Impact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices

Background:

Several jurisdictions attempting to reform primary care have focused on changes in physician remuneration. The goals of this study were to compare the delivery of preventive services by practices in four primary care funding models and to identify organizational factors associated with superior preventive care.

Methods:

In a cross-sectional study, we included 137 primary care practices in the province of Ontario (35 fee-for-service practices, 35 with salaried physicians [community health centres], 35 practices in the new capitation model [family health networks] and 32 practices in the established capitation model [health services organizations]). We surveyed 288 family physicians. We reviewed 4108 randomly selected patient charts and assigned prevention scores based on the proportion of eligible preventive manoeuvres delivered for each patient.

Results:

A total of 3284 patients were eligible for at least one of six preventive manoeuvres. After adjusting for patient profile and contextual factors, we found that, compared with prevention scores in practices in the new capitation model, scores were significantly lower in fee-for-service practices (β estimate for effect on prevention score = −6.3, 95% confidence interval [CI] −11.9 to −0.6) and practices in the established capitation model (β = −9.1, 95% CI −14.9 to −3.3) but not for those with salaried remuneration (β = −0.8, 95% CI −6.5 to 4.8). After accounting for physician characteristics and organizational structure, the type of funding model was no longer a statistically significant factor. Compared with reference practices, those with at least one female family physician (β = 8.0, 95% CI 4.2 to 11.8), a panel size of fewer than 1600 patients per full-time equivalent family physician (β = 6.8, 95% CI 3.1 to 10.6) and an electronic reminder system (β = 4.6, 95% CI 0.4 to 8.7) had superior prevention scores. The effect of these three factors was largely but not always consistent across the funding models; it was largely consistent across the preventive manoeuvres.

Interpretation:

No funding model was clearly associated with superior preventive care. Factors related to physician characteristics and practice structure were stronger predictors of performance. Practices with one or more female physicians, a smaller patient load and an electronic reminder system had superior prevention scores. Our findings raise questions about reform initiatives aimed at increasing patient numbers, but they support the adoption of information technology.Primary care providers are increasingly interested in ensuring that preventive health care be part of their work routines.¹ This reorientation fits with the evidence that recommendations from family practitioners increase substantially the likelihood of patients undergoing preventive manoeuvres,² whereas the lack of such recommendations has been linked with patient noncompliance.^3,4Studies evaluating adherence to recommended preventive care suggest that the most pervasive barriers rest with the organization of the health care system and the practice itself, such as the absence of external financial incentives for the work done and the lack of a reminder system in the office.^3,5–9Countries attempting to reform their delivery of primary care and improve the delivery of preventive services have often directed their efforts in finding alternatives to the traditional fee-for-service model, in which providers receive payment for each service provided. There are two predominant alternative funding models: capitation (providers receive a fixed lump-sum payment per patient per period, independent of the number of services performed) and salaried remuneration. Some health care systems blend components of fee for service with either of these models or offer additional incentives for reaching defined quality-of-care targets. Despite considerable rhetoric, there is little evidence to point to the remuneration models associated with superior delivery of primary care services.¹⁰ The complexity of health care systems makes the evaluation of models through international comparisons difficult.In Canada, the province of Ontario has four primary care funding models (11

Table 1:

Characteristics of the four primary care models in the province of Ontario in 2005/06

		Fee for service		Capitation
Characteristic	Salaried (community health centres)*	Traditional*	Reformed†	New (family health networks)	Established (health services organizations)
Year introduced	1970s	–	2004	2001	1970s
Group size, no. of physicians	> 1 (no specific size requirement)	1	≥ 3	≥ 3	≥ 3
Physician remuneration	Salary	Fee for service	Fee for service and incentives	Capitation with 10% fee- for-service component, and incentives	Capitation and incentives
Patient enrolment	Required; no limit on size of roster	Not required	Required; no limit on size of roster	Required; disincentive to enrol > 2400	Required; disincentive to enrol > 2400
Incentive for enhanced preventive care‡
Influenza immunization (age ≥ 65 yr)	None	None	None	April 2002	July 2003
Colorectal cancer screening (age 50–74 yr)	None	None	April 2006	April 2006	April 2006
Breast cancer screening (age 50–70 yr)	None	None	None	April 2002	April 2003
Cervical cancer screening (age 35–70 yr)	None	None	None	April 2002	April 2003

Open in a separate window^*Community health centres and fee-for-service practices did not receive productivity or quality incentives. No model offered incentives for screening of visual or auditory impairment.^†Late in 2004, the Ontario Ministry of Health and Long-term Care created a reformed fee-for-service model — the family health group — to which fee-for-service practices could transition. We combined these two fee-for-service models for our analyses.^‡Incentives for service enhancement of preventive manoeuvres, available through the Ministry of Health and Long-Term Care for the study period. Dates when the incentive bonuses came into effect are indicated in the cells. Incentives cover care delivered during the 30 months before the date the incentives became effective.Source: Adapted from the Ontario Medical Association document comparing models (www.oma.org/Member/Resources/Documents/2008PCRComparisonChart.pdf), and supplemented with other information found on the Ontario Medical Association website.We conducted this study to compare the delivery of preventive services by practices in the four funding models and to identify organizational factors associated with superior preventive care. This study is part of a larger evaluation of primary care models in Ontario funded by the Ontario Ministry of Health and Long-Term Care through its Primary Health Care Transition Fund.