Does the way we pay primary care providers influence emergency department use during after-hours?
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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