Enhanced FFS Model and Patient Access: Evidence from FHG Model in Ontario

1. Enhanced FFS Model and Patient Access: Evidence from FHG Model in Ontario Jasmin Kantarevic, Boris Kralj, Darrel Weinkauf Ontario Medical Association

2. Outline Patient Enrolment Models in Ontario Comparison of FFS and FHG Models Data and Empirical Framework Results FHG physicians provide more services, visits, and see more patients than comparable FFS physicians. No adverse impact on referral rates or patient selection.

3. Primary Care Renewal in Ontario • Started in early 2000s • The focus is on how to pay family physicians • Goals of new reform: • Improved access • Improved quality • Lower cost • Rejection of pure FFS, capitation, or salary • Introduction of Patient Enrolment Models (PEM)

4. Patient Enrolment Models Base Payment (FFS, Capitation, or Salary) + Additional Elements:

5. Percent of Family Physicians in PEM, 1999-2009

6. Primary Care Physicians in Ontario, January 2010

7. In This Paper: Zoom in on Family Health Groups Introduced in 2003 Enhanced FFS model Most popular model for family physicians Usually the first stop from FFS to PEM Focus on access to physician services Services, visits, patients

8. Comparison of FFS and FHG Models

9. Data • Ontario Health Insurance Plan (OHIP) Claims • Fiscal 1992/3 to 2008/9 • Almost all family physicians in Ontario • 11 years before and 5 years after introduction of FHG • Lots of detail at the service level • Payment/administrative data • Minimal demographics (age, sex, postal code)

10. Empirical Strategy y log of outcome (services, visits, distinct patients)  physician fixed effects  year fixed effects  physician-specific linear trend w time-varying controls FHG =1 if FHG, = 0 if FFS  Difference in difference estimate of FHG impact

11. Selecting Comparison Sample • Sample of all family physicians in 2002 • Propensity to Ever Join FHG • Covariates = age, gender, expected income gain, after-hour days, 14 geographic (LHIN) indicators • Selecting Comparison Sample • Nearest neighbor matching • Replacement Option • Follow this sample over 1992-2008 period

12. Summary Statistics, 2002

13. Common Trend Assumption: Log of annual services

14. Common Trend Assumption: Log of annual visits

15. Common Trend Assumption: Log of annual distinct patients

16. Initial Estimates

17. Multiple “Experiments”

18. Leads and Lags:Log of annual services

19. Leads and Lags:Log of annual visits

20. Leads and Lags:Log of annual distinct patients

21. Alternative Samples:Shadow Claims and Harmonized Physicians

22. Alternative Samples:Income Restrictions

23. Impact by Age and Gender

24. Impact by Location

25. Decomposition of Impact on Services

26. Impact on Referrals and Complexity

27. Implications • How we pay physicians may affect patient access • FHG a promising alternative to traditional FFS model • Access important in many jurisdictions: • Aging physician population • Increasing number of female physicians • Changing preferences

28. Future Research • Impact of FHG incentives on cost and quality • Study of entire spectrum of PEM models • Determinants of transition • Impact of transition on physician behaviour