The capitation model takes into account the age and sex of patients. (CBC)

Doctors in Ontario who opted to be paid a flat rate to care for patients over a year rather than billing each time they provided a service had fewer sicker patients, a new study suggests.

But more work needs to be done to enhance services to low-income people, the study's lead author said.

"[C]ompared with the enhanced fee-for-service practices, the capitation practices had fewer sick patients, provided less after-hours care, had higher rates of use of emergency department services and enrolled fewer new patients," the study's authors concluded in Tuesday's issue of the Canadian Medical Association Journal.

One of the big issues is that primary care is the first line of defence, Dr. Richard Glazier of the Institute for Clinical Evaluative Sciences in Toronto said in an interview with CBC News.

"It's getting some very needed investments to improve access to care and quality of care. These plans still need some adjustment because they're not reaching low-income people."

Since Ontario introduced changes in how doctors are paid, about 850,000 people in the province are still without a family doctor, down from 1.2 million in 2005.

In Ontario, it's now estimated that 850,000 people, including those in cities such as Kitchener and Guelph and Peterborough in southeastern Ontario, live in areas where family doctors are not accepting new patients, Glazier said.

In part to address shortfalls — patients faced long waits at emergency, had trouble getting appointments when ill and medical students were not attracted to family medicine — in 2001 Ontario introduced a capitation model that pays a flat rate per patient per year, with slightly different rates depending on age and sex.

In 2003, under an enhanced fee-for-service model, family doctors could opt to be paid a set fee for each medical visit and service they provide, and collect extra payments for working nights and offering preventive care such as Pap tests, mammogram and colorectal cancer screening, flu shots and other immunizations.

Poor, chronically sick left out

The study of more than 500 physician groups in the province in 2005 and 2006 and their patients showed many of these new patients who found family doctors under the capitation model were healthier and wealthier on average.

"When you put resources into a system in an uncontrolled way with few rules or regulations, the people who can take best advantage of those resources are the best off," said Glazier, who also works at the centre for research on inner city health at St. Michael's Hospital in Toronto.

Doctors working in advantaged areas who had healthier patients on average in their practices would have been attracted to receiving a flat fee per year since some young healthy patients may never come in, he explained.

The two systems were found to be comparable in terms of comprehensiveness at offering 22 main medical services, and in continuity of care.

Eliminating disparity

It was assumed that all segments of society were participating. But now that these gaps have been found, the Ontario government is determined to put 50 new teams of family doctors in areas of greatest need, and level of sickness is now included in the Ontario Health Ministry's agreement with doctors, Glazier said.

In a commentary accompanying the study, Dr. Barbara Starfield of Johns Hopkins University in Baltimore, Md., noted countries like Spain and France have encouraged long-term relationships between patients and doctors.

"Any reform that aims to improve population health and eliminate disparities must foster a primary care model, as in Ontario," Starfield concluded.

Glazier agreed, noting countries with stronger primary care have better care that reaches the disadvantaged.

Most U.S. states and the U.K., European and Asian countries that have capitation models adjust payment rates depending on how sick or poor patients are to level the playing field.

Adjusting for sicker and poor patients is more complicated compared to sex and age alone, and doctors and the ministry would need to agree on the rate, Glazier noted.