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BMC Health Services Research

, 16:542

Utilization, expenditure, economics and financing systems


BackgroundReimbursement systems provide incentives to health care providers and may drive physician behaviour. This review assesses the impact of reimbursement system on socioeconomic and racial inequalities in access, utilization and quality of primary care.

MethodsA systematic search was performed in Web of Science and PubMed for English language studies published between 1980 and 2013, supplemented by reference tracking. Articles were selected based on inclusion criteria, and data extraction and critical appraisal were performed by two authors independently. Data were synthesized in a narrative manner and categorized according to study outcome and reimbursement system.

ResultsTwenty seven articles, mostly from the United States and United Kingdom, were included in the data synthesis. Reimbursement systems seem to have limited effect on socioeconomic and racial inequity in access, utilization and quality of primary care. Capitation might have a more beneficial impact on inequity in access to primary care and number of ambulatory care sensitive admissions than fee-for-service, but did worse in patient satisfaction. Pay-for-performance had little or no impact on socioeconomic and racial inequity in the management of diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, and preventive services.

ConclusionWe found little scientific evidence supporting an association between reimbursement system and socioeconomic or racial inequity in access, utilization and quality of primary care. Overall, few studies addressed this research question, and heterogeneity in context and outcomes complicates comparisons across studies. Further empirical studies are warranted.

KeywordsInequality Healthcare disparities Socioeconomic factors Ethnic groups Health services accessibility Quality of health care Outcome assessment Health policy Reimbursement mechanisms Capitation fee AbbreviationsACE-inhibitorsAngiotensin-converting enzyme inhibitors

ACSCAmbulatory care sensitive conditions

AHAAntihypertensive agents

BPBlood pressure

CHDCoronary heart disease


HMOHealth maintenance organization

OHAOral hypoglycaemic agents


PCPPrimary care practitioner

QOFQuality and outcomes framework

SEPSocioeconomic position

UKUnited Kingdom

USUnited States

Electronic supplementary materialThe online version of this article doi:10.1186-s12913-016-1805-8 contains supplementary material, which is available to authorized users.

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Autor: Wenjing Tao - Janne Agerholm - Bo Burström


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