General practice incentives: a review of the international literature.
Clinical Snapshot
PICO Framework
| P — Population | General practice settings providing multidisciplinary primary and preventive care for people with complex chronic conditions |
| I — Intervention | Blended payment models incorporating pay-for-performance (P4P) with capitation payments or fee-for-service |
| C — Comparator | Traditional fee-for-service funding models or other payment mechanisms |
| O — Outcomes | Quality outcomes in primary care, intermediate health outcomes, and process measures for complex chronic conditions |
Bottom Line
This systematic review of reviews found that blended payment models combining pay-for-performance with either capitation or fee-for-service payments show promise for improving quality outcomes in general practice, particularly for diabetes care. However, the evidence is highly variable across healthcare systems and study designs. Improvements were mainly observed in incentivised activities and in less rigorous studies, with ceiling effects limiting further gains. Importantly, capitation payments alone showed no evidence of improving care quality. For Australian general practice considering alternatives to pure fee-for-service models, these findings suggest that while blended payment approaches may offer modest benefits, any implementation should include robust evaluation mechanisms to monitor both quality and equity impacts. The variable evidence base means that wholesale adoption would be premature without careful pilot testing and ongoing assessment.
Key Findings
P Value: Not reported in abstract
Effect Size: Small improvements (specific magnitude not quantified in abstract)
Primary Outcome: Small improvements in quality outcomes with blended payment models incorporating pay-for-performance
Nnt Or Sensitivity: Most evident improvements in diabetes care; inconclusive for other chronic conditions
Confidence Interval: Not reported in abstract
Clinical Application
Implementation would require careful system-wide evaluation and monitoring of both quality and equity outcomes Highly relevant to current Medicare reform discussions and potential alternatives to fee-for-service models in Australian general practice Australian general practices providing care for patients with complex chronic conditions, particularly diabetes
Abstract
BACKGROUND: In Australia, the general practice sector faces significant challenges, leading to a re-evaluation of its predominantly fee-for-service (FFS) funding models. AIM: To conduct a systematic review of reviews that evaluated the efficacy of funding models in general practice on quality outcomes in multidisciplinary primary and preventive care for people with complex chronic conditions, as well as the contextual factors that have influenced their implementation. DESIGN AND SETTING: Only systematic reviews and meta-analyses were included. Search terms covered funding mechanisms, primary care, and general practice. The review followed PRISMA guidelines for systematic reviews. METHOD: PubMed, Cochrane, Embase, CINAHL, PsycInfo, PAIS, and Web of Science databases were searched in November 2023 for publications from 2010 onwards. RESULTS: Twenty reviews were included. Blended payment models incorporating pay-for-performance (P4P) with either capitation payments or FFS were associated with small improvements in quality outcomes, particularly in multidisciplinary settings. Changes in intermediate health outcomes and process measures for people with complex chronic conditions were most evident in diabetes care but inconclusive for other health outcomes and conditions. Improvements were mainly observed in incentivised activities and in less rigorously designed studies, with ceiling effects and variation reported across healthcare systems. There was no evidence that introducing capitation payments as part of blended payments improved quality of care. CONCLUSION: Although blended payment models show promise, evidence for the effectiveness of models including P4P is highly variable. If adopted, careful evaluation of each incentive's impact on both quality and equity will be essential.
References
- 1.Harris, M., Rhee, J., Barr, M., Sharma, A., Harris-Roxas, B., Burns, M., Marshall, K., Ali, R., Sunjaya, A. P., van Kemenade, C., & Kidd, M. (2026). General practice incentives: a review of the international literature. British Journal of General Practice. https://doi.org/10.3399/BJGP.2025.0143
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