Primary care payment models and avoidable hospitalizations in Ontario, Canada: A multivalued treatment effects analysis.

Improving access to primary care physicians' services may help reduce hospitalizations due to Ambulatory Care Sensitive Conditions (ACSCs). Ontario, Canada's most populous province, introduced blended payment models for primary care physicians in the early- to mid-2000s to increase access to primary care, preventive care, and better chronic disease management. We study the impact of payment models on avoidable hospitalizations due to two incentivized ACSCs (diabetes and congestive heart failure) and two non-incentivized ACSCs (angina and asthma). The data for our study came from health administrative data on practicing primary care physicians in Ontario between 2006 and 2015. We employ a two-stage estimation strategy on a balanced panel of 3710 primary care physicians (1158 blended-fee-for-service (FFS), 1388 blended-capitation models, and 1164 interprofessional team-based practices). First, we account for the differences in physician practices using a generalized propensity score based on a multinomial logit regression model, corresponding to three primary care payment models. Second, we use fractional regression models to estimate the average treatment effects on the treated outcome (i.e., avoidable hospitalizations). The capitation-based model sometimes increases avoidable hospitalizations due to angina (by 7 per 100,000 patients) and congestive heart failure (40 per 100,000) relative to the blended-FFS-based model. Switching capitation physicians into interprofessional teams mitigates this effect, reducing avoidable hospitalizations from congestive heart failure by 30 per 100,000 patients and suggesting better access to primary care and chronic disease management in team-based practices.

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

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.

Quality of Diabetes Care in Blended Fee-for-Service and Blended Capitation Payment Systems.

OBJECTIVES: In the middle to late 2000s, many family physicians switched from a Family Health Group (FHG; a blended fee-for-service model) to a Family Health Organization (FHO; a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model. METHODS: Using longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on 8 quality indicators related to diabetes care. Because FHO physicians are likely to be systematically different from FHGs, we employed propensity-score-based inverse probability-weighted fixed-effects regression models. All analyses were conducted at the physician level. RESULTS: We found that FHO physicians were more likely to provide glycated hemoglobin testing by 2.75% (95% confidence interval [CI], 1.89% to 3.60%), lipid assessment by 2.76% (CI, 1.95% to 3.57%), nephropathy screening by 1.08% (95% CI, 0.51% to 1.66%) and statin prescription by 1.08% (95% CI, 0.51% to 1.66%). Patients under FHOs had a lower estimated risk of mortality by 0.0124% (95% CI, 0.0123% to 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting enzyme inhibitors (or angiotensin II receptor blockers) and patients' risk of avoidable diabetes-related hospitalizations. CONCLUSIONS: Compared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care.

Physician remuneration schemes, psychiatric hospitalizations and follow-up care: Evidence from blended fee-for-service and capitation models.

Psychiatric hospitalizations could be reduced if mental illnesses were detected and treated earlier in the primary care setting, leading to the World Health Organization recommendation that mental health services be integrated into primary care. The mental health services provided in primary care settings may vary based on how physicians are incentivized. Little is known about the link between physician remuneration and psychiatric hospitalizations. We contribute to this literature by studying the relationship between physician remuneration and psychiatric hospitalizations in Canada's most populous province, Ontario. Specifically, we study family physicians (FPs) who switched from blended fee-for-service (FFS) to blended capitation remuneration model, relative to those who remained in the blended FFS model, on psychiatric hospitalizations. Outcomes included psychiatric hospitalizations by enrolled patients and the proportion of hospitalized patients who had a follow-up visit with the FP within 14 days of discharge. We used longitudinal health administrative data from a cohort of practicing physicians from 2006 through 2016. Because physicians practicing in these two models are likely to be different, we employed inverse probability weighting based on estimated propensity scores to ensure that switchers and non-switchers were comparable at the baseline. Using inverse probability weighted fixed-effects regressions controlling for relevant confounders, we found that switching from blended FFS to blended capitation was associated with a 6.2% decrease in the number of psychiatric hospitalizations and a 4.7% decrease in the number of patients with a psychiatric hospitalization. No significant effect of remuneration on follow-up visits within 14 days of discharge was observed. Our results suggest that the blended capitation model is associated with fewer psychiatric hospitalizations relative to blended FFS.

Stirring the pot: Switching from blended fee-for-service to blended capitation models of physician remuneration.

In Canada's most populous province, Ontario, family physicians may choose between the blended fee-for-service (Family Health Group [FHG]) and blended capitation (Family Health Organization [FHO] payment models). Both models incentivize physicians to provide after-hours (AH) and comprehensive care, but FHO physicians receive a capitation payment per enrolled patient adjusted for age and sex, plus a reduced fee-for-service while FHG physicians are paid by fee-for-service. We develop a theoretical model of physician labor supply with multitasking to predict their behavior under FHG and FHO, and estimable equations are derived to test the predictions empirically. Using health administrative data from 2006 to 2014 and a two-stage estimation strategy, we study the impact of switching from FHG to FHO on the production of a capitated basket of services, after-hours services and nonincentivized services. Our results reveal that switching from the FHG to FHO reduces the production of capitated services to enrolled patients and services to nonenrolled patients by 15% and 5% per annum and increases the production of after-hours and nonincentivized services by 8% and 15% per annum.

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada.

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.

Production of physician services under fee-for-service and blended fee-for-service: Evidence from Ontario, Canada.

We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.

Unmet health care and health care utilization.

The objective of this study is to examine the causal effect of health care utilization on unmet health care needs. An IV approach deals with the endogeneity between the use of health care services and unmet health care, using the presence of drug insurance and the number of physicians by health region as instruments. We employ three cycles of the Canadian Community Health Survey confidential master files (2003, 2005, and 2014). We find a robustly negative relationship between health care use and unmet health care needs. One more visit to a medical doctor on average decreases the probability of reporting unmet health care needs by 0.014 points. The effect is negative for the women-only group whereas it is statistically insignificant for men; similarly, the effect is negative for urban dwellers but insignificant for rural ones. Health care use reduces the likelihood of reporting unmet health care. Policies that encourage the use of health care services, like increasing the coverage of public drug insurance and increasing after hours accessibility of physicians, can help reduce the likelihood of unmet health care.

Social capital and having a regular family doctor: Evidence from longitudinal data.

Access to a regular source of health-care is problematic for some, irrespective of whether the regime is publicly or privately funded. Yet, evidence shows that access to a regular family doctor improves health outcomes. We are the first to examine the impact of social capital (e.g., tangible support, friends and family) on having a regular family doctor taking into account that social capital may be endogenously determined. Using the Canadian National Population Health longitudinal survey (1994-2010: n = 41,022) and a dynamic random effects probit model (with and without endogenous initial conditions) we find robust evidence of a statistically significant and positive causal relationship between social capital and the probability of having a regular family doctor. Since past access to a family doctor is a strong predictor of both current and future access, we show that social capital is much more important in helping individuals find a family doctor than for keeping one.

Characteristics, Outcomes, and Cost Patterns of High-Cost Patients in the Intensive Care Unit.

BACKGROUND: ICU care is costly, and there is a large variation in cost among patients. METHODS: This is an observational study conducted at two ICUs in an academic centre. We compared the demographics, clinical data, and outcomes of the highest decile of patients by total costs, to the rest of the population. RESULTS: A total of 7,849 patients were included. The high-cost group had a longer median ICU length of stay (26 versus 4 days, P < 0.001) and amounted to 49% of total costs. In-hospital mortality was lower in the high-cost group (21.1% versus 28.4%, P < 0.001). Fewer high-cost patients were discharged home (23.9% versus 45.2%, P < 0.001), and a large proportion were transferred to long-term care (35.1% versus 12.1%, P < 0.001). Patients with younger age or a diagnosis of subarachnoid hemorrhage, acute respiratory failure, or complications of procedures were more likely to be high cost. CONCLUSIONS: High-cost users utilized half of the total costs. While cost is associated with LOS, other drivers include younger age or admission for respiratory failure, subarachnoid hemorrhage, or after a procedural complication. Cost-reduction interventions should incorporate strategies to optimize critical care use among these patients.

Family physician remuneration schemes and specialist referrals: Quasi-experimental evidence from Ontario, Canada.

Understanding how family physicians respond to incentives from remuneration schemes is a central theme in the literature. One understudied aspect is referrals to specialists. Although the theoretical literature has suggested that capitation increases referrals to specialists, the empirical evidence is mixed. We push forward the empirical research on this question by studying family physicians who switched from blended fee-for-service to blended capitation in Ontario, Canada. Using several health administrative databases from 2005 to 2013, we rely on inverse probability weighting with fixed-effects regression models to account for observed and unobserved differences between the switchers and nonswitchers. Switching from blended fee-for-service to blended capitation increases referrals to specialists by about 5% to 7% per annum. The cost of specialist referrals is about 7 to 9% higher in the blended capitation model relative to the blended fee-for-service. These results are generally robust to a variety of alternative model specifications and matching techniques, suggesting that they are driven partly by the incentive effect of remuneration. Policy makers need to consider the benefits of capitation payment scheme against the unintended consequences of higher referrals to specialists.

Revisiting the relationship between wages and sleep duration: The role of insomnia.

This paper uses the 2005 and 2010 Canadian General Social Surveys (Time Use) to investigate the effect of wages on the sleep duration of individuals in the labour force. The endogeneity of wages is taken into account with an instrumental variables approach; we find that the wage rate affects sleeping time in general, corroborating Biddle and Hamermesh's (1990) main conclusion. A ten percent increase in the wage rate leads to an 11-12min decrease in sleep per week. But this number masks several effects. The responsiveness of sleep time to wage rate changes depends upon the sex of the individual, whether or not sleep problems are present and general economic conditions. By far the largest adjustment is found for insomniacs in 2010, a year of general economic downturn in Canada. We also investigate the non-randomness of insomnia in the population by using a Heckman procedure, and find that the sleep time of female non-insomniacs is even more responsive to wage rate changes once account is taken of this selection bias, but otherwise selection was not a problem in our samples.

The Effect of Leisure-Time Physical Activity on Obesity, Diabetes, High BP and Heart Disease Among Canadians: Evidence from 2000/2001 to 2005/2006.

Although studies have looked at the effect of physical activity on obesity and other health outcomes, the causal nature of this relationship remains unclear. We fill this gap by investigating the impact of leisure-time physical activity (LTPA) and work-related physical activity (WRPA) on obesity and chronic conditions in Canadians aged 18-75 using instrumental variable and recursive bivariate probit approaches. Average local temperatures surrounding the respondents' interview month are used as a novel instrument to help identify the causal relationship between LTPA and health outcomes. We find that an active level of LTPA (i.e., walking ≥1 h/day) reduces the probability of obesity by five percentage points, which increases to 11 percentage points if also combined with some WRPA. WRPA exhibits a negative effect on the probability of obesity and chronic conditions.

Social networks and the probability of having a regular family doctor.

Social supports have been shown to affect health in a variety of ways. This paper explores a hitherto ignored avenue linking social supports to health, namely through their influence on having a regular family doctor. We examine the role played by social supports in helping to explain why a significant portion of the Canadian population does not have a regular family doctor even though primary care is fully covered by the public insurer and when having a regular physician is associated with better care and with access to specialists. Five Canadian Community Health Surveys spanning 2001 to 2010 (n = 13,872 to n = 30,814) are employed, containing information on three measures of social support: sense of belonging to the local community, how often an individual has someone to confide in, and number of close friends and relatives. We find evidence of a positive link between social supports, especially sense of belonging, and having a regular doctor. Our results suggest that the benefits associated with policies geared towards community development and strengthening neighborhoods may also include facilitating access to primary-care physicians and, importantly, improving the matching of patients with regular family doctors.

Patient-reported access to primary care in Ontario: effect of organizational characteristics.

OBJECTIVE: To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics. DESIGN: Cross-sectional survey. SETTING: One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres). PARTICIPANTS: Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator. MAIN OUTCOME MEASURES: Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care. RESULTS: Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access. CONCLUSION: This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.

Delivery of primary health care to persons who are socio-economically disadvantaged: does the organizational delivery model matter?

BACKGROUND: As health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada. METHODS: Cross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity. RESULTS: Low income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were overrepresented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For-Service model only. CONCLUSIONS: Primary care service measures did not differ significantly across socio-economic status or primary care delivery models. In Ontario, capitation-based remuneration is age and sex adjusted only. Patients of low socio-economic status had fewer additional visits compared to those with high socio-economic status under the Capitation model. This raises the concern that Capitation may not support the provision of additional care for more vulnerable groups. Regions undertaking primary care model reforms need to consider the potential impact of the changes on the more vulnerable populations.

Practice size, financial sharing and quality of care.

BACKGROUND: Although we are observing a general move towards larger primary care practices, surprisingly little is known about the influence of key components of practice organization on primary care. We aimed to determine the relationships between practice size, and revenue sharing agreements, and quality of care. METHODS: As part of a large cross sectional study, group practices were randomly selected from different primary care service delivery models in Ontario. Patient surveys and chart reviews were used to assess quality of care. Multilevel regressions controlled for patient, provider and practice characteristics. RESULTS: Positive statistically significant associations were found between the logarithm of group size and access, comprehensiveness, and disease prevention. Negative significant associations were found between logarithm group size and continuity. No differences were found for chronic disease management and health promotion. Practices that shared revenues were found to deliver superior health promotion compared to those who did not. Interacting group size with the presence of a revenue-sharing arrangement had a negative impact on health promotion. CONCLUSIONS: Despite the limitations of our study, our findings have provided preliminary evidence of the tradeoffs inherent with increasing practice size. Larger group size is associated with better access and comprehensiveness but worse continuity of care. Revenue sharing in group practices was associated with higher health promotion compared to sharing only common costs. Further work is required to better inform policy makers and practitioners as to whether the pattern revealed in larger practices mitigates any of the previously reported benefits of continuity of primary care. We found few benefits of revenue sharing--even then the effect of revenue sharing on health promotion seemed diminished in larger practices.

Canadian family physicians' decision to collaborate: age, period and cohort effects.

One of the core primary care reform initiatives seen across provinces in Canada is the introduction of inter-professional primary healthcare teams in which family physicians are encouraged to collaborate with other health professionals. Although a higher proportion of physicians are collaborating with various health professionals now compared to the previous decade, a substantial number of physicians still do not work in a collaborative setting. The objective of this paper is to examine the age, period and cohort effects of Canadian family physicians' decisions to collaborate with seven types of health professionals: specialists, nurse practitioners, nurses, dieticians, physiotherapists, psychologists and occupational therapists. To this end, this paper employs a multivariate probit model consisting of seven equations and a cross-classified fixed-effects strategy to explain the collaborative decisions of family physicians. Utilizing three cross-sectional physician surveys from Canada over the 2001-2007 period, cohorts are defined over five-year intervals according to their year of graduation from medical school. We find that newer cohorts of physicians are more likely to collaborate with dieticians, physiotherapists, psychologists and occupational therapists; newer female cohorts are more likely to collaborate with nurses while newer male cohorts are less likely to collaborate with nurses but more likely to collaborate with specialists. Older physicians are more likely to collaborate with specialists, physiotherapists, psychologists, and occupational therapists; the age effect for nurses is U-shaped for male physicians while it is inverse U-shaped for females. Family physicians are collaborating more with all seven health professionals in 2004 and 2007 compared to 2001. Belonging to a group practice has a largely positive influence on collaborations; and being paid by a fee-for-service remuneration scheme exerts a negative influence on collaboration, ceteris paribus. The findings suggest that combining a non-fee-for-service remuneration arrangement with a group practice structure would facilitate effective collaboration.

Estimating patient demographic profiles from practice location.

OBJECTIVE: To test the accuracy of imputing a practice population's average socioeconomic characteristics (such as average education levels and average income) using census data centred on the location of the practice. DESIGN: Comparison of census data with survey data collected in primary care offices. SETTING: Ontario. PARTICIPANTS: A cross-sectional sample of patients from 116 urban practices. MAIN OUTCOME MEASURES: Patient data were compared with census data at different levels of aggregation using mean absolute relative error (ARE), median ARE, and Spearman rank correlations. RESULTS: A total of 4413 patient surveys were collected. Differences between patient profiles and census data were large. Most mean AREs were clustered between 0.70 and 0.80, and median AREs were as high as 1.67. Correlations were low (ρ = 0.02) to moderate (ρ = 0.48). These results held across both levels of aggregation. CONCLUSION: The use of imputation techniques based on practice location is inadvisable, given the large differences that were observed.

Comparative efficiency assessment of primary care service delivery models using data envelopment analysis.

This paper compares the relative productive efficiencies of four models of primary care service delivery using the data envelopment analysis method on 130 primary care practices in Ontario, Canada. A quality-controlled measure of output and two input scenarios are employed: one with full-time-equivalent labour inputs and the other with total expenditures. Regression analysis controls for the mix of patients in the practice population. Overall, we find that community health centres fare the worst when it comes to relative efficiency scores.