Numerous studies have shown that fee-for-service (FFS) leads to increased provision of care, while capitation leads to reduced provision of care.My own research shows that there are system-wide effects, and The impact of capitated payments for primary care physicians on services may depend on whether specialists are also reimbursed through fee-for-service. However, it is unclear how increasing the proportion of capitation reimbursement affects the delivery of health care services. This is important for a number of reasons. First, CMS increasingly turns to alternative payment models It’s looking more and more like capitation.Second, most health care services in the United States are Hybrid reimbursement plan.3. Reimbursement type Different countries have different; For example, in Norway and Denmark, FFS accounts for 70% to 80% of total reimbursement, but in the home health organization plan in Ontario, Canada, the FFS component only covers 10% of total reimbursement.
To study this issue, the authors published a paper Skosgaard et al. (2023) In 2018, Denmark introduced changes to general practitioner reimbursement specifically for treating patients with type 2 diabetes. The specific changes are as follows:
In addition to the basic one-time capitation fee per patient, the new one-time capitation fee for patients with type 2 diabetes is set at DKK 2045 (approximately US$280) per patient per year. This amount is higher than the corresponding mean FFS for patients with type 2 diabetes who discontinue medication. Note that capitation replaces FFS for all contacts of a person with type 2 diabetes (not just diabetes-related contacts). The remaining FFS charges beyond the reforms include a range of supplementary services, including guideline-recommended HbA1c monitoring, influenza vaccination, and microalbuminuria testing by assessing protein in the urine.The services recommended by these guidelines are process quality measures that show whether changes in service delivery affect the quality of care
https://onlinelibrary.wiley.com/doi/full/10.1002/hec.4736
In terms of empirical strategy, the author adopts a difference-in-difference method. Pre-release is the difference between outcomes and interest before and after the annual control visit. We examined service changes to control access in 2018-2019 compared to 2015-2016. Outcomes or interests are: (i) number of doctor visits (in person, phone and email), (ii) number of diabetes-related laboratory tests (e.g. urine sticks and HbA1c tests), (iii) influenza vaccinations, (iv) number of diabetes-related laboratory tests related supplementary services, and (v) supplementary services not related to diabetes.
Using this approach, the authors found:
The impact of enrolling patients into the new program is negative, decreasing by approximately 2% compared to baseline values (ATT = -0.27%; -1.9%)…The impact of enrollment on supplementary services (s) results related to diabetes guidelines were negative, with a decrease of approximately 4% compared to baseline (ATT = -12.29%; -4.4%)… Results [also] showed reductions of 5.0%, 5.4%, and 4.2% in urine sticks, blood samples, and affected vaccinations, respectively, compared to baseline.
To test the robustness of their findings, the authors looked at services not included in the new reimbursement plan (such as lipid-lowering medications) and found no effect in this placebo test.
The authors speculate that the reason that the decrease in supplemental services is greater than the decrease in office visits is because face-to-face visits have been replaced by telephone and email contacts, which now allow for immediate provision of supplementary services.
You can read the full article here.
