Capitation and primary care in Canada: Financial incentives and the evolution of health service organizations

Alternative approaches to the funding, organization, and delivery of primar y care have been the subject of ongoing discussion and debate in many indus trialized nations for many years. One common recommendation has been to use capitation, as opposed to fee-for-service, as the payment method for physi cians, In this study the authors use data from interviews with physicians a nd Ministry of Health officials to trace the evolution of Ontario's Health Service Organization (HSO) program, the only program of capitation-funded p hysician care in Canada. The program has developed in three phases: formati on in the early 1970s, expansion in the late 1970s and throughout the 1980s , and restructuring in the 1990s. The analysis focuses on the perceptions a nd actions of policymakers and physicians who became involved with the prog ram at different points in its evolution, and identifies how they perceived and responded to the financial incentives that were introduced to promote the program. This case study allows an examination of the shifting objectiv es, communications, perceptions, and responses of policymakers and stakehol ders in changing contexts over a period of more than 20 years. The long his tory of the HSO program provides the opportunity to examine the factors tha t can cause financial incentives to go awry, The authors suggest how this c ase study offers lessons for financial incentive policymaking.