Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Master of Science


Epidemiology and Biostatistics


Sarma, Sisira

2nd Supervisor

Anderson, Kelly K.



Treating mental illness in primary care improves access to care, but it is unclear how to encourage family physicians to provide adequate mental health services. One approach may be changing how they are remunerated. The objectives of this thesis were to: 1) review the literature on the association between physician remuneration and provision of mental health services, and 2) assess the impact of blended capitation, compared to blended fee-for-service (FFS), on mental health services provision in Ontario. The review found that capitation appears to be associated with fewer services compared to FFS; however, studies of ED visits for mental health reasons were limited. The impact of remuneration models of Ontario physicians was assessed using longitudinal administrative data from ICES and analyzed using fixed-effects linear regression models. Blended capitation was associated with fewer mental health services provided and a slight decrease in the number of ED visits for mental health reasons.

Summary for Lay Audience

Many patients with mental illness are not receiving treatment. One method of addressing this gap may be changing how physicians are remunerated, to encourage them to provide more mental health care; research has shown that physicians change how they provide care in response to how they are paid.

In recent years, most Ontario family physicians (FPs) are paid by blended fee-for-service (FFS) or blended capitation. In FFS, physicians are paid based on how many services they provide; they are incentivized to provide more care, but may provide unnecessary services to increase their income. In blended FFS, physicians are paid mostly by FFS but also receive other bonuses. Under capitation, physicians are paid by the number of enrolled patients they have and are expected to provide a basket of services to these patients; they are unlikely to provide unnecessary services, but may not provide needed care unless payments are appropriately risk-adjusted. In blended capitation, physicians receive the bulk of their income from capitation payments, and receive bonuses similar to blended FFS. Previous studies have found that physicians paid by capitation generally provided fewer mental health services compared to FFS, but the effect on emergency department (ED) visits for mental health reasons was not clear. Furthermore, as most previous studies are from the US, these findings may not be applicable to Canada.

To assess the association between physician remuneration and provision of mental health services in Ontario, we analyzed mental health services from health administrative databases over ten years (2007-2016). FPs who were in blended FFS and switched to blended capitation were compared to those who were in the blended FFS throughout the study period. Mental health services provided by the FP, and ED visits for mental health reasons were assessed. We found that FPs paid by blended capitation tended to provide fewer mental health services overall, but provided more mental health services during after-hours. Furthermore, although they provided fewer mental health services, capitation was also associated with fewer ED visits for mental health reasons. These findings may reflect better access to mental healthcare under blended capitation.

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.