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Effects of removing a fee-for-service incentive on specialist chronic disease services: a time-series analysis

Appleton A, Lam M, Le B, Shariff S, Gershon A. Health Promot Chronic Dis Prev Can. 2021; 41(2):57-64. Epub 2021 Feb 1. DOI:

Introduction — Physician payment models are known to affect the nature and volume of services provided. Our objective was to study the effects of removing a financial incentive, the fee-for-service premium, on the provision of chronic disease follow-up services by internal medicine, cardiology, nephrology and gastroenterology specialists.

Methods — We collected linked administrative health care data for the period 1 April 2013 to 31 March 2017 from databases held at the Institute for Clinical Evaluative Sciences (ICES) in Ontario, Canada. We conducted a time-series analysis before and after the removal of the fee-for-service premium on 1 April 2015. The primary outcome was total monthly visits for chronic disease follow-up services. Secondary outcomes were monthly visits for total follow-up services and new patient consultations. We compared internal medicine, cardiology, nephrology and gastroenterology specialists practising during the study timeframe with respirology, hematology, endocrinology, rheumatology and infectious diseases specialists who remained eligible to claim the premium. We chose this comparison group as these are all subspecialties of internal medicine, providing similar services.

Results — The number of chronic disease follow-up visits decreased significantly after removal of the premium, but there was no decrease in total follow-up visits. There was also a significant downward trend in new patient consultations. No changes were observed in the comparison group.

Conclusion — The decrease in volume of chronic disease follow-up visits can be explained by diagnostic criteria being met less often, rather than an actual reduction in services provided. Potential effects on patient outcomes require further exploration.

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