title: Paying for primary care: a cross-sectional analysis of cost and morbidity distributions across primary care payment models in Ontario Canada.
abstract: Policy-makers desire an optimal balance of financial incentives to improve productivity and encourage improved quality in primary care, while also avoiding issues of risk-selection inherent to capitation-based payment. In this paper we analyze risk-selection in capitation-based payment by using administrative data for patients (n = 11,600,911) who were rostered (i.e., signed an enrollment form, or received a majority of care) with a primary care physician (n = 8621) in Ontario, Canada in 2010/11. We analyze this data using a relative distribution approach and compare distributions of patient costs and morbidity across primary care payment models. Our results suggest a relationship between being in a capitation-based payment scheme and having low cost patients (and presumably healthy patients) compared to fee-for-service physicians. However, we do not have evidence that physicians in capitation-based models are reducing the care they provide to sick and high cost patients. These findings suggest there is a relationship between payment type and risk-selection, particularly for low-cost and healthy patients.
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Ontario, Canada; Canadian Centre for Health Economics, Canada. Electronic address: david.rudoler@utoronto.ca.
authors.forename: David
authors.initials: D
authors.lastname: Rudoler
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Ontario, Canada; Canadian Centre for Health Economics, Canada.
authors.forename: Audrey
authors.initials: A
authors.lastname: Laporte
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Ontario, Canada.
authors.forename: Janet
authors.initials: J
authors.lastname: Barnsley
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Ontario, Canada; Centre for Research on Inner City Health, and St. Michael's Hospital, Ontario, Canada; Family and Community Medicine, University of Toronto and St. Michael's Hospital, Canada.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Glazier
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Ontario, Canada; Canadian Centre for Health Economics, Canada.
authors.forename: Raisa B
authors.initials: RB
authors.lastname: Deber
mesh_terms: D003430:Cross-Sectional Studies; D003953:Diagnosis-Related Groups / Q000191:economics*; D005249:Fees and Charges; D017048:Health Care Costs; D006801:Humans; D007349:Insurance, Health, Reimbursement; D018803:Models, Economic; D009313:National Health Programs / Q000191:economics*; D009864:Ontario; D011320:Primary Health Care / Q000191:economics*; D012052:Reimbursement, Incentive
keywords: Canada; Case mix; Ontario; Payment incentives; Physician behavior; Primary care; Relative distribution