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Impact of physician payment mechanism on emergency department operational performance

  • Grant D. Innes (a1), Frank X. Scheuermeyer (a2), Julian Marsden (a2), Chad Kim Sing (a3), Dan Kalla (a2), Rob Stenstrom (a2), Michael Law (a4) and Eric Grafstein (a2)...

Abstract

Objective

Fee-for-service payment may motivate physicians to see more patients and achieve higher productivity. In 2015, emergency physicians at one Vancouver hospital switched to fee-for-service payment, while those at a sister hospital remained on contract, creating a natural experiment where the compensation method changed, but other factors remained constant. Our hypothesis was that fee-for-service payment would increase physician efficiency and reduce patient wait times.

Methods

This interrupted time series with concurrent control analysed emergency department (ED) performance during a 42-week period, encompassing the intervention (fee for service). Data were aggregated by week and plotted in a time series fashion. We adjusted for autocorrelation and developed general linear regression models to assess level and trend changes. Our primary outcome was the wait time to physician.

Results

Data from 142,361 ED visits were analysed. Baseline wait times rose at both sites during the pre-intervention phase. Immediately post-intervention, the median wait time increased by 2.4 minutes at the control site and fell by 7.2 minutes at the intervention site (difference=9.6 minutes; 95% confidence interval, 2.9-16.4; p=0.007). The wait time trend (slope) subsequently deteriorated by 0.5 minutes per week at the intervention site relative to the expected counterfactual (p for the trend difference=0.07). By the end of the study, cross-site differences had not changed significantly from baseline.

Conclusion

Fee-for-service payment was associated with a 9.6-minute (24%) reduction in wait time, compatible with an extrinsic motivational effect; however, this was not sustained, and the intervention had no impact on other operational parameters studied. Physician compensation is an important policy issue but may not be a primary determinant of ED operational efficiency.

Objectif

Le mode de paiement à l’acte peut inciter les médecins à voir plus de patients et ainsi à accroître la productivité. En 2015, des urgentologues travaillant dans un hôpital de Vancouver sont passés au mode de paiement à l’acte, tandis que d’autres travaillant dans un hôpital de type et de grosseur comparables ont conservé le mode de paiement contractuel, ce qui a permis de mener une expérience naturelle dans laquelle seuls les modes de rémunération avaient changé, les autres facteurs étant restés égaux par ailleurs. Aussi l’étude visait-elle à vérifier l’hypothèse selon laquelle le paiement à l’acte augmenterait l’efficience des médecins et réduirait le délai d’attente des patients.

Méthode

Il s’agit d’une étude de séries temporelles interrompues, comparative avec témoin concomitant, qui visait à analyser la performance au service des urgences (SU) sur une période de 42 semaines, après la mise en œuvre de l’intervention (le paiement à l’acte). Les données ont d’abord été agrégées sur une base hebdomadaire, puis représentées sous forme de graphique tracé en fonction des séries temporelles. Il y a eu un rajustement des données pour tenir compte de l’autocorrélation et nous avons élaboré des modèles généraux de régression linéaire afin d’évaluer les changements de valeur et de tendance. Le principal critère d’évaluation était le délai d’attente des patients avant la consultation médicale.

Résultats

Ont été recueillies, puis analysées des données concernant 142 361 consultations au SU. Les délais d’attente ont augmenté au départ dans les deux hôpitaux durant la phase avant l’intervention. Immédiatement après l’intervention, le délai d’attente médian a augmenté de 2,4 minutes dans le centre témoin et a diminué de 7,2 minutes dans le centre expérimental (écart=9,6 minutes; intervalle de confiance à 95 % : 2,9-16,4; p=0,007). Par la suite, le délai d’attente s’est détérioré et tendait (pente) à augmenter de 0,5 minute par semaine, dans le centre expérimental par rapport à la valeur contre-factuelle prévue (écart de tendance : p=0,07). À la fin de l’étude, l’écart entre les deux hôpitaux avait peu changé par rapport aux valeurs de départ.

Conclusion

Le mode de paiement à l’acte a certes été associé à une réduction du délai d’attente de 9,6 minutes (24 %), réduction compatible avec un effet de motivation extrinsèque, mais le rythme ne s’est pas maintenu par la suite, si bien que l’intervention n’a eu aucune incidence sur d’autres paramètres fonctionnels étudiés. La rémunération des médecins soulève une question importante de politique, mais elle pourrait bien ne pas constituer un déterminant fondamental de l’efficience opérationnelle au SU.

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Copyright

Corresponding author

Correspondence to: Dr. Grant Innes, 781 East 8th Street, North Vancouver, BC V7L 2A1; Email: Grant.innes@ahs.ca

References

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1. Leger, P. Physician payment mechanisms: an overview of policy options for Canada; 2011. Available at: http://www.cfhi-fcass.ca/sf-docs/default-source/hospital-funding-docs/CHSRF-LegerPhysicianRenumerationENG.pdf?sfvrsn=0 (accessed 12 August 2016).
2. Gosden, T, Forland, F, Kristiansen, IS, et al. Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database Syst Rev 2000;3:CD002215, 10.1002/14651858.CD002215.
3. Office of the Auditor General of BC. Alternative payment to physicians: a program in need of change; 2003. Available at: http://www.bcauditor.com/pubs/2003/report4/alternative-payments-physician-program-compensation (accessed 14 August 2016).
4. Khullar, D, Chokshi, DA, Kocher, R, et al. Behavioral economics and physician compensation – promise and challenges. N Engl J Med 2015;372:2281-2283.10.1056/NEJMp1502312
5. Blomqvist, A, Busby, C. How to pay family doctors: why pay per patient is better than fee for service; 2012. Available at: https://www.cdhowe.org/public-policy-research/how-pay-family-doctors-why-pay-patient-better-fee-service (accessed 19 July 2016).
6. Innes, GD. Eat what you kill. CJEM 2000;2(4):228-229.10.1017/S1481803500007211
7. Schroeder, S, Frist, W. Phasing out fee-for-service payment. N Engl J Med 2013;368:2029-2032.10.1056/NEJMsb1302322
8. Eric Grafstein (Chair, VCH Regional Emergency Services Council). Personal communication. February 2016.
9. Fox, J, Weisberg, S. An {R} companion to applied regression, 2nd ed. Thousand Oaks: Sage; 2011.
10. Coghlan, A. A little book of R for multivariate analysis. Available at: https://little-book-of-r-for-multivariate-analysis.readthedocs.io/en/latest/.
11. Pinheiro, J, Bates, D, DebRoy, S, Sarkar, D, R Core Team: _nlme. Linear and Nonlinear Mixed Effects Models_. R package version 3.1-118; 2014. Available at: http://CRAN.R-project.org/package=nlme (accessed 12 February 2018).
12. Croskerry, P. Critical thinking and decision-making: avoiding the perils of thin-slicing. Ann Emerg Med 2006;48:720-722.10.1016/j.annemergmed.2006.03.030
13. Croskerry, P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ 2009;14:27-35.10.1007/s10459-009-9182-2
14. Rathlev, NK, Chessare, J, Olshaker, J, et al. Time series analysis of variables associated with daily mean emergency department length of stay. Ann Emerg Med 2007;49(3):265-271, 10.1016/j.annemergmed.2006.11.007.10.1016/j.annemergmed.2006.11.007
15. Zun, LS. Analysis of the literature on emergency department throughput. West J Emerg Med 2009;10(2):104-109.
16. Affleck, A, Parks, P, Drummond, A, et al. Emergency department overcrowding and access block. CJEM 2013;15(6):359-370, 10.2310/8000.CAEPPS.10.1017/S1481803500002451
17. Asplin, BR, Magid, DJ, Rhodes, KV, et al. A conceptual model of emergency department crowding. Ann Emerg Med 2003;42:173-180.10.1067/mem.2003.302
18. Fretheim, A, Zhang, F, Ross-Degnan, D, et al. A reanalysis of cluster randomized trials showed interrupted time-series studies were valuable in health system evaluation. J Clin Epidemiol 2015;68(3):324-333, 10.1016/j.jclinepi.2014.10.003.10.1016/j.jclinepi.2014.10.003
19. Penfold, RB, Zhang, F. Use of interrupted time series analysis in evaluating health care quality improvements. Acad Pediatr 2013;13(6 Suppl):S38-S44, 10.1016/j.acap.2013.08.002.10.1016/j.acap.2013.08.002
20. Wagner, AK, Soumerai, SB, Zhang, F, Ross-Degnan, D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002;27:299-309.10.1046/j.1365-2710.2002.00430.x
21. Shadish, W, Cook, T, Campbell, D. Quasi-experiments: interrupted time-series designs. Experimental and quasi-experimental designs for generalized causal inference. Boston: Houghton Mifflin Company; 2002: 171-206.

Keywords

Impact of physician payment mechanism on emergency department operational performance

  • Grant D. Innes (a1), Frank X. Scheuermeyer (a2), Julian Marsden (a2), Chad Kim Sing (a3), Dan Kalla (a2), Rob Stenstrom (a2), Michael Law (a4) and Eric Grafstein (a2)...

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