General practitioners' altered preferences for private practice vs. salaried positions: a consequence of proposed policy regulations?

Factors that influence specialist physician preferences for fee-for-service and salary-based payment models: A qualitative study

Most physicians across the world are paid through fee-for-service. However, there is increased interest in alternative payment models such as salary, capitation, episode-based payment, pay-for-performance, and strategic blends of these models. Such models may be more aligned with broad health policy goals such as fiscal sustainability, delivery of high-quality care, and physician and patient well-being. Despite this, there is limited research on physicians' preferences for different models and a disproportionate focus on differences in income over other issues such as physician autonomy and purpose. Using qualitative interviews with 32 specialist physicians in Alberta, Canada, we examined factors that influence preferences for fee-for-service (FFS) and salary-based payment models. Our findings suggest that a series of factors relating to (1) physician characteristics, (2) payment model characteristics, and (3) professional interests influence preferences. Within these themes, flexibility, autonomy, and compatibility with academic roles were highlighted. To encourage physicians to select a specific payment model, the model must appeal to them in terms of income potential as well as non-monetary values. These findings can support constructive discussions about the merits of different payment models and can assist policy makers in considering the impact of payment reform.

Primary Care Doctors' Assessment of and Preferences on Their Remuneration

Despite numerous studies on primary care doctors' remuneration and their job satisfaction, few of them have quantified their views and preferences on certain types of remuneration. This study aimed at reporting these views and preferences on behalf of Greek doctors employed at public primary care. We applied a 13-item questionnaire to a random sample of 212 doctors at National Health Service health centers and their satellite clinics. The results showed that most doctors deem their salary lower than work produced and lower than that of private sector colleagues. Younger respondents highlighted that salary favors dual employment and claim of informal fees from patients. Older respondents underlined the negative impact of salary on productivity and quality of services. Both incentives to work at border areas and choose general practice were deemed unsatisfactory by the vast majority of doctors. Most participants desire a combination of per capita fee with fee-for-service; however, 3 clusters with distinct preferences were formed: general practitioners (GPs) of higher medical grades, GPs of the lowest medical grade, residents and rural doctors. Across them, a descending tolerance to salary-free schemes was observed. Greek primary care doctors are dissatisfied with the current remuneration scheme, maybe more than in the past, but notably the younger doctors are not intended to leave it. However, Greek policy makers should experiment in capitation for more tolerable to risk GPs and introduce pay-for-performance to achieve enhanced access and quality. These interventions should be combined with others in primary care's new structure in an effort to converge with international standards.

Private or salaried practice: how do young general practitioners make their career choice? A qualitative study

BACKGROUND

Young French postgraduates in general practice increasingly prefer salaried practice to private practice in spite of the financial incentives offered by the French government or local communities to encourage the latter. This study aimed to explore the determinants of choice between private or salaried practice among young general practitioners.

METHODS

A qualitative study was conducted in the South West of France. Semi-structured interviews of young general practitioners were audio-recorded until data saturation. Recordings were transcribed and then analyzed according to Grounded Theory by three researchers working independently.

RESULTS

Sixteen general practitioners participated in this study. For salaried and private doctors, the main factors governing their choice were occupational factors: working conditions, need of varied scope of practice, quality of the doctor-patient relationship or career flexibility. Other factors such as postgraduate training, having worked as a locum or self-interest were also determining. Young general practitioners all expected a work-life balance. The fee-for-service scheme or home visits may have discouraged young general practitioners from choosing private practice.

CONCLUSIONS

National health policies should increase the attractiveness of ambulatory general practice by promoting the diversification of modes of remuneration and encouraging the organization of group exercises in multidisciplinary medical homes and community health centers.

Duration of general practitioner contracts

BACKGROUND

The regular GP scheme is intended to promote continuity in the relationship between doctor and patient. The duration of GP contracts is therefore a key factor in the success of the scheme. This study examines how long the GP contracts last and whether their duration varies according to doctors' gender and age, municipality size and list size.

MATERIAL AND METHOD

The study encompasses 7,359 GP contracts throughout Norway, entered into between municipalities and doctors in the period 1 May 2001 - 1 May 2014. Duration is measured as the time from which the contract was signed until its expiry or the end of the study period. The material was analysed with measures of central tendencies and dispersion, Kaplan-Meier survival curve analysis and Cox proportional hazards regression.

RESULTS

Median duration of a GP contract at the time of the study was 5.91 years. It varied between 2.75 years in the smallest municipalities and 8.37 years in the largest ones. The duration of a GP contract increased significantly if the doctor was a woman, or with the doctor's age at the start of the contract, increased municipality size and increased list size.

INTERPRETATION

If it is assumed that continuity in the doctor-patient relationship provides a qualitatively better GP service, the results indicate that patients in small municipalities are generally offered a lower-quality service than patients in large municipalities.

Young doctors' preferences for payment systems: the influence of gender and personality traits

OBJECTIVE

Activity-based payment contracts are common among doctors, but to what extent are they preferred? The aim of this paper is to elicit young doctors' preferences for alternative payment systems before they have adapted to an existing system. We examine the existence of gender differences and the extent to which personality traits determine preferences.

METHODS

A cross-sectional survey of all final-year medical students and all interns in Norway examined the extent to which preferences for different payment systems depend on gender and personality traits. Data analysis relied on one-way ANOVA and multinomial logistic regression.

RESULTS

The current activity-based payment systems were the least preferred, both in hospitals (16.6%) and in general practice (19.7%). The contrasting alternative "fixed salary" achieved similar relative support. Approximately half preferred the hybrid alternative. When certainty associated with a payment system increased, its appeal rose for women and individuals who are less prestige-oriented, risk-tolerant or effort-tolerant. Activity-based systems were preferred among status- and income-oriented respondents.

CONCLUSION

The vast majority of young doctors prefer payment systems that are less activity-based than the current contracts offered in the Norwegian health service. Recruitment and retention in less prestigious medical specialities might improve if young doctors could choose payment systems corresponding with their diverse preferences.