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Incentive payments for family doctors may not have intended results


An incentive payment called the “access bonus,” designed to encourage better access to family medicine and discourage patients from seeking care outside their family doctor’s office, may be inadvertently benefiting family doctors with lower levels of access in Ontario, according to a new study by researchers at ICES and St. Michael’s Hospital.

The “access bonus” is a substantial fee Ontario doctors are paid if their patients do not seek care outside their group, such as at a walk-in clinic. The study found that the average amount family physicians were receiving for the “access bonus” ranged from over $17,000 per physician and exceeding $36,000 for physicians in the highest quintile.

The study published today in the April issue of Health Affairs, showed that the “access bonus,” is being paid more often to family doctors in rural Ontario communities who have healthier patients, who made fewer primary care visits and received less after-hours care. The bonus payment could serve as an incentive for physicians to advise their patients to use emergency departments instead of lower-cost walk-in clinics because under the incentive plan, the bonus was reduced if patients sought outside care, but emergency department visits were not counted as outside care.

“Primary care payment reform needs to be designed and implemented differently for diverse settings such as small rural communities and densely populated downtown cores,” says Dr. Richard Glazier, senior author of the study and ICES senior scientist.

Most doctors in Ontario who are eligible for the “access bonus” are paid under the Family Health Organization model which was introduced in 2006. This model involves formal patient enrollment; a requirement that family doctors provide extended office hours on weekday evenings and on weekends; and blended payments to physicians that include capitation (a fee per person enrolled per month), incentives and bonuses, and fee-for-service payments.

The researchers found that the incentive bonus did not flow to physicians with the best after-hours availability or most complex patients and there were higher rates of emergency department visits for patients whose family doctor received the access bonus.

“Our findings show that these payments and their intended purpose do not align. Financial incentives should be evaluated and frequently revisited to ensure that they are helping the healthcare system be more efficient and equitable,” adds Glazier, who is also a family physician and researcher at St. Michael’s.

Author block: Richard Glazier, Michael E. Green, Eliot Frymire, Alex Kopp, William Hogg, Kamila Premji, and Tara Kiran.

The report “Do incentive payments reward the wrong providers? A study of primary care reform in Ontario, Canada,” is published in the April 1 issue of Health Affairs.

ICES is an independent, non-profit research institute that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. In October 2018, the institute formerly known as the Institute for Clinical Evaluative Sciences formally adopted the initialism ICES as its official name. For the latest ICES news, follow us on Twitter: @ICESOntario

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future healthcare professionals in 29 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

Unity Health Toronto, comprised of Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital, works to advance the health of everyone in our urban communities and beyond. Our health network serves patients, residents and clients across the full spectrum of care, spanning primary care, secondary community care, tertiary and quaternary care services to post-acute through rehabilitation, palliative care and long-term care, while investing in world-class research and education. For more information, visit www.unityhealth.to.

For more information, please contact:

Deborah Creatura
Media Advisor, ICES
[email protected]
(o) 416-480-4780 or (c) 647-406-5996

Michael Oliveira
Manager, Media Relations, St. Michael’s Hospital
[email protected]


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