Impact of physician payment mechanism on emergency department operational performance

Abstract

CLINICIAN'S CAPSULEWhat is known about the topic? Fee-for-service compensation may motivate physicians to see more patients and improve throughput, or drive excessive testing and referral behaviour that undermine emergency performance. What did this study ask? Does fee-for-service payment reduce emergency wait times, length of stay, and left without being seen rates? What did this study find? We observed an unsustained 24% reduction in time to physician, but no change in length of stay or left without being seen rates. Why does this study matter to clinicians? Fee-for-service compensation may have transient motivational effect but is unlikely to generate system-level improvement. ABSTRACTObjective: Fee-for-service payment may motivate physicians to see more patients and achieve higher productivity. In 2015, emergency physicians at one Vancouver hospital switched to fee-for-service payment, while those at a sister hospital remained on contract, creating a natural experiment where the compensation method changed, but other factors remained constant. Our hypothesis was that fee-for-service payment would increase physician efficiency and reduce patient wait times. Methods: This interrupted time series with concurrent control analysed emergency department (ED) performance during a 42-week period, encompassing the intervention (fee for service). Data were aggregated by week and plotted in a time series fashion. We adjusted for autocorrelation and developed general linear regression models to assess level and trend changes. Our primary outcome was the wait time to physician. Results: Data from 142,361 ED visits were analysed. Baseline wait times rose at both sites during the pre-intervention phase.Immediately post-intervention, the median wait time increased by 2.4 minutes at the control site and fell by 7.2 minutes at the intervention site (difference = 9.6 minutes; 95% confidence interval, 2.9-16.4; p = 0.007). The wait time trend (slope) subsequently deteriorated by 0.5 minutes per week at the intervention site relative to the expected counterfactual (p for the trend difference = 0.07). By the end of the study, cross-site differences had not changed significantly from baseline. Conclusion: Fee-for-service payment was associated with a 9.6-minute (24%) reduction in wait time, compatible with an extrinsic motivational effect; however, this was not sustained, and the intervention had no impact on other operational parameters studied. Physician compensation is an important policy issue but may not be a primary determinant of ED operational efficiency. RÉSUMÉObjectif: Le mode de paiement à l'acte peut inciter les médecins à voir plus de patients et ainsi à accroître la productivité. En 2015, des urgentologues travaillant dans un hôpital de Vancouver sont passés au mode de paiement à l'acte, tandis que d'autres travaillant dans un hôpital de type et de grosseur comparables ont conservé le mode de paiement contractuel, ce qui a permis de mener une expérience naturelle dans laquelle seuls les modes de rémunération avaient c...

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