Association of physician payment model and team-based care with timely access in primary care: a population-based cross-sectional study

Abstract

Background: It is unclear how patient-reported access to primary care differs by physician payment model and participation in team-based care. We examined the association between timely and after-hours access to primary care and physician payment model and participation in team-based care, and sought to assess how access varied by patient characteristics.

Methods: We conducted a cross-sectional analysis of adult (age ≥ 16 yr) Ontarians who responded to the Ontario Health Care Experience Survey between January 2013 and September 2015, reported having a primary care provider and agreed to have their responses linked to health administrative data. Access measures included the proportion of respondents who reported same-day or next-day access when sick, satisfaction with time to appointment when sick, telephone access and knowledge of an after-hours clinic. We tested the association between practice model and measures of access using logistic regression after stratifying for rurality.

Results: A total of 33 665 respondents met our inclusion criteria. In big cities, respondents in team and nonteam capitation models were less likely to report same-day or next-day access when sick than respondents in enhanced fee-for-service models (team capitation 43%, adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.79-0.98; nonteam capitation 39%, adjusted OR 0.78, 95% CI 0.70-0.87; enhanced fee-for-service 46% [reference]). Respondents in team and nonteam capitation models were more likely than those in enhanced fee-for-service models to report that their provider had an after-hours clinic (team capitation 59%, adjusted OR 2.59, 95% CI 2.39-2.81; nonteam capitation 51%, adjusted OR 1.90, 95% CI 1.76-2.04; enhanced fee-for service 34% [reference]). Patterns were similar for respondents in small towns. There was minimal to no difference by model for satisfaction with time to appointment or telephone access.

Interpretation: In our setting, there was an association between some types of access to primary care and physician payment model and team-based care, but the direction was not consistent. Different measures of timely access are needed to understand health care system performance.

Figure 1:

Flow diagram showing selection of survey respondents included in study and responses to the 4 questions related to timely access to primary care. Note: OHIP = Ontario Health Insurance Plan.

Figure 2:

Proportion of respondents in survey wave 15–16 who reported favourable access to the 4 questions related to timely access to primary care (same-day or next-day access when sick, satisfaction with time to visit when sick, telephone access and awareness of after-hours clinic), stratified by practice model (A) (n = 1486) and rurality (B) (n = 1540).

Figure 3:

Adjusted log of odds ratios (ORs) for respondents in different practice models who reported favourable access, stratified by rurality. All models were adjusted for age, sex, education, tight financial situation, self-rated health, comorbidity and health plan registration within the previous 10 years. Full parameter estimates are presented in Appendix 2, Supplemental Table S3. Error bars represent 95% confidence intervals.