Primary care physicians’ perceptions of the role of alternative payment models in recruitment and retention in rural Alberta: a qualitative study

Yewande Ogundeji; Fiona Clement; Darryn Wellstead; Brenlea Farkas; Braden Manns

doi:10.9778/cmajo.20200202

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Table 1:

Characteristics of 14 primary care physicians practising in rural communities in Alberta

Characteristic	Salary-based model n = 6	FFS n = 8
Gender
Female	3	2
Male	3	6
Career stage
Early career (up to 10 yr in practice)	5	4
Mid–late career (> 10 yr in practice)	1	4
Medical school training
Foreign	1	5
Canada	5	3

Note: FFS = fee-for-service.

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Table 2:

Summary of themes and categories

Themes	Subthemes	Categories^*
Factors attracting physicians to rural areas	Community factors	Attracted to rural lifestyle; quality of life; valued contribution or work in the community
	Financial incentives	Monetary and nonmonetary incentives
	Personal and family-related factors	Access to child care; retirement plan; previous personal rural experience; spousal factors
	Professional factors (motivators)	Autonomy or independence; patient–physician relationships; variety in the scope of practice
Barriers and challenges associated with rural or remote practice	Challenges related to patient care	Complex patient panel; limited access to specialists; outdated or old equipment or facilities
	Community challenges	Cold or severe climate; cultural or ideological differences; community pressures
	Family-related and personal factors	Season of life needs; spousal factors; work–life balance
	Practice and professional challenges	Keeping up with clinical knowledge; high on-call burden; travel-or professional-related barriers
Potential role of APMs in recruitment and retention	Ability to share workload with allied health care workers on an APM; APM could attract new physicians
Factors that physicians consider in decisions around payment model changes (factors that influence physician preferences for APMs)	Contract concerns	Fair contracts; potential to earn less; fear of loss of autonomy and flexibility; feasibility of one payment model for all types of clinical work; involvement of physicians in payment model design
	Implementation concerns	Difficulty in administration; financial losses associated with changing payment models
	Peculiarities of rural practice	Population fluctuations; travel costs
Physician perspectives on payment models	Impact on patient care and physician practice	APM impacts: enables holistic patient care; more time with patients; potential loss of physician autonomy FFS impacts: improved patient access; tendency to have more follow-ups; tendency to spend shorter periods with patients
	Remuneration impacts	APM: income security; paid vacation time; potential cost savings FFS: under pressure for income to keep practice running; income less stable
	Potential for perverse incentives	APM impacts: loss of drive to innovate, improve or see patients; “free rider problem” FFS impacts: might incent some physicians to see too many patients

Note: APM = alternative payment model, FFS = fee-for-service.
↵* Bolded categories represent categories most commonly mentioned or most important.