Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article

Degree

Doctor of Philosophy

Program

Epidemiology and Biostatistics

Supervisor

Sarma, Sisira

Abstract

In the early 2000s, Ontario introduced extensive primary care reforms to increase around-the-clock access to comprehensive primary care in response to inadequate access to primary care, including the way Ontario primary care physicians were paid. This thesis investigates the extent to which changes in physician payment could affect emergency department visits. First, a review evaluating the impact of access to primary care on primary care and emergency department utilization was conducted. Secondly, the impact of Ontario’s after-hours premium on emergency department visits was investigated, first within Ontario, then compared to four control provinces. Finally, rates of primary care services and emergency department visits were compared between the two most popular physician remuneration models. Data sources include databases housed at ICES as well as the Canadian Community Health Survey linked to the National Ambulatory Care Reporting System. The review found that while improving access to primary care increased primary care visits, the effects on emergency department visits were often limited, and the effects depends on the intervention used to improve access to care and the context of the health care system. The introduction of Ontario’s after-hours premium was associated with a reduction in less-urgent emergency department visits, particularly during after-hours; however, subsequent increases in the premium were found to have only a small further reduction in emergency department visits and comparisons to other provinces suggested that an increase in the premium was unlikely to be causal. Physicians paid by blended capitation were found to provide fewer primary care services than physicians paid by enhanced/blended fee-for-service model, especially outside regular working-hours. For most patients, having a physician paid by blended capitation was associated with making more emergency department visits; however, for patients with multiple chronic conditions, blended capitation was associated with a reduction in more urgent emergency department visits. The way primary care physicians are remunerated can influence the way patients receive care, in both the primary care and emergency department setting, as patients in the blended capitation model may receive fewer primary care services but make more less-urgent emergency department visits.

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Summary for Lay Audience

The Ontario government changed the way primary care physicians are paid in response to many residents not being able to get appointments, especially outside of the regular working-hours. Many changes were applied to extend services outside the regular working-hours and this thesis investigates whether they may have reduced emergency department visits. A literature review of current evidence found that better access to primary during after-hours increased use of primary care services, but any reduction in emergency department visits depended on how access was improved and within what type of health care system. Ontario’s after-hours premium, an incentive for primary care physicians to provide appointments outside the regular working-hours was found to lead to a reduction in less-urgent emergency department visits when it was introduced, but later increases in its value were found to lead to only small effects. When compared to other provinces, the increase in the after-hours premium from 20% to 30% did not lead to a reduction in less-urgent emergency department visits. Physicians who were paid based on the number of patients in the practice were found to deliver fewer primary care services compared to physicians who were paid based on the number of services provided, especially for services provided during after-hours. Physicians who were paid based on the number of patients in the practice also had patients who used the emergency department more, except for patients who had multiple chronic conditions, who made fewer urgent emergency department visits. The way primary care physicians are paid can lead to differences in how they deliver services to their patients and how accessible these services are outside of the regular working-hours. These changes in delivery can in turn affect how their patients use the emergency department, with patients in models paid based on the number of patients receiving fewer primary care services but making more visits to the emergency department.

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Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.

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