Fee capitation vs. fee-for-service primary care

Primary care physicians in Ontario, Canada who volunteered to adopt the new capitation model for payment, compared with those who opted for an enhanced fee-for-service model, had fewer sick patients, less after-hours billing, more patients who visited the emergency department and fewer new patients, found a new study in CMAJ http://www.cmaj.ca/press/pgE72.pdf (www.cmaj.ca).

One of the first population-based studies of one of the world’s largest short-term voluntary shifts from fee-for-service to capitation, the study involved more than 500 physicians and almost 500,000 patients under capitation. It included both rural and urban practices.

Primary health care is facing serious concerns internationally, including whether it is a viable model in some areas. Physician shortages, uneven distribution of access to care, and large gaps between guideline-recommended care and actual delivery are key issues. In Canada, almost 4 million people lack a family doctor and more than 2 million have problems getting immediate care.

The differences between capitation and enhanced fee-for-service appeared to be pre-existing rather than due to enrolment in the new model of payment, write Dr. Richard Glazier from the Institute for Clinical Evaluative Sciences (ICES) and coauthors. “While the capitation model provides an alternative to fee-for-service practice, its characteristics should be the focus of future policy development and research.”

Policy makers around the world are considering a variety of initiatives such as new reimbursement models, after-hours care and telephone support, interdisciplinary teams and more.

In a related commentary http://www.cmaj.ca/press/pg1091.pdf, Dr. Barbara Starfield, Johns Hopkins University writes “new approaches to organizing health care services are unlikely to improve unless they are based on a recognition that care needs to be focused on the patient rather than on the disease.” Reforms that aim to improve health and eliminate disparities must support a primary care model as in Ontario.

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