Fee-for-service v. salary: the debate is heating up
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* Shelley Martin

More than one-quarter of Canada's physicians (27%) would prefer to be paid by salary, results from the CMA's 2003 Physician Resource Questionnaire (PRQ) indicate. This result, combined with the fact that only 37% of physicians now cite fee-for-service (FFS) as their preferred payment method, raises questions about the future of that payment model. Its popularity has dropped by 26% (from 50%) since the 1995 PRQ, the survey the CMA has used to track physicians' attitudes since 1982.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/169/7/701.1/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/169/7/701.1/F1)

Figure. 

The latest results also indicate that the proportion of physicians receiving 90% or more of their professional income from FFS payments continues to decline, from a high of 68% in 1990 to 58% in 2002 and 57% in 2003. Physicians under age 35 are least likely to receive the bulk of their income from FFS (45%), and female physicians are less likely than males to receive the bulk of the professional income via FFS (53% vs. 59%).

Respondents' comments indicate that battle lines are firmly drawn. “Fee-for-service payments tend to reward higher patient flow, [but] many of the patients need more time/teaching/education, which is neglected with FFS,” said one.

“Salary-position physicians do not see as many patients, and therefore add to the problem of physician shortage and patient access,” stated another.

Almost half of physicians (48%) said their workload increased in the past year, while 9% reported a decrease. In the former group, only 41% saw a corresponding increase in their net income, while 19% reported that their net income had decreased in the past year. “My patients are presenting with more and more difficult problems and complaints,” wrote one doctor. “This increases effort and time per patient, and reduces income.” Overall, 31% of physicians had an increase in net professional income in the past year, while 22% saw a net decrease.

Physicians worked an average of 52.9 hours per week, excluding on-call duty. Female physicians worked fewer hours than their male colleagues (47.5 hours/week compared with 55.6), while surgical specialists logged more hours (57.6) than medical specialists (54.5) or GP/FPs (50.9).

Thirty-two percent of respondents said they are involved in decision-making surrounding the health care system. Male physicians are more likely to be involved than female MDs (35% vs. 26%), and doctors under age 35 or over age 65 were least likely to be involved (22% and 20%).

The PRQ is Canada's largest annual survey of MD activities. It was mailed to a random sample of 7922 doctors, and the response rate was 28.4%. National results are accurate to within ± 2.1%, 19 times out of 20. Detailed results from the 2003 PRQ will be available at [www.cmaj.ca](http://www.cmaj.ca). — *Shelley Martin*, CMA