Does how primary care physicians are paid impact on their behaviour?

It is believed widely that the method by which physicians are paid affects their professional behaviour. In the fee-for-service (FFS) model, physicians are paid a fee for each unit of care they provide. With target payments, physicians are paid a lump sum only if a specified target level of service is provided. Under capitation, physicians are remunerated for each registered patient, to cover the services provided to them. Salaried physicians receive a lump sum salary for a specified number of work hours. Payment systems for physicians have been manipulated to attempt to achieve policy objectives such as improving quality of care, cost containment and recruitment to underserved areas.

Key messages

• Very low quality evidence suggests that fee-for-service can achieve higher compliance with recommended frequencies of patient visits. The impact of fee-for-service on the quantity of primary care services is not well documented and is likely to depend on fee-for-service rates
• A small study found that salaried primary care professionals may have fewer scheduled visits and well child visits, and more emergency visits, compared with fee-for-service primary care professionals. However, fee-for-service physicians have more visits than a recommended schedule
• Evidence on the impact of target payments, compared to fee-for-service, on immunisation rates is inconclusive
• All of the included studies were from high income countries