Quality of diabetes care in blended fee-for-service and blended capitation payment systems

Objectives — In the mid- to late-2000s, many family physicians switched from Family Health Group (FHG) (a blended fee-for-service model) to Family Health Organization (FHO) (a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model.

Methods — Using longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on eight quality indicators related to diabetes care. Since FHO physicians are likely to be systematically different from FHGs, we employed propensity-score based inverse probability weighted fixed-effects regression models. All analyses were conducted at the physician-level.

Results — We found that FHO physicians were more likely to provide HbA1c testing by 2.75% (95% confidence interval (CI): 1.89%, 3.60%), lipid assessment by 2.76% (CI: 1.95%, 3.57%), nephropathy screening by 1.08% (CI: 0.51%, 1.66%), and statin prescription by 1.08% (CI: 0.51%, 1.66%). Patients under FHOs had lower estimated risk of mortality by 0.0124% (CI: 0.0123%, 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting-enzyme inhibitors (or angiotensin II receptor blockers), and patients’ risk of avoidable diabetes-related hospitalizations.

Conclusions — Compared to blended fee-for-service, blended capitation payment is associated with a small but statistically significant improvement in some aspects of diabetes care.