Impact of alternative payment plans on professional equity and daily distress of physicians
The way physicians are paid for the provision of care is a relevant aspect of health care systems. Fee-for-service (FFS) payment system has been criticized for affecting quality of care, contributing to the fragmentation of health care, and for rising costs of health care systems. Alternative payment plans (APP) have been introduced as options to the traditional FFS payment scheme. Despite the link between payment methods and behavior of physicians that has been established; there is a lack of evidence about the impact of payment systems on wellness of physicians, specifically on their perception of professional equity and daily distress of physicians. The purpose of this study was to explore the effects of APP on physicians’ perceptions of professional equity and daily distress. The following questions guided this dissertation: 1) Does professional equity perceived by physicians vary among practitioners paid by FFS, APP, or blended alternatives? 2) Is the payment method associated with daily distress of medical practitioners? and 3) Are levels of professional equity, daily distress, and career satisfaction of physicians different by gender and payment methods? In 2011, a cross-sectional study was conducted with physicians practicing in the Saskatoon Health Region (SHR), the largest health authority of Saskatchewan, Canada. Physicians completed a questionnaire evaluating their perceptions of professional equity and daily distress. Analyses of variances (ANOVA) were performed to assess differences in professional equity (overall and by its fulfillment, financial, and recognition dimensions) and daily distress among physicians paid by FFS, APP, and blended schemes. As multivariable analyses, a linear regression was used to test the interaction between specialty and payment methods on the perception of professional equity, controlling for the number of patients, gender, and age group. A mixed linear regression model was built to predict daily distress, testing demographics, workload, complexity of patients, payment method, career satisfaction, and practice profile; the random component of the model considered the influence of geographic area of practice. Also, a multivariate analysis of variance (MANOVA) was conducted to evaluate differences among professional equity, daily distress, and career satisfaction by payment method and gender. In total, 382 (48.1%) physicians participated in the study. Response bias was tested and found to be negligible (Appendix F). The ANOVA identified that physicians paid by APP perceived higher professional equity than those paid by FFS (p=0.005), as well as higher levels of income (p=0.03) and recognition (p=0.001) equity than those with FFS. In the multivariable analyses, a higher level of professional equity was predicted among family practitioners (FPs) paid by APP and blended schemes in comparison to those paid by FFS. Additionally, the payment method was a predictor of daily distress when adjusted by other factors. Lower levels of distress were found among physicians who had more than 75% of patients with complex conditions and were paid by APP compared to those paid by FFS and blended methods. The MANOVA identified that female physicians had poorer wellness indicators than male practitioners. Multiple comparisons identified higher levels of equity among male physicians paid by APP than those with FFS, although this benefit was not observed among female ones. In conclusion, physicians paid by APP perceived higher professional equity (fair economic rewards and appropriate recognition) in comparison to those paid by FFS. Particularly, FPs paid by APP perceived higher professional equity than those FPs paid by FFS. Additionally, the payment method was identified as an associated factor with distress; lower levels of daily distress were predicted among physicians paid by APP who see high proportions of patients with complex conditions. Notwithstanding, female physicians had poorer wellness indicators and the impact of APP on professional equity was only distinguished among males. A potential unequal impact of APP must be recognized between female and male physicians.
Physicians, Payment methods, Alternative payment plans (APP), Fee-for-service (FFS), Wellness of physicians, Professional equity, Daily distress, Gender, Career satisfaction, Saskatoon Health Region (SHR)
Doctor of Philosophy (Ph.D.)
School of Public Health