Payment Systems for Hospital Specialists in 10 High-Income Countries

Background Payment mechanisms for specialists are important because the inherent financial incentives influence treatment decision of specialists – who control the vast majority of resources used in hospitals. This study aimed at comparing specialist payment systems in ten high-income countries based on a predefined framework in order to systematically describe different payment mechanisms and non-financial benefits. Methods Based on a scoping review, 10 high-income countries (Canada, England, France, Germany, Korea, Luxemburg, Sweden, Switzerland, The Netherlands, USA (Medicare)) with different payment systems (mainly fee-for-service (FFS), mainly salary, and combinations of both) were selected for analysis with a view to including countries with particularly sophisticated systems and/or countries with recent reform initiatives. A survey was designed to collect information from national experts on (1) main national payment mechanisms, (2) contractual relationships between hospitals and specialists, and (3) the different components that make up the total income of specialists. Results In England, Germany, Sweden, and Switzerland, almost all specialists (≥90%) are employed by hospitals and receive a salary, while specialists in the United States, Canada, and Luxembourg are mostly (≥70%) self-employed and paid on the basis of FFS. Payment mechanisms may differ across hospitals (e.g. public vs. private or teaching vs. non-teaching), across specialties (e.g. surgical versus medical specialties), or by setting (inpatient care vs. outpatient care). In Switzerland, the United States and Korea, base salaries are increasingly combined with FFS based bonuses. In the Netherlands, the scope of FFS payments was broadened with the introduction of DRG-based hospital payment. Conclusions Specialist payment systems differ greatly across and usually also within countries. Specialist payment could be optimized in several countries by taking into consideration experiences from other countries. Key messages Specialist payment systems can combine different payment mechanisms in order to balance the intended and unintended incentives of fee-for-service payments or traditional salary systems Differences in payment systems across countries can motivate change by providing examples of alternative options for payment of specialists in hospitals

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