What's the link between doctor pay and health-care outcomes?

Does the way we pay doctors affect the care they provide?

That’s the provocative, even taboo question that Cumming School of Medicine postdoc Amity Quinn is looking to answer by mining a rich database on Alberta patients. She is comparing care provided by physicians paid fee-for-service versus salary for patients with diabetes or kidney disease, work for which she has just been awarded a prestigious Banting Postdoctoral Fellowship.

“We take for granted that pay has an impact in other types of work, but there’s some reticence to believe that it affects health care,” Dr. Quinn, PhD, says. “Our goal with this study is to evaluate the merits of different payment models and to contribute to future physician payment policy in Alberta.”

The high cost of chronic disease

Chronic diseases like diabetes, heart disease and kidney disease account for two-thirds of health-care expenditures in Canada. Managing those patients — and that cost — is a pressing question for health-care systems across the country. In Alberta, nearly 85 per cent of doctors are paid using a fee-for-service model, which is nearly double the average internationally where most doctors receive a salary.

Comparing these models will shed much-needed insight on the advantages and pitfalls of each. The study relies on data collected through the Interdisciplinary Chronic Disease Data Repository (ICDC), a unique resource that includes lab, pharmacy, hospital and doctor visit information for all Albertans over many years.

“Our hypothesis is that patients with salary-based specialist physicians will have a lower visit rate, higher illness severity, and lower health-care costs compared to those with doctors paid fee-for-service,” Quinn says. “Salaried doctors have the incentive to deliver preventive care, reduce service volume, and co-ordinate care with other providers since they are not paid for additional visits.”

Turning raw data into meaningful information

And while the ICDC is a rich databank to work with — dating back as far as 2004 , including the current study totalling more than 100,000 patients — the hard work for Quinn is in connecting the dots and creating meaningful findings out of raw data on hospital stays, lab results, medications and outpatient visits. Like a pointillist painter, Quinn needs to create a complete patient picture from discrete data points. After that, she sorts patients according to whether they are seeing a fee-for-service or salaried physician.

“I have to take all that data, figure out where all the things are that I need in different files, pull them all together focusing on the dates I’m interested in. Everyone is de-identified, and there is not necessarily a single variable that says they have chronic kidney disease. What I have to do is link individuals to their data, that’s the starting point,” Quinn says.

“It was clear right off the bat that patients seeing salaried physicians were sicker, and that was an interesting outcome in itself,” Quinn says. But those differences also complicate Quinn’s work: “If patients are sicker in the first place, it is harder to know if a payment model had a significant effect.”

To overcome those challenges and to isolate the payment variable as much as possible, Quinn used propensity score matching, creating pairs of patients who were comparable in every characteristic aside from the way their physician was paid.

A standout applicant, a perfect fit

“In looking at postdocs to complement our team, Amity’s CV certainly stood out,” says her supervisor Dr. Braden Manns, MD, a nationally recognized researcher and kidney disease specialist, Svare professor in health economics, associate chief medical officer of the Alberta Health Services Strategic Clinical Networks and co-lead of the ICDC. “She had done a lot of work on funding models already, she’s used to working with costing data sets, and she’s used to thinking about how a funding model might incentivize care.”

“This was exactly the perfect job,” Quinn says. “Braden was already interested in this area of study, and I had a background in my work in the US looking at funding models and addiction and mental health care. It has been a great fit.”

About a year in, the team already has some findings to report, with two papers under review and a third on the way. “We’ve observed that indeed fee-for-service payment results in patients being seen more frequently, but it doesn’t appear that this leads to better care, so we might be spending more without getting more,” says Manns, a professor in the departments of medicine and community health sciences and member of the O’Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta. “But actually, neither model was perfect.”

The third phase of Quinn’s work is to interview doctors in person, to better understand whether "how" they get paid impacts the care they provide.

“There are so many questions that have arisen from this work,” Quinn says. “I’m looking forward to the next stage of the study when we will be conducting interviews with people within the system to learn more about what is going on.”

Banting program recognizes research that will positively contribute to Canada’s growth

The Banting Postdoctoral Fellowships were announced yesterday at the University of Alberta. In addition to Quinn, University of Calgary postdoc Dr. Georgia Balsevich, PhD, has received a Banting Postdoctoral Fellowship for her research on chronic stress and metabolism. Balsevich is a previous Killam Postdoctoral Laureate, training with Dr. Matthew Hill, PhD, associate professor in the departments of psychiatry, and cell biology and anatomy, and member of the Hotchkiss Brain Institute at the CSM.

“We are pleased that the Government of Canada has recognized Georgia Balsevich and Amity Quinn for their pursuit of new knowledge and transformative research,” says Dr. Ed McCauley, vice-president (research). “Banting Postdoctoral Fellowships position young scholars for success as tomorrow’s research leaders, and we are thrilled to be part of this exciting phase of their careers.”

The University of Calgary Postdoctoral Program attracts the best and brightest emerging scholars with world-class professional training that prepares them to pursue rewarding careers in industry, academia, government, and non-governmental organizations. Through the unique Eyes High Postdoctoral Scholars Competition, the university has invested in more than 185 postdocs, bringing the total number of postdoctoral scholars on campus to over 500, ranking the program among the top five in Canada.