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Acknowledgements

We thank two anonymous reviewers of this journal for their thoughtful suggestions and comments for improvement. Funding for this research by the Canadian Institutes of Health Research (CIHR) operating grant (MOP–130354), Health Services Research Priority Announcement grant (PJI-184005) and Early Researcher Award by the Ontario Ministry of Research and Innovation is gratefully acknowledged. Michael Hong would like to thank funding from the University of Western Ontario (Western Graduate Research Scholarship), CIHR Graduate Scholarship and Ontario Graduate Scholarship. We also thank Dr. Nibene Somé, former ICES Analyst for the cutting the data for this study. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). This study was completed at the ICES Western site, where core funding is provided by the Academic Medical Organization of Southwestern Ontario (AMOSO), the Schulich School of Medicine and Dentistry (SSMD), Western University, and the Lawson Health Research Institute (LHRI). Parts of this material and data are based on information from the MOHLTC and the Canadian Institute of Health Information (CIHI). Opinions, results, and conclusions are those of the authors and independent from the funding sources. No endorsements by ICES, UWO, MAOSO, SSMD, LHRI, CIHI, or the MOHLTC is intended or should be inferred.

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Authors and Affiliations

  1. Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

    Michael Hong, Gregory S. Zaric, Amardeep Thind & Sisira Sarma

  2. Department of Economics, University of Ottawa, Ottawa, ON, Canada

    Rose Anne Devlin

  3. Ivey Business School, Western University, London, ON, Canada

    Gregory S. Zaric

  4. Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

    Amardeep Thind

  5. Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

    Amardeep Thind

  6. Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada

    Sisira Sarma

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  1. Michael Hong
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Correspondence to Sisira Sarma.

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Hong, M., Devlin, R.A., Zaric, G.S. et al. Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada. Eur J Health Econ 25, 363–377 (2024). https://doi.org/10.1007/s10198-023-01591-w

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  • DOI: https://doi.org/10.1007/s10198-023-01591-w

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