A systematic review of the effect of payment mechanisms on family physicians service provision and referral rate behavior

BACKGROUND:

Family medicine is undergoing reforms in several countries. In order to attain the health care objectives such as quality, efficiency and accessibility, different tools are being utilized including legislation, organizational models and financial incentives. The purpose of this literature review is to discuss the impact of different methods of payment to family physicians and general practitioners, quantity of service provision and referral rate behavior.

METHODS:

We carried out a systematic literature search in five electronic databases including PubMed, Science Direct, Emerald, Wiley Inter Science, Springer Link and ANNFAMMED published to September 2011. We also reviewed the references of the final selected articles to identify the relevant articles. Search strategy included the following combination of keywords: “payment”, “reimbursement”, “compensation method”, “general practitioner” and “service provision”. From 2738 articles that were identified in our first search, eleven articles were included in the final review. We extracted data from the selected articles and performed content analyses in regards to the type of intervention.

RESULTS:

In comparison to salary and capitation, fee-for-service (FFS) was associated with 9%-12% lower referral rate presumably because physicians wanted to treat patients and increase their incomes by producing more services. Compared with FFS, capitation payment decreased the number of provided services (14% lower visits in the outpatient settings and 50%-60% lower visits in the inpatient settings) due to budget limitations. We found that referral rate to hospitals and specialists increased up to 20% in capitation.

CONCLUSION:

This literature review shows that each payment method for family physicians and health professionals creates a particular set of incentives for physician. While nations act differently and in line with their health system goals and context, international experience suggests some guidance for policy makers. New policies should ensure a payment system that is optimal for local health care delivery structure and compliant with local laws, regulations, and tax system.