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This month’s CJEM includes a unique study on how changing a payment system affects emergency department (ED) flow and patient wait times. The authors strategically took advantage of a parting of the ways between two closely affiliated hospitals; one changed to fee for service (FFS), whereas the other remained on a pre-existing alternate contract. Conventional wisdom would suggest that, under FFS, flow would improve but the quality of care and perhaps even physician morale would suffer. Defenders of FFS–mostly physicians who prefer to practice this way, and their associations–would vehemently disagree. There is precious little evidence to resolve the dispute. In this case, the authors found a very modest and non-sustained improvement in wait time but no change in the length of stay. What can we conclude from this? The authors review the issues and limitations of their study and rightly concede that their data cannot settle the debate. But is the classic debate–Is FFS better than alternative approaches to physician payment at ensuring flow and quality in the ED?–actually the right question? After 3 decades in ED administration and policy advocacy, I would say “No.” Instead of searching for the ideal payment model, the more important consideration is the strategy that can be used to keep ED physicians happy in their jobs. The key factor in this is not how they are paid, but how much they are paid relative to their peers; this is where Canadian health systems are failing emergency medicine. Experiences with alternate funding arrangements in Ontario over the past 2 decades have led to a majority of EDs opting for the contract option, with a small but stable minority remaining firmly in favour of FFS. The main differences between the two groups appear to be more philosophical than financial. The contract groups have a formal organization structure that creates group accountability with contractual protections ensuring fairness in decision-making and transparency around finances. An ED’s annual volume and acuity determine gross funding, but the group can determine internal payment schemes, and there has been considerable innovation in creating and adjusting these. Nothing prevents the FFS groups from pooling their income and emulating the same model in whole or in part on a voluntary basis. There is no doubt that some physicians will feel more comfortable in one sort of group culture than in another; although at a macro level in Ontario, distinguishing outcomes by a payment system is not possible. To the extent that I am defending FFS, my comments are specific to emergency medicine. One of the major concerns about FFS in community practice is that it leads to a greater intensity of service and unnecessary visits as doctors fill their schedules with return visits. This does not apply to us in the ED; we have very little opportunity to control our volumes. I believe that choice and flexibility in payment systems are likely as or more important than details of the structure of a given system. I also believe that a group structure that includes collective responsibility over finances and scheduling can permit creative approaches to specific challenges of emergency medicine, such as coverage for unsocial shifts and concessions for seniority. I have observed groups stressed over non-financial approaches to covering nights, weekends, holidays, and so forth. While fairness and collegiality are critical, my own group has generally solved these problems painlessly by raising the relative value of hard-to-cover shifts until

Model of payment should not be the key concern when it comes to emergency department physicians’ remuneration