title: Who gets a family physician through centralized waiting lists?
abstract: BACKGROUND
  North American patients are experiencing difficulties in securing affiliations with family physicians. Centralized waiting lists are increasingly being used in Organisation for Economic Co-operation and Development countries to improve access. In 2011, the Canadian province of Quebec introduced new financial incentives for family physicians' enrolment of orphan patients through centralized waiting lists, the Guichet d'accès aux clientèles orphelines, with higher payments for vulnerable patients. This study analyzed whether any significant changes were observed in the numbers of patient enrolments with family physicians' after the introduction of the new financial incentives. Prior to then, financial incentives had been offered for enrolment of vulnerable patients only and there were no incentives for enrolling non-vulnerable patients. After 2011, financial incentives were also offered for enrolment of non-vulnerable patients, while those for enrolment of vulnerable patients were doubled.
  
  
  METHODS
  A longitudinal quantitative analysis spanning a five-year period (2008-2013) was performed using administrative databases covering all patients enrolled with family physicians through centralized waiting lists in the province of Quebec (n = 494,697 patients). Mixed regression models for repeated-measures were used.
  
  
  RESULTS
  The number of patients enrolled with a family physician through centralized waiting lists more than quadrupled after the changes in financial incentives. Most of this increase involved non-vulnerable patients. After the changes, 70% of patients enrolled with a family physician through centralized waiting lists were non-vulnerable patients, most of whom had been referred to the centralized waiting lists by the physician who enrolled them, without first being registered in those lists or having to wait because of their priority level.
  
  
  CONCLUSIONS
  Centralized waiting lists linked to financial incentives increased the number of family physicians' patient enrolments. However, although vulnerable patients were supposed to be given precedence, physicians favoured enrolment of healthier patients over those with greater health needs and higher assessed priority. These results suggest that introducing financial incentives without appropriate regulations may lead to opportunistic use of the incentive system with unintended policy consequences.
authors: Charles-LeMoyne Hospital Research Centre, Longueuil Campus, 150 Place Charles-LeMoyne, Room 200, Longueuil, J4L 0A8, , Quebec, Canada. mylaine.breton@usherbrooke.ca.|Université de Sherbrooke, Sherbrooke, Quebec, Canada. mylaine.breton@usherbrooke.ca.
authors: Mylaine
authors: M
authors: Breton
authors: Charles-LeMoyne Hospital Research Centre, Longueuil Campus, 150 Place Charles-LeMoyne, Room 200, Longueuil, J4L 0A8, , Quebec, Canada. astrid.brousselle@usherbrooke.ca.|Université de Sherbrooke, Sherbrooke, Quebec, Canada. astrid.brousselle@usherbrooke.ca.
authors: Astrid
authors: A
authors: Brousselle
authors: University of Montreal, Montreal, Quebec, Canada. antoine.boivin@umontreal.ca.|University of Montreal Hospital Research Centre, Montreal, Quebec, Canada. antoine.boivin@umontreal.ca.
authors: Antoine
authors: A
authors: Boivin
authors: Charles-LeMoyne Hospital Research Centre, Longueuil Campus, 150 Place Charles-LeMoyne, Room 200, Longueuil, J4L 0A8, , Quebec, Canada. daniele.roberge@usherbrooke.ca.|Université de Sherbrooke, Sherbrooke, Quebec, Canada. daniele.roberge@usherbrooke.ca.
authors: Danièle
authors: D
authors: Roberge
authors: University of Montreal, Montreal, Quebec, Canada. rpineaul@santepub-mtl.qc.ca.|University of Montreal Hospital Research Centre, Montreal, Quebec, Canada. rpineaul@santepub-mtl.qc.ca.
authors: Raynald
authors: R
authors: Pineault
authors: Charles-LeMoyne Hospital Research Centre, Longueuil Campus, 150 Place Charles-LeMoyne, Room 200, Longueuil, J4L 0A8, , Quebec, Canada. djamal.berbiche@usherbrooke.ca.
authors: Djamal
authors: D
authors: Berbiche
mesh_terms: D065187:Controlled Before-After Studies; D005194:Family Practice / Q000191:economics / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008137:Longitudinal Studies; D009042:Motivation; D010361:Patients / Q000706:statistics & numerical data*; D010821:Physicians, Family / Q000191:economics; D011792:Quebec; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012042:Registries; D014850:Waiting Lists
references: Health Aff (Millwood). 2013 Dec;32(12):2205-15
references: 24226092
references: Milbank Q. 2008 Sep;86(3):375-434
references: 18798884
references: Healthc Policy. 2011 Nov;7(2):e122-35
references: 23115575
references: N Engl J Med. 2013 Mar 14;368(11):980-2
references: 23484824
references: Ann Fam Med. 2005 May-Jun;3(3):223-8
references: 15928225
references: Milbank Q. 2005;83(3):457-502
references: 16202000
references: CMAJ. 2009 May 26;180(11):E72-81
references: 19468106
references: Implement Sci. 2013;8:61
references: 23742217
references: Can Fam Physician. 2001 Jan;47:70-6
references: 11212436
references: Health Aff (Millwood). 2013 Apr;32(4):686-94
references: 23569048
references: JAMA. 2010 Jun 2;303(21):2186-7
references: 20516421
references: J Health Serv Res Policy. 2010 Jul;15(3):178-84
references: 20555042
references: Can Fam Physician. 2012 Sep;58(9):921-2
references: 22972719
references: Med Care. 1996 Feb;34(2):138-51
references: 8632688
references: Qual Saf Health Care. 2005 Feb;14(1):4-5
references: 15691995
references: Ann Fam Med. 2008 Mar-Apr;6(2):107-15
references: 18332402