Ratio Of Primary Care Physicians Research Articles

Moving toward health equity: A journey

Moving toward health equity: A journey

Post-ACA Trends in the US Primary Care Physician Shortage with Index of Relative Rurality.

Index of Relative Rurality (IRR) captures multiple indicators of health care access but is underrepresented in the primary care literature. This research investigates trends in primary care physician supply in US counties with respect to IRR and time since the Affordable Care Act (ACA) was passed. In this ecologic study, annual ratio of primary care physicians per 100,000 population in US counties was computed for 2010-2017 (3,138 counties over 8 years, N = 25,104). IRR assigned in 2010 placed counties on a rural-urban continuum without the use of a threshold. Primary outcomes were associations of IRR and year with physician ratio and annual change in physician ratio. Multivariable regression models were used to detect associations. The a priori hypothesis was that neither rurality nor year was associated with physician ratio or annual growth. IRR and year were independently inversely associated with the ratio of primary care physicians per 100,000 and annual growth in physician ratio. A post-hoc analysis of highly rural US states revealed positive median growth rates in some areas. Despite significant policies in the ACA designed to address the maldistribution of the US primary care physician workforce, more funding and further innovative reforms are urgently necessary to avert a rural workforce crisis in the coming decades. IRR may be a useful continuous, threshold-free metric of rurality in future health services research.

Diabetes Prevention Program Sites Compared With Diabetes Prevalence and Ratio of Primary Care Physicians in Texas.

Diabetes Prevention Program Sites Compared With Diabetes Prevalence and Ratio of Primary Care Physicians in Texas.

How Specialists Become Primary Care Physicians in Japan

Background: Most countries have a shortage of Primary Care (PC) physicians. Japan has mitigated this problem by specialists making a mid-career change to PC when they go into private practice. This study examines the circumstances under which specialists shift to PC. Methods: Since the division between specialists and PC physicians is blurred in Japan, we focus on Physicians Providing Home Visits (PPHV). The list of PPHV was obtained from the local medical associations in two neighboring medical planning areas in Japan. The methods used were a questionnaire and in-depth interviews. Results: Of the 46 listed as PPHV, 38 responded to the questionnaires. Physicians mainly acquired their knowledge and skills in primary care from post-graduate clinical training and on the job training after becoming PPHV. The specialists who had moved to PC were equally knowledgeable regarding PC as those had taken the PC accreditation exam. The in-depth interviews revealed that the higher income earned in clinics and being able to retain their identity as a specialist were also important factors. Conclusions: The factors that contributed to physicians making a mid-career change from specialists to PC were their experiences after being certified, the higher income in clinics and the ability to retain their professional identity as specialists. These enabling factors might also be applicable for increasing the ratio of PC physicians at the global level although further studies are required.

A review of the benefits and limitations of a primary care-embedded psychiatric consultation service in a medically underserved setting.

A significant percentage of patients with psychiatric disorders are exclusively seen for health-care services by primary care physicians. To address the mental health needs of such patients, collaborative models of care were developed including the embedded psychiatry consult model which places a consultant psychiatrist on-site to assist the primary care physician to recognize psychiatric disorders, prescribe psychiatric medication, and develop management strategies. Outcome studies have produced ambiguous and inconsistent findings regarding the impact of this model. This review examines a primary care-embedded psychiatric consultation service in place for nine years in a family medicine residency program. Psychiatric consultants, family physicians, and residents actively involved in the service participated in structured interviews designed to identify the clinical and educational value of the service. The benefits and limitations identified were then categorized into physician, consultant, patient, and systems factors. Among the challenges identified were inconsistent patient appointment-keeping, ambiguity about appropriate referrals, consultant scope-of-practice parameters, and delayed follow-up with consultation recommendations. Improved psychiatric education for primary care physicians also appeared to shift referrals toward more complex patients. The benefits identified included the availability of psychiatric services to underserved and disenfranchised patients, increased primary care physician comfort with medication management, and improved interprofessional communication and education. The integration of the service into the clinic fostered the development of a more psychologically minded practice. While highly valued by respondents, potential benefits of the service were limited by residency-specific factors including consultant availability and the high ratio of primary care physicians to consultants.

Regional Variation in Primary Care Involvement at the End of Life.

Variation in end-of-life care in the United States is frequently driven by the health care system. We assessed the association of primary care physician involvement at the end of life with end-of-life care patterns. We analyzed 2010 Medicare Part B claims data for US hospital referral regions (HRRs). The independent variable was the ratio of primary care physicians to specialist visits in the last 6 months of life. Dependent variables included the rate of hospital deaths, hospital and intensive care use in the last 6 months of life, percentage of patients seen by more than 10 physicians, and Medicare spending in the last 2 years of life. Robust linear regression analysis was used to measure the association of primary care physician involvement at the end of life with the outcome variables, adjusting for regional characteristics. We assessed 306 HRRs, capturing 1,107,702 Medicare Part B beneficiaries with chronic disease who died. The interquartile range of the HRR ratio of primary care to specialist end-of-life visits was 0.77 to 1.21. HRRs with high vs low primary care physician involvement at the end of life had significantly different patient, population, and health system characteristics. Adjusting for these differences, HRRs with the greatest primary care physician involvement had lower Medicare spending in the last 2 years of life ($65,160 vs $69,030; P = .003) and fewer intensive care unit days in the last 6 months of life (2.90 vs 4.29; P <.001), but also less hospice enrollment (44.5% of decedents vs 50.4%; P = .004). Regions with greater primary care physician involvement in end-of-life care have overall less intensive end-of-life care.

Long term regional migration patterns of physicians over the course of their active practice careers

The geographic distribution of physicians in the United States of America has been often described as unbalanced or maldistributed. There is much in the literature on the regional distribution of physicians but far less is written about their pattern of movement. This study aimed to examine the geographic transition of physicians at two points in time (1981 and 2003), in and out the four US census regions (Northeast, Midwest, South, and West). We identified 83 383 non-federal clinically active primary care physicians (CAPCP) who were clinically active both in 1981 and in 2003 as registered in the American Medical Association Physician Masterfiles. The main variable was the migration status observed between 1981 and 2003, and they were categorized into three groups: (1) non-migrants (same county of practice); (2) internal migrants (different counties of practice, same region); or (3) external migrants (different regions of practice). Covariables were gender and age for the CAPCP, and the percentage of non-whites in the population, the mean per capita income of the population, the ratio of primary care physicians and the ratio of hospital beds per 1000 inhabitants, as well as the rural/urban status for the county of practice in 1981 (large metropolitan area, small metropolitan area, or non-adjacent). Overall, 13.2 % of CAPCP moved from one region to another between 1981 and 2003. Women and young CAPCPs were more prone to migrate during their career. Proportionally, a greater outflow of the 1981 workforce is observed for the Northeast and Midwest regions with 16% and 18%, respectively, compared with 10% for both the West and South regions. When taking into account the total flow (in and out) for each region, the West and the South 'benefited' from CAPCPs' migration, with respectively a 1.10 and 1.07 increase in 2003 when compared with 1981; while the Midwest and the Northeast regions ended with a 0.90 and 0.92 decrease in 2003. Both logistic regression and regression-tree analyses show that a physician's age is the most important covariate for all regions, with CAPCPs in their 30s being the most prone to migrate outside the region, whereas gender is a significant factor only in older CAPCPs in the Midwest and South region. The percentage of non-white population in the county of origin is also a significant covariate for all regions. This study looked at the net movement of clinically active primary care physicians across census regions between 1981 and 2003, and underscores the importance of performing specific regional analysis in large countries where socio-demographical and geographical heterogeneities can be observed. Overall, 13.2% CAPCP moved from one region to another over the 22 year period: the South and West regions benefited while the Midwest region was disadvantaged by the migration flow. Age is the major determinant of migrant CAPCP. Logistic and regression tree models also show that percentage of non-white population of the county of origin is a major determinant of migration.

The Impact of Health Plan Delivery System Organization on Clinical Quality and Patient Satisfaction

The purpose of this study was to examine the extent to which measures of health plan clinical performance and measures of patient perceptions of care are associated with health plan organizational characteristics, including the percentage of care provided based on a group or staff model delivery system, for-profit (tax) status, and affiliation with a national managed care firm. Data describing health plans on region, age of health plan, for-profit status, affiliation with a national managed care firm, percentage of Medicare business, total enrollment, ratio of primary care physicians to specialists, HMO penetration, and form of health care delivery system (e.g., IPA, network, mixed, staff, group) were obtained from InterStudy. Clinical performance measures for women's health screening rates, child and adolescent immunization rates, heart disease screening rates, diabetes screening rates, and smoking cessation were developed from HEDIS data. Measures of patient perceptions of care are obtained from CAHPS survey data submitted as Healthplan Employer Data and Information Set, Consumer Assessment of Health Plans 2.0 H. Multivariate regression cross-sectional analysis of 272 health plans was used to evaluate the relationship of health plan characteristics with measures of clinical performance and patient perceptions of care. The form of delivery system, measured by percent of care delivered by staff and group model systems, is significantly related (p < or = .05) with four of the five clinical performance indices but none of the three satisfaction performance indices. Other variables significantly associated with performance were being geographically located in the Northeast, having nonprofit status, and for patient satisfaction, not being part of a larger insurance company. These comparative results provide evidence suggesting that the type of delivery system used by health plans is related to many clinical performance measures but is not related to patient perceptions of care. These findings underscore the importance of the form of the delivery system and the need for further inquiry that examines the relationship between organizational form and performance.

Rural Physicians and Community Leadership: Skills for Building Health Infrastructure in Rural Communities

ew physicians at the beginning stage of their careers are so audacious as to describe themselves as “community health leaders.” Nevertheless, nearly every physician who finds him/herself practicing in a rural community will often be inexorably drawn into discussions about greater health-related needs in the broader community. Once a healthcare professional is able to step back and take a panoramic view of the “health” of the community in which his/her practice is located, he/she often realizes that there are many health needs and barriers to care, and he/she quickly learns that it takes more than individual effort to meet these needs. Whether through the initiative of practicing physicians or others, community-wide initiatives to define existing problems, to plan a range of options for meeting these needs, and the effort to fund and then administer these emerging programs will usually require physician involvement … and even leadership. This commentary addresses some reasons why rural physicians need to become involved in solving some of these rural health problems, and how they can effectively provide needed clinical leadership even if they haven’t previously thought of themselves in such a role. The status of rural healthcare in North Carolina can be described as precarious at best. Many rural communities continue to be plagued by shortages of resources to serve the growing needs of a rural population that is increasingly aged and uninsured. The shortage of physicians in rural communities remains a chronic problem. 1 Despite some progress in the last decade in dealing with this maldistribution, significant disparities persist between metropolitan and rural areas. 2 Although most counties in North Carolina from 1998 to 2003 experienced an increase in the ratio of primary care physicians to 10,000 population, 38 of the state’s 100 counties lost ground. Of the counties with increasing primary care shortages, about half were due to loss of physicians, and about half were due to rapid population growth that outpaced the supply of physicians. 3 Furthermore,

Impact of President Clinton's Health Security Act on residency programs.

The Clinton Health Security Act calls for a major shift in the emphasis of medical training. While family practice, general pediatrics, general internal medicine, and obstetrics and gynecology stand to benefit, other specialties will see decreases in their programs and their residency slots. In light of the present sparsity of programs in family practice and the prevalent student disinterest in the specialty, only heroic efforts will make possible achievement of the 55/50 ratio of primary care physicians to other specialists outlined by the Clinton plan. Problems inevitable in the transition are described and incentives for change suggested.

Health in Israel: Patterns of equality and inequality

While Israel does not have a nationalized health care system, 94.5% of its population is covered by comprehensive health insurance which includes curative and preventive ambulatory care as well as hospitalization. There is formal equality in access, distribution, and quality of the health services; nevertheless, there are pockets of deprivation that affect certain segments of the population. The paper focuses on three topics: (a) structure of the health care delivery system in terms of coverage, geographical and social distribution, and the public/private balance of the services; (b) processes of health care delivery in terms of utilization and quality; (c) health outcomes in terms of mortality, morbidity, health behavior, and disease vulnerability. Inequality in Israel appears to be structured in terms of six dimensions: coverage of health insurance, distribution of health services, the balance of public and private sectors of health services, utilization of existing services, quality of health services, and health outcomes as expressed by mortality, morbidity, health behavior and risk factors. Only two types of health care are not covered by the general health insurance: (a) dental care, and (b) long-term nursing care. Given the small area of Israel there are striking differences in the geographic distribution of health personnel of various types. There is evidence gor gaps between needs and institutional services for many elderly who are on waiting lists for institutionalization. The ratio of primary care physicians to population is 1:2326 in development towns and 1:1852 in the older more established veteran communities. Kibbutzim, which are also located in large part in geographically remore areas, enjoy high quality health services and are not characterized by low ratios of health care personnel. In 1968–69, 6% of those insured by the sick funds purchased services at least once from a private physician, while in 1975–76 this figure rose to 32%. As in other countries, utilization of preventive services is generally correlated with socio-economic status and with education. While the network of primary care facilities in Israel is widespread and generally accessible, it is poorly integrated with the hospital system. Longevity has increased over the past years and is relatively high; 76.6 for women and 73.1 for men in 1984. Nevertheless, differences between Jews and non-Jews may still be seen among both men and women. The same may be said concerning mortality and especially with regard to infant mortality. Differences with regard to certain risk factors among Jews infants and adults are correlated with socio-economic class and country of origin.