Open Access Research article

Do list size and remuneration affect GPs' decisions about how they provide consultations?

Michael J van den Berg1*, Dinny H de Bakker13, Gert P Westert23, Jouke van der Zee14 and Peter P Groenewegen15

Author Affiliations

1 NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands

2 RIVM, Netherlands Institute for Public Health and the Environment, Bilthoven, The Netherlands

3 Tilburg University, Faculty of Social and Behavioural Sciences, Tilburg, The Netherlands

4 Maastricht University, Faculty of Health Sciences, Maastricht, The Netherlands

5 Utrecht University, Faculty of Social sciences, Utrecht, The Netherlands

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BMC Health Services Research 2009, 9:39  doi:10.1186/1472-6963-9-39

Published: 26 February 2009

Abstract

Background

Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work means more money. In the case of capitation based payment, workload is not directly linked to income since the fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment, and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and these three variables are affected by remuneration.

Methods

List size was used because this is an important determinant of objective workload. List size was corrected for number of older patients and patients who lived in deprived areas. We focussed on three dependent variables that we expected to be related to remuneration and list size: consultation length; waiting time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to assess the hypothesized relationships.

Results

Our results indicate that list size is negatively related to consultation length, especially among GPs with relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation between list size and the likelihood of a home visit were only found for GPs with small practices. These correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to get an appointment tend to become shorter with increasing patient lists when there is a larger capitation percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation percentage is small.

Conclusion

Remuneration appears to affect GPs' decisions about how they provide consultations, especially among GPs with relatively small patient lists. This role is, however, small compared to other factors such as patient characteristics.