Family physicians provide care at most medical visits in Canada.1 However, the rates of burnout among family physicians (FPs) are high2-4 and recent surveys suggest as many as 6.5 million people in Canada do not have a regular primary care provider.5 Recognizing the urgency of addressing primary care access challenges, federal and provincial governments have committed substantial investments to drive transformative, multifaceted reforms.6,7 A focus of these reforms is altering physician payment models.6 There are long-standing calls to address pay inequity among medical specialties and to closely examine the potential unintended consequences of the widely used fee-for-service (FFS) payment model.8
New, blended, FP payment models are being rapidly implemented in several Canadian provinces.9-14 These models have been developed through collaboration between ministries of health and physician associations, and include compensation based on hours worked, fees per patient visit, and annual incentives for panel size and patient complexity. British Columbia was the first province to provide a blended model and, according to media coverage, adopting the model could result in approximately 20% more income in a typical year.15 This combination of blended elements has not been previously implemented or evaluated, nor has there been any public access to changes in family physician income in British Columbia.
The stated objectives of these blended models vary by jurisdiction but they share common goals: increasing the desirability of family medicine as a specialty and enhancing the availability of community-based family practice.9-12 Press releases suggest that they could reduce administrative burdens, allow physicians to spend more time with patients, and make it easier for unattached patients to find family doctors.10,13,14,16,17
Historically, physician remuneration models have been classified along a variable versus fixed continuum.18 FFS is a variable model whereby payments vary based on the volume and type of services provided. Until recently, FFS has accounted for most FP payments in Canada. In contrast, salaried models offer a fixed income regardless of service volume, for a defined “basket of services” outlined in a job description. Capitation—payment per patient on a physician’s roster—falls in between these models. Each has limitations suggested by theory and empirical research. The FFS model might incentivize volume over quality, while salaried models might limit service quantity and valuable care. Capitation could encourage “cream skimming” where FPs might favour younger, healthier patients.19
The new blended models appear to be intentionally designed to balance the potential negative incentives of pure fixed or variable payment models and align positive incentives with high-quality care and positive patient outcomes, while also increasing FP pay.
How, and how much, doctors are paid likely plays a pivotal role in shaping the health care landscape, and remuneration is a key part of health care policy, influencing physician behaviour, patient care, system outcomes, and costs.19-22 The Canadian-developed Wranik–Durier-Copp physician remuneration framework outlines how payment structures potentially shape physician behaviour, which can affect patient access, health equity, comprehensiveness of practice, continuity of care, and willingness to collaborate and provide continuity of care.23 However, reporting and studies on the FP payment models and how they impact patient care, access, and physician retention are limited and show mixed results.20,24-28 A systematic review from 2001 noted that while there is some evidence that payment systems affect FP behaviour, the lack of high-quality studies is surprising, given the importance of the issue.25 We still lack reliable evidence 24 years later and the primary care crisis has worsened.
The new blended models have generated substantial media attention and statements of optimism from physician associations.29-31 Early reports from British Columbia suggest that the blended model is acceptable to many FPs who were previously paid via the longstanding FFS model.32 However, it is unclear whether and how the new model has improved patient attachment to family doctors, health equity, or care quality, or if it has reduced physician burnout. It is also unclear how we will determine if any observed impacts result solely from the model change or from the increase in physician income.
The goals of increasing attachment and reducing administrative burden are arguably essential elements in addressing the primary care crisis. However, the blended models cannot add hours to a workday (which would enable physicians to see more people), and in their current form, they do not directly address health equity or facilitate a shift to team-based care. While they provide hourly compensation for indirect patient care and other administrative work that might reduce the financial and psychological burden of this work, they do not decrease the number of required tasks. Like most efforts to date, the policies supporting the blended models treat individual physicians as the unit of the solution rather than considering clinics, communities, or the health care system as a whole.6,33-36
Given the substantial investment in these new remuneration models and the high hopes pinned on them to address the primary care crisis, rigorous and transparent evaluation is essential. Ideally, we would see FPs across the country participating in this evaluation by including their health record information in research networks and signing up for focus groups and interviews to provide information about their personal experience.37 This evaluation should answer questions around 4 key areas.
Quality and patient experience of care
Will the new payment models improve the quality of care patients receive, and will patients who have experienced inequity or barriers have greater ability to access care? While we have some research about how FP behaviour changes under different payment models,38 the impact of physician payment on patient experience and health outcomes is even less clear. It is crucial to understand how the new blended model affects care coordination and patient-centredness to improve health care quality and equity.
Patient attachment, service volume, costs
Will the new blended models allow more people to access primary care, in a timely manner, and at a cost that is sustainable by the system? Only limited, older studies explore the effects of payment models on health care system capacity and patient access. Some results show that variable payment models increase service volume, including patient visits and care continuity, compared with fixed models.20,25 One study showed that patients whose FPs are paid by fixed remuneration (eg capitation) were less likely to get same- or next-day appointments, but this problem was reduced in team-based care settings.39 Other research has shown that when FPs already providing comprehensive care are provided a pay increase, they are able to scale back their hours, possibly to prioritize their own well-being and the sustainability of their practice.40 Examining how the blended model will influence attachment, patient wait times, appointment availability, and health care utilization is essential.
Clinician experience
Do FPs paid using the new blended models enjoy their work more and experience less burnout and is administrative burden reduced? Insight into how remuneration models influence physician experiences, burnout, and practice choices is limited. We do know that FPs have changed their expectations about what constitutes a satisfying work environment in the past 10 years,41,42 and the intention to pursue comprehensive versus focused practice has been studied.43,44 However, we do not know how remuneration models shape these experiences.
Recruitment and retention
Will the new blended models increase the net new number of family doctors providing comprehensive primary care and will the new model delay retirement? Most research on FP recruitment and retention to date has focused on rural and remote areas and it is not known if those findings also apply to more urban settings.28,45 Given the primary care health workforce gaps in almost every community, we need to understand the influence of specific remuneration models on FP recruitment and retention in most Canadian settings. It is also important to understand what the impact of having more family doctors doing comprehensive practice is on staffing for other key areas of the health workforce (eg, emergency department physicians or hospitalists) that also rely on FPs.
Conclusion
Canada’s introduction of blended payment models for primary care physicians is a large investment to address the primary care crisis. While these models are promising, their impact is yet unknown. Rigorous evaluation is essential to determine their effectiveness in revitalizing primary care. Success hinges on aligning with broader health care goals, supporting team-based care, and addressing inequities. Collaborative efforts among policy-makers, providers, and researchers are crucial to monitor outcomes, make adjustments, and ensure these models serve both patients and physicians to build a more robust and equitable primary care system.
Footnotes
The opinions expressed in this article are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
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This article has been peer reviewed.
Cet article se trouve aussi en français à la page 388.
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