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Q J Med 1999; 92: 47-55
© 1999 Association of Physicians

How should we pay doctors? A systematic review of salary payments and their effect on doctor behaviour

T. Gosden, L. Pedersen and D. Torgerson1

From the National Primary Care Research and Development Centre, University of Manchester, Manchester, and 1 Centre for Health Economics, University of York, Helsington, UK

Received 1 September 1998 and in revised form 10 November 1998

We reviewed the published and unpublished international literature to determine the influence of salaried payment on doctor behaviour. We systematically searched Medline, BIDS Embase, Econlit and BIDS ISI and the reference lists of located papers to identify relevant empirical studies comparing salaried doctors with those paid by alternative methods. Only studies which reported objective outcomes and measures of the behaviour of doctors paid by salary compared to an alternative method were included in the review. Twenty-three papers were identified as meeting the selection criteria. Only one of the studies in this review reported a proxy for health status, but none examined whether salaried doctors differentiated between patients on the basis of health needs. Therefore, we were unable to draw conclusions on the likely impact of salaried payment on efficiency and equity. However, the limited evidence in our review does suggest that payment by salaries is associated with the lowest use of tests, and referrals compared with FFS and capitation. Salary payment is also associated with lower numbers of procedures per patient, lower throughput of patients per doctor, longer consultations, more preventive care and different patterns of consultation compared with FFS payment.

Address correspondence to T. Gosden, National Primary Care Research and Development Centre, 5th Floor Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL


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