SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
September, 2009 - SUPPORT Summary of a systematic review | print this article |
It is believed widely that the method by which physicians are paid affects their professional behaviour. In the fee-for-service (FFS) model, physicians are paid a fee for each unit of care they provide. With target payments, physicians are paid a lump sum only if a specified target level of service is provided. Under capitation, physicians are remunerated for each registered patient, to cover the services provided to them. Salaried physicians receive a lump sum salary for a specified number of work hours. Payment systems for physicians have been manipulated to attempt to achieve policy objectives such as improving quality of care, cost containment and recruitment to underserved areas.
People making decisions about payment systems for primary care physicians.
Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L. Impact of payment method on behaviour of primary care physicians: a systematic review. J Health Serv Res Policy. 2001; 6:44-55. See in PubMed
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
The payment methods by which physicians are remunerated, are be-lieved to have an impact on physician behaviour.
Because FFS and target payments link payment to outputs, they pro-vide an incentive to physicians to maximise output (the quantity of care), as long as the fees exceed their personal (own time) and fi-nancial costs. With target payments, physicians have an incentive to provide the target level of care only and to provide no care if there is a risk of not meeting the target.
Generally, if physicians respond to these incentives, salaried and capitation payments may encourage cost containment behaviour and result in under-treatment whereas FFS may encourage over-treatment. The impact of these payment systems on patient health status is not clear since both under-treatment and over-treatment may be detrimental.
Payment systems may also influence the recruitment and retention of primary care physicians. For example, primary care physicians may be more likely to accept salaried employment in underserved areas, compared with FFS arrangements, since a fixed income provides more financial security.
Payment systems may also have different administration costs. FFS systems entail the highest costs since claims have to be made for each service. In capitation schemes the physician claims a fixed payment per patient. Salary payment is simplest in terms of administrative costs.
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Review objective: To assess the effects of different reimbursement schemes on physician behaviour |
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| / | What the review authors searched for | What the review authors found |
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| Interventions | Comparisons of FFS, capitation, salary, mixed remu-neration systems, and target payments. RCT, ITS or CBA designs were included. |
Capitation payment versus FFS (1 RCT, 1 CBA); salaried payment versus FFS (1 RCT); mixed capitation versus FFS (1 CBA); target payment versus FFS (1 RCT, 1 ITS). |
| Participants |
Primary care physicians |
GPs (3 studies), paediatricians (2 studies), “primary care physicians” (1 study). |
| Settings |
Primary healthcare settings |
USA (3 studies), Canada (1 study), UK (1 study), Denmark (1 study). |
| Outcomes |
Objective measurement of: health professional out-comes, health professional processes, health services utilisation, patient outcomes, healthcare costs, equity of care, primary care physician satisfaction. |
Enrolled patients (1 study), primary care physician visits (3), com-pliance with recommended frequency of visits (2), continuity of care (1), service utilisation (1), referrals (2), emergency room visits (2), hospitalisation (2), patient satisfaction (1), and immunisation coverage (2). |
| Date of most recent search: 1997 | ||
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Limitations: This is a good quality systematic review but the included studies have major limitations. This is a good quality systematic review but the included studies have major limitations.
Abbreviations: RCT Randomized controlled trial, FFS Fee for Service, ITS Interrupted time series, CBA Controlled before after
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Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L. Impact of payment method on behaviour of primary care physicians: a systematic review. J Health Serv Res Policy. 2001; 6:44-55. See in PubMed
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review authors found 6 studies of the impact of payment methods on primary care physicians’ behaviour. There was considerable variation in the quality of reporting, study setting and the range of outcomes measured.
One randomised controlled trial (RCT) and 1 controlled before-after (CBA) study compared capitation with FFS. The RCT randomised 80 paediatricians into 3 groups (capitation; a (new) high rate FFS group; and a (old) low rate FFS control group) over 6 months. Children in the capitation and the high rate FFS group had more primary care visits compared with the control group. In the capitation group, compliance with the recommended schedule for child health was lower than in the FFS groups.
The CBA study compared the impact of introducing FFS in a capitation system with a control group of primary care physicians already paid by capitation with FFS. The number of telephone consultations and diagnostic and curative services rose among primary care physicians 6 months after the introduction of FFS and were still higher after 12 months. Face-to-face consultations were higher after 6 months, but not after 12 months. Referrals to specialists and hospitals, which were not paid for by FFS, were lower in the intervention group after 12 months.
Capitation compared to fee-for-service |
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| Patient or population: Paediatricians and primary care physicians Settings: Primary care Intervention: FFS Comparison: Capitation |
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| Outcomes | Impact |
Number of participants (studies) |
Quality of the evidence (GRADE) |
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Number of primary care physician visits |
Children in the capitation group had 0.5–0.6 more primary care visits per year and the FFS group had 0.8–0.9 more visits, both compared to the control group |
80 |
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Compliance with recommended periodicity schedule |
In the capitation group compliance was lower than in the FFS groups (8 to 12% differences) |
80 (1 study) |
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GRADE: GRADE Working Group grades of evidence (see above and last page) |
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One CBA study enrolled 116 physicians (77 capitation and FFS [mixed capitation] and 39 FFS). After four years there were no statistically significant differences in patient admission rates or days in hospital between the two groups.
One RCT randomised 18 paediatric residents (trainees) to salary (10) or FFS (8), with a follow-up of 9 months. The average number of patients enrolled per primary care physician was higher in salaried compared with FFS primary care physicians (27% relative difference). There were no statistically significant differences between salaried and FFS primary care physicians in the average number of initial or follow-up visits per patient. However, salaried primary care physicians had a lower percentage of visits in excess of a recommended number compared with FFS primary care physicians. The average number of emergency visits per patient was higher for salaried compared with FFS primary care physicians (a relative difference of 83.3%), whereas the salaried primary care physicians carried out fewer scheduled visits and well child visits per enrolled patient. Salaried primary care physicians attended a lower percentage of visits with their own patients (a measure of continuity of care) compared with FFS primary care physicians. The only statistically significant difference reported across four domains of patient satisfaction was for access, which favoured the salaried primary care physicians.
One RCT randomised 54 practices in the USA to target payments plus FFS (27) or FFS only (27), with 1 year of follow-up. There was no statistically significant difference in influenza vaccination rates between physicians receiving fees only compared to the target payments group.
An interrupted time series study of 313 primary care physicians in the UK, followed over 20 months, showed that the overall linear trend in immunisation rates did not change as a result of the target payments.
Target payments compared with FFS |
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| Patient or population: Primary care physicians Settings: Primary care Intervention: Target payment Comparison: FFA |
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| Outcomes | Impact | Number of participants (studies) |
Quality of the evidence (GRADE) |
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Rate of influenza vaccination |
The physicians receiving target payments had an influenza vaccination rate 9.4% higher than the FFS group, but this was not statistically significant. |
54 (1 study) |
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GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
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| APPLICABILITY | |
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| EQUITY | |
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The potential impacts of different payment systems on equity are largely unevaluated. For example, capitation rates can be adjusted to provide incentives to physicians practicing in disadvantaged areas. Target payments can also provide incentives for providing services to more disadvantaged populations. However, the impacts of such incentives appear not to have been evaluated.
Disadvantaged populations often experience a higher burden of disease, including greater complexity of needs. While FFS may be appropriate for relatively straightforward forward and uncomplicated service delivery, the level of patient co-payments associated with some FFS arrangements may be a significant impediment for disadvantaged groups with complex needs who require well coordinated care from a range of providers working as a team. Capitation or salaried arrangements may offer greater flexibility in the composition and roles within teams
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| ECONOMIC CONSIDERATIONS | |
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| MONITORING & EVALUATION | |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Related literature
Donaldson C, Gerard K. Paying general practitioners: Shedding light on the review of health services. Journal of the Royal College of General Practitioners 1989; 39: 114–117
Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues. International Journal for Quality in Health Care 2000; 12: 133–142
The systematic review summarized here is based on two other systematic reviews
Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L. Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002215.
Giuffrida A, Gosden T, Forland F, Kristiansen IS, Sergison M, Leese B, Pedersen L, Sutton M. Target payments in primary care: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000531.
This summary was prepared by
Agustín Ciapponi and Sebastián García Martí, Argentine Cochrane Centre IECS -Institute for Clinical Effectiveness and Health Policy- Iberoamerican Cochrane Network, Argentina
Conflict of interest
None declared. For details, see: Conflicts of Interest
Acknowledgements
This summary has been peer reviewed by: Julie McDonald, Australia; Andrew Hutchings, UK; Rukhsana Gazi, Bangladesh.
This summary should be cited as
Ciapponi A, García Martí S. Does how primary care physicians are paid impact on their behaviour? A SUPPORT Summary of a systematic review. September 2009.
This summary was prepared with additional support from:
The South African Medical Research Council aims to improve health and quality of life in South Africa, through promoting and conducting relevant and responsive health research.
www.mrc.ac.za
The South African Cochrane Centre, the only centre of the international Cochrane Collaboration in Africa, aims to ensure that health care decision making in Africa is informed by high quality, timely and relevant research evidence.
www.mrc.ac.za/cochrane/cochrane.htm
