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Brief analytical summaries or syntheses #24

Did changing primary care delivery models change performance?

A population based study using health administrative data


Primary care reform in Ontario started with the introduction of new enrolment models, the two largest of which are Family Health Networks (FHNs), a capitation-based model, and Family Health Groups (FHGs), a blended fee-for-service model. The purpose of this study was to evaluate differences in performance between FHNs and FHGs and to compare performance before and after physicians joined these new primary care groups.


It has been increasingly recognized that health care systems with a strong primary care component are more efficient and better able to handle current and future health care pressures. This has led to several primary care reform strategies in the U.K., Australia, the U.S. and Canada. Common to all of these reform strategies is a movement away from providing service based on a fee-for-service payment system to a more blended payment mechanism, which includes incentives for improving quality and performance.
In Canada, performance measurements and quality of care indicators have been developed for the attributes and components of primary care medicine. The application of these measures are wide ranging and serve to provide valuable feedback on improving quality care, identifying care deficits in vulnerable populations, and providing information to policy makers on program planning.

Analysis and results

Performance measures did not vary consistently between the two models. In some cases, performance approached current benchmarks (Pap smears, mammograms). In other cases it was improving in relation to previous measures (colorectal cancer screening). There were no changes in screening for cervical cancer or breast cancer after joining either a FHN or FHG. Colorectal cancer screening increased in both FHNs and FHGs as did diabetes care. However, annual eye examinations decreased for younger people with diabetes after joining a FHG or FHN. There were no changes in performance measures for heart failure management or asthma care after enrolling in either a FHG or FHN.


Some improvements in preventive screening and diabetes management seen among people after they enrolled may be attributed to incentive payments offered to physicians within FHGs and FHNs. FHNs, a capitation-based model, demonstrated some improvements in care, especially in rural regions. To some degree these improvements may be attributed to incentive payments offered within FHGs and FHNs. However, these primary care delivery models need to be compared with other delivery models and fee-for-service practices in order to describe more specifically what aspects of model delivery and incentives affect care.

Implications and recommendations

Several factors may influence chronic disease management in family medicine. For example, practices located in rural regions are challenged by less access to technology or specialty care to help diagnose or monitor some conditions. For chronic diseases, this may affect some aspects of patient care such as echocardiogram and spirometry testing and ophthalmologic assessment. Physician knowledge, experience or comfort in managing chronic disease may influence medical therapy and medications their patients receive. Practice structures such as interdisciplinary care can facilitate chronic disease management. Physician remuneration models and pay for performance incentives may improve chronic disease performance measures.

Since 2002, several clinical evidence-based guidelines have been disseminated to primary care practitioners for diabetes management. The present analysis revealed improvements in the prescribing of metformin, angiotensin converting enzyme inhibitor (ACEI) and lipid-lowering medications after patients enrolled in either a FHG or FHN, which may have resulted from incentive payments for diabetes care as well as success in knowledge translation.

Although evidence based guidelines for the management of heart failure patients have been developed by the Canadian Cardiology Association, their dissemination into primary care practice has been limited. Rather than concluding that primary care delivery models have no effect on heart failure management, the study points to a lack of knowledge translation of current heart failure guidelines into primary care. Likewise, the lack of improvement on performance measures for asthma care may be attributed to the lack of incentive payments for managing asthma. 

Although the proportion of study patients receiving colorectal screening was low, it did improve significantly after patients joined either a FHG or FHN. Further comparison with primary care models that do not have incentive payments may enable a better understanding of the impact of these initiatives on colorectal cancer screening rates.

Among the recommendations made to ensure success with pay for performance incentives are the selection and definition of pay for performance targets on the basis of baseline room for improvement. This may be the situation for breast cancer and cervical cancer screening activity in Ontario. Prior to the introduction of FHGs and FHNs, these screening rates were approaching 75%. Colorectal cancer screening rates were extremely low prior to the introduction of FHNs and FHGs, and therefore incentive payments, along with other provincial strategies, may have contributed to the improvements seen in screening rates.


Did changing primary care delivery models change performance? A population based study using health administrative data

Gouvernement du Québec
© Gouvernement du Québec, 2018