Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation.
Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation.
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DOI：
10.1503/cmaj.081316
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发表时间：
2009-05-26
期刊：
影响因子：
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通讯作者：
Sibley, Lyn M
中科院分区：
文献类型：
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作者：
Glazier, Richard H;Klein-Geltink, Julie;Sibley, Lyn M
背景：加拿大安大略省的初级保健改革包括在2001-2002年间启动混合按人头计价模式，并在2003年推出增强的按服务收费模式。这两种模式都涉及患者名册、预防护理激励措施和下班后护理要求。我们评估了这两种模式下的实践特征和护理模式。方法：使用管理数据，我们确定了从9月1日开始的整个时期内属于按人头计算或增强型收费服务组的医生。2005年1月至2006年8月31日，以及他们登记的患者。实践按地点分层(城市与农村)。我们比较了两组的实践特征和护理模式，包括护理的全面性、连续性、下班后护理、急诊科就诊和接纳新患者。结果：住院患者和强化收费服务做法的患者具有相似的人口学特征。实行按人头计算法的患者的发病率和共病指数较低。两组护理的全面性和连续性相似。与加强收费做法的患者相比，实行按人头计价做法的患者的下班后护理较少(调整后的比率比[RR]0.68，95%可信区间[CI]0.61-0.75)，而去急诊科的次数较多(调整后的比率比1.20，95%可信区间1.15-1.25)。总体而言，按人头计费组的医生招收的新患者比按服务付费增强型的医生少(37.0vs.52.0/医生)；应届毕业生也是如此(60.3vs72.1/医生)。干预：按人头计价模式登记的医生与按服务收费模式的医生具有不同的执业特征。这些特点似乎是预先存在的，并不是因为采用了新的模式。虽然按人头计价模式为按服务收费的做法提供了一种替代办法，但其特点应成为未来政策发展和研究的重点。
BACKGROUND: Primary care reform in Ontario, Canada, included the initiation of a blended capitation model in 2001-2002 and an enhanced fee-for-service model in 2003. Both models involve patient rostering, incentives for preventive care and requirements for after-hours care. We evaluated practice characteristics and patterns of care under both models.METHODS: Using administrative data, we identified physicians belonging to either the capitation or the enhanced fee-for-service group throughout the period from Sept. 1, 2005, to Aug. 31, 2006, and their enrolled patients. Practices were stratified by location (urban v. rural). We compared the groups in terms of practice characteristics and patterns of care, including comprehensiveness of care, continuity of care, after-hours care, visits to the emergency department and uptake of new patients.RESULTS: Patients in the capitation and enhanced fee-for-service practices had similar demographic characteristics. Patients in capitation practices had lower morbidity and comorbidity indices. Comprehensiveness and continuity of care were similar between the 2 groups. Compared with patients in enhanced fee-for-service practices, those in capitation practices had less after-hours care (adjusted rate ratio [RR] 0.68, 95% confidence interval [CI] 0.61-0.75) and more visits to emergency departments (adjusted RR 1.20, 95% CI 1.15-1.25). Overall, physicians in the capitation group enrolled fewer new patients than did physicians in the enhanced fee-for-service group (37.0 v. 52.0 per physician); the same was true of new graduates (60.3 v. 72.1 per physician).INTERPRETATION: Physicians enrolled in the capitation model had different practice characteristics than those in the enhanced fee-for-service model. These characteristics appeared to be pre-existing and not due to enrolment in a new model. Although the capitation model provides an alternative to fee-for-service practice, its characteristics should be the focus of future policy development and research.