Paying doctors differently and adding other health professionals to the team appears to result in moderately improved diabetes care for patients in Ontario, Canada's largest province, according to research published in CMAJ (Canadian Medical Association Journal)
Countries such as the United States and Canada are exploring ways to deliver better primary care such as changing the way doctors are paid and practices organized. Many family physicians are moving away from fee-for-service payment toward salaried or capitation payment. In capitation, physicians earn a set fee per patient per year, regardless of the number of patient visits, rather than a fee per service provided. Since 2002 in Ontario, 45% of primary care physicians have moved to capitation payment, and about half of these physicians are part of a family health team, where they deliver care with a team of other health professionals.
This study, based on data on more than 10 million patients, looked at whether the move of physicians to blended capitation models with care provided by a health care team improved patient outcomes. The data came from the Ontario Health Insurance Plan (OHIP) and the Institute for Clinical Evaluative Sciences (ICES).
Patients who were cared for by physicians in a family health team were more likely to be monitored for diabetes (40% v. 32%), and to undergo screening for breast cancer (77% v. 72%) and colorectal cancer (63% v. 61%), than those in a fee-for-service practice. After adjusting for patient and physician factors, patients cared for by family health teams were 22% more likely to receive recommended diabetes testing, 6% more likely to be screened for breast cancer and 3% more likely to be screened for colorectal cancer than patients in a fee-for-service model. Patients with family health teams experienced the greatest improvements in diabetes care over time but had similar improvements in mammography and colorectal cancer as patients not with a family health team.
"Our findings suggest that the shift to capitation payment and the addition of nonphysician health professionals to the care team have led to moderate improvements in processes of diabetes care, but the effects on cancer screening are less clear," writes Dr. Tara Kiran, Department of Family and Community Medicine, St. Michael's Hospital and ICES, Toronto, Ontario, with coauthors.
The researchers note big differences in the characteristics of physicians and patients in family health teams compared with those not in such teams. For example, patients in family health teams were more likely to be Canadian-born, live in rural areas and have fewer health problems. These differences may have influenced the findings, despite the authors' attempts to control for them.
The authors suggest that changing the way physicians are paid and adding other health professionals to the team has the potential to improve quality of care, although this needs to be weighed against the cost of reforms. The Ontario government has recently restricted physician entry into family health teams.