Q&A: Incentivizing physicians to work after business hours reduces ED visits

A financial incentive that the Ontario government provides to eligible Canadian family physicians who work outside regular business hours was associated with a reduction in nonurgent ED visits, according to researchers.

“One prominent health policy issue confronting many countries is overcrowding of the emergency department,” Michael Hong, BMSc, a PhD candidate from Schulich Medicine & Dentistry at Western University in Canada, and colleagues wrote. “Not only does overcrowding result in longer wait times in the emergency department, but it may be associated with patient dissatisfaction and higher risk of death, as well as contribute to higher health system costs.”

In July 2003, Ontario introduced an after-hours premium for family physicians who provide primary care services after hours, according to Hong and colleagues. The researchers recently conducted a retrospective cohort study to investigate the impact of the after-hours premium on the number of less-urgent ED visits in the province. They analyzed data from 586,534 patients in Ontario between 2002 and 2006. From that initial sample, the researchers further assessed data on 201,594 patients who were followed from 2005 to 2016.

Patients were categorized by their physician’s eligibility to bill for the after-hours premium each month. Physicians who participated in patient enrollment models — which is a combination of fee-for-service, blended capitation and other specialized models — were eligible to receive the after-hours premium; those who used a traditional fee-for-service model were not.

Hong and colleagues found that for each 1,000 patients, the after-hours premium was associated with 1.26 fewer less-urgent visits to an ED monthly (95% CI, –1.48 to –1.04), after controlling data for patient and physician characteristics, seasonality and time-invariant patient confounding factors.

“Most of this reduction was observed in after-hours visits,” the researchers wrote in the Canadian Medical Association Journal.

They added that the findings are consistent with a previous study that found incentivizing physicians to be available for longer hours was associated with a small reduction in nonurgent ED visits. However, the findings differ from another study that showed a patient enrollment model led to more ED visits in Ontario.

Below, study coauthor Sisira Sarma, PhD, of the department of epidemiology and biostatistics at Schulich Medicine & Dentistry, provides more information.

Healio Primary Care: Can you please describe the incentive?

Sarma: The after‐hours premium is an incentive for family physicians working within the patient enrollment models. It was introduced in July 2003 at 10%, increased to 15% in April 2005, 20% in April 2006 and to 30% in September 2011.

Sisra Sarma

Family physicians can claim this incentive on a specific set of services provided to patients enrolled to their practice when provided during evenings and overnight (eg, 5 p.m. to 8 a.m.), as well as on weekends and statutory holidays.

The after‐hours premium was one of the first incentives along with other reforms developed during the primary care reform initiatives of the government of Ontario in the early 2000s. The overarching objective was to improve access to primary care in the population.

Healio Primary Care: What were some of the responses that physicians and patients had to the incentive?

Sarma: There has been a strong uptake of this incentive by physicians since its adoption. Although we have not focused on responses of patients, some evidence suggests improved access to primary care services by patients.

Healio Primary Care: How does the pandemic impact the need for this incentive?

Sarma: The after‐hours premium could potentially be reducing hospital strain [and] diverting patients who can be managed in the primary care setting. Improved primary care access outside of the regular working hours, now over the phone, would allow patients to continue to seek care from their primary care physicians, helping patients who are concerned about seeking care in the ED given the pandemic.

Reference:

Hong M, et al. CMAJ. 2021;doi:10.1503/cmaj.200277.