AB009. How should doctors be paid?—a systematic review of the impacts of provider payment methods for primary care physicians on patient healthcare utilisation

Background: Physician payment methods are valuable supply-side measures that may be reformed to achieve health policy objectives. However, few studies provide a comparison of the various methods of payment, to inform policy development. This review examines how payment methods for primary care physicians (PCPs) affect their patients’ healthcare utilisation, as a reflection of quality of care.

Methods: PubMed, Embase, MEDLINE, EconLit, CINAHL Complete, and Web of Science were searched to identify papers in English investigating comparisons of payment methods for PCPs and their patients’ care usage. Payment methods included fee-for-service (FFS), capitation, salary, pay-for-performance (P4P), or a blend of these. Relevant outcomes were patient use of inpatient, outpatient or emergency care services.

Results: Thirty-one studies involving 49,008 PCPs and 11,998,174 patients were included. The most commonly examined reimbursement mechanism was FFS (N=23), followed by capitation (N=18), P4P (N=13), and salary (N=6). Most outcomes concerned inpatient care (N=21), compared to emergency (N=15) and outpatient (N=1) care; some studies compared multiple methods and outcomes. Of the eight countries covered, the two most widely represented were USA (N=14) and Canada (N=9). The most consistent finding was improvement in outcomes under PCPs with a P4P adjunct compared to PCPs without; this was demonstrated in six of the nine studies. Of the thirteen studies comparing FFS and capitation reimbursement, four of seven studies with statistically significant outcomes showed that patients under FFS PCPs had lower care utilisation. No significant relationships were observed for studies comparing FFS and salary payments or investigating mixed payment models.

Conclusions: This is the largest and most up-to-date study evaluating commonly used payment methods in terms of patient healthcare utilisation, and may serve as preliminary evidence in guiding policy reforms. Further research should employ more rigorously controlled designs, longer follow-up periods, and a wider range of quality outcomes to establish stronger conclusions.

Keywords: Medical care utilisation; payment methods; primary health care; reimbursement mechanisms