Specialist Physician Payment Method and Outcomes

I opened one email this morning that had links to several research pieces.  Several of those undermined beliefs that are widely held in the health policy community.  Is nothing sacred anymore; is there nothing we can rely on?  Okay, so I admit it there is a part of me that kind of enjoys this.  Anyway, the study involved assessing treatment patterns and outcomes for physicians paid on a salaried basis versus on a fee-for-service basis.  Supposedly doctors who are salaried aren’t as likely to have excessive utilization.  The study was published in the Journal of the American Medical Association Network Open.   (JAMA Article)   The study was conducted in Canada and involved treatment of patients with chronic disease.  Frequency of visits, costs of care and quality were the outcomes studied.  The patients had diabetes or chronic kidney disease and hadn’t been seen by a specialist in the last four years, so were likely newly diagnosed.  About 90,000 patients were seen by fee-for-service doctors and 19,000 by salaried ones.  The patient cohorts were matched by a variety of factors.  Unadjusted visit rates were slightly higher for patients seeing FFS specialists, but after adjustment, patients who were treated by salaried doctors had higher, but not statistically significant, visit rates.  The visit rate for patients at greater health risk was higher across both types of specialist.  There were no statistically significant differences in delivery of guideline recommended care to the patients of either salaried or fee-for-service specialists.  There did not appear to be any difference in rates of emergency room use or hospitalizations for disease treatment-sensitive causes.  Medication and imaging costs were higher for patients seeing FFS doctors in the first year after the initial visit, all other costs were lower and the total average costs were similar.

The results suggest that how specialists are paid doesn’t have a large impact on how patients are treated or the costs of their treatment.  The authors did, however, note that there is substantial variation in treatment patterns among specialists, but it appears unrelated to how they are compensated.  This is consistent with findings in the US of considerable variation in practice patterns, even at very local levels, that is hard to explain.  In regard to this study, it is also important to note that there could be differences in which doctors select which payment method and in what patients they are willing to see and those differences could impact the results.  But overall, it doesn’t seem that putting all physicians on salary is going to magically improve outcomes or reduce costs.