There has been a presumption that specialist physicians spend more on care for similar patients than do primary care ones, partly because they have higher incomes and partly because they tend to order more possibly unnecessary tests and procedures. The same presumption has often been applied to specialists paid on a fee-for-service versus salary basis, again on the theory that they may be incented to deliver more to enhance their incomes. A study in the Journal of the American Medical Association Network Open examines this question. (JAMA Article) The study was carried out in Canada on patients newly referred for specialty care. About 19,200 patients with diabetes or chronic kidney disease who received an initial referred visit from salaried specialist doctors were compared to 90,600 patients who visited physicians paid on a fee-for-service basis. The patients were propensity score matched and their care was analyzed in regard to outpatient visit rates, hospital and emergency room use, quality of care and overall spending.
Salary-based doctors actually had a higher follow-up physician visit rate–1.74 compared to 1.54 for the fee-for-service physicians, but the difference was not statistically significant. There was no statistically significant difference in rates of guideline recommended care, such as prescribed medications or certain diagnostic tests. Rates of hospitalization or emergency room visits for ambulatory care sensitive conditions were the same. And average total spending was the same, although in the first year fee-for-service specialists had higher prescription drug and imaging spending, but lower spending in other categories. Among and across all physicians in both groups, however, there was a large amount of variation in care patterns. This is consistent with research in the United States. Since the doctors had generally been able to choose their payment method, it is possible that doctors tending to practice one way or the other were more likely to select a certain method, which could affect the results. Overall, however, the suggestion that either FFS or salaried payments strongly affect care delivery was not supported by this study.