Association between the Clinical and Economic Outcomes and Specialist Payment Model in the Care of Patients with Heart Failure in Alberta, Canada

Abstract

Objective: Heart failure (HF) affects approximately 2% of adults in Alberta. Most HF care is delivered by either primary care practitioners, internal medicine physicians, or cardiologists. Payment model design for these physicians may impact decision-making with respect to resource utilization and, hence overall healthcare costs in the care of HF patients. Our study focuses on physician payment models for internists and cardiologists in the context of an HF population. Prior analyses have shown that fee-for-service (FFS) cardiologists and internists perform two to three times more tests than salaried cardiologists and internists. It is not clear that this increased utilization has a favourable impact on clinical outcomes. This thesis is presented in two parts. First, a systematic review comprehensively summarizes the existing literature on cardiology payment models and the association with clinical outcomes. Second, an Alberta-based retrospective comparison of five-year healthcare utilization, clinical and cost outcomes between HF patients seen by FFS and salaried cardiologists and internists is presented. Methods: The systematic review searched the literature from database inception to August 2025 for articles relevant to cardiologists' payment models and reported clinical and cost outcomes. 4,156 publications were found, of which 87 were included for full-text review. A total of 6 publications met the inclusion criteria for final analysis. The title and abstracts were screened independently by three reviewers, followed by the full text by two reviewers, and the systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A narrative approach was followed to report the overall outcomes due to missing data, differences in patient population, healthcare setting, measures of endpoints, cardiac testing, and procedures. In the retrospective population-based cohort study, newly referred adult HF patients seen by cardiologists or internists between 2014 and 2018 were identified using new consult codes from physician claims and International Classification of Diseases, 9th and 10th revision codes from administrative data, then followed for five years from the index visit. Propensity score matching balanced baseline characteristics between the FFS versus the Salaried group. Healthcare utilization including cardiac tests, subsequent follow-up visits, and clinical outcomes such as hospitalizations due to HF, emergency department visits due to HF, and all-cause mortality were compared. Direct healthcare costs were estimated using a gross-costing approach and adjusted for 2024-year inflation. Subgroup and sensitivity analyses were performed. Conclusion: For the care of HF patients in Alberta, patients with HF seen by FFS specialists consistently received higher rates of cardiac testing, resulting in significantly higher testing costs and higher overall per-patient costs over five years, without corresponding improvements in patient outcomes. No statistical difference in all-cause mortality was observed between patients cared for by FFS and salaried specialists. Thus, a salary-based payment model for cardiologists and internists may improve health system value through a structuring payment incentive to control health system costs without any apparent adverse effect on key HF patient outcomes.