Contraception Usage and Workforce Trends Through 2022.

This cross-sectional study uses a national data set of medical prescription claims to examine contraception service and workforce changes from January 2019 through December 2022 in the US.

Training in Residency and Provision of Reproductive Health Services Among Family Medicine Physicians.

Importance: Contraception and abortion services are essential health care, and family medicine (FM) physicians are an important part of the workforce providing this care. Residency could inform the reproductive health services FM physicians provide. Objective: To determine which residency training factors are associated with FM physicians' provision of reproductive health services to Medicaid beneficiaries. Design, Setting, and Participants: This cross-sectional, population-based observational study of inpatient and outpatient FM physicians who completed residency between 2008 and 2018 and treated at least 1 Medicaid beneficiary in 2019 was conducted from November 2022 to March 2023. The study used 2019 American Medical Association Masterfile and Historical Residency file, as well as the 2019 Transformed Medicaid Statistical Information System claims. Exposures: Residency training in community-based or reproductive health-focused programs. Main Outcomes and Measures: The outcomes were providing the following to at least 1 Medicaid beneficiary in 2019: prescription contraception (pill, patch, and/or ring), intrauterine device (IUD) and/or contraceptive implant, and dilation and curettage (D&C). Odds of providing each outcome were measured using correlated random-effects regression models adjusted for physician, residency program, and county characteristics. Results: In the sample of 21 904 FM physician graduates from 410 FM residency programs, 12 307 were female (56.3%). More than half prescribed contraception to Medicaid beneficiaries (13 373 physicians [61.1%]), with lower proportions providing IUD or implant (4059 physicians [18.5%]) and D&C (152 physicians [.7%]). FM physicians who graduated from a Reproductive Health Education in Family Medicine program, which fully integrates family planning into residency training, had significantly greater odds of providing prescription contraception (odds ratio [OR], 1.23; 95% CI, 1.07-1.42), IUD or implant (OR, 1.79; 95% CI, 1.28-2.48), and D&C (OR, 3.61; 95% CI, 2.02-6.44). Physicians who completed residency at a Teaching Health Center, which emphasizes community-based care, had higher odds of providing an IUD or implant (OR, 1.51; 95% CI, 1.19-1.91). Conclusions and Relevance: In this cross-sectional study of FM physicians providing Medicaid service, characteristics of residency training including community-based care and integration of family planning training are associated with greater odds of providing reproductive health services. With growing reproductive health policy restrictions, providing adequate training in reproductive health is critical to maintaining access to care, especially for underserved populations.

How Governor Directives Changed Health Workforce Flexibility in Response to the COVID-19 Pandemic.

OBJECTIVES: In times of heightened population health needs, the health workforce must respond quickly and efficiently, especially at the state level. We examined state governors' executive orders related to 2 key health workforce flexibility issues, scope of practice (SOP) and licensing, in response to the COVID-19 pandemic. METHODS: We conducted an in-depth document review of state governors' executive orders introduced in 2020 in all 50 states and the District of Columbia. We conducted a thematic content analysis of the executive order language using an inductive process and then categorized executive orders by profession (advanced practice registered nurses, physician assistants, and pharmacists) and degree of flexibility granted; for licensing, we indicated yes or no for easing or waiving cross-state regulatory barriers. RESULTS: We identified executive orders in 36 states containing explicit directives addressing SOP or out-of-state licensing, with those in 20 states easing regulatory barriers pertaining to both workforce issues. Seventeen states issued executive orders expanding SOP for advanced practice nurses and physician assistants, most commonly by completely waiving physician practice agreements, while those in 9 states expanded pharmacist SOP. Executive orders in 31 states and the District of Columbia eased or waived out-of-state licensing regulatory barriers, usually for all health care professionals. CONCLUSION: Governor directives issued through executive orders played an important role in expanding health workforce flexibility in the first year of the pandemic, especially in states with restrictive practice regulations prior to COVID-19. Future research should examine what effects these temporary flexibilities may have had on patient and practice outcomes or on permanent efforts to relax practice restrictions for health care professionals.

Association of Primary Care Physicians' Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries.

Importance: Little is known about primary care physicians who provide contraceptive services to Medicaid beneficiaries. Evaluating this workforce may help explain barriers to accessing these services since contraceptive care access is critical for Medicaid beneficiaries' health. Objective: To describe the primary care physician workforce that provides contraceptive services to Medicaid beneficiaries and explore the factors associated with their Medicaid contraceptive service provision. Design, Setting, and Participants: This cross-sectional study, conducted from August 1 to October 10, 2022, used data from the Transformed Medicaid Statistical Information System from 2016 for primary care physicians from 4 specialties (family medicine, internal medicine, obstetrics and gynecology [OBGYN], and pediatrics). Main Outcomes and Measures: The main outcomes were providing intrauterine devices (IUDs) or contraceptive implants to at least 1 Medicaid beneficiary, prescribing hormonal birth control methods (including a pill, patch, or ring) to at least 1 Medicaid beneficiary, the total number of Medicaid beneficiaries provided IUDs or implants, and the total number Medicaid beneficiaries prescribed hormonal birth control methods in 2016. Physician- and community-level factors associated with contraceptive care provision were assessed using multivariate regression methods. Results: In the sample of 251 017 physicians (54% male; mean [SD] age, 49.17 [12.58] years), 28% were international medical graduates (IMGs) and 70% practiced in a state that had expanded Medicaid in 2016. Of the total physicians, 48% prescribed hormonal birth control methods while 10% provided IUDs or implants. For OBGYN physicians, compared with physicians younger than 35 years, being aged 35 to 44 years (odds ratio [OR], 3.51; 95% CI, 2.93-4.21), 45 to 54 years (OR, 3.01; 95% CI, 2.43-3.72), or 55 to 64 years (OR, 2.27; 95% CI, 1.82-2.83) was associated with higher odds of providing IUDs and implants. However, among family medicine physicians, age groups associated with lower odds of providing IUDs or implants were 45 to 54 years (OR, 0.66; 95% CI, 0.55-0.80), 55 to 64 years (OR, 0.51; 95% CI, 0.39-0.65), and 65 years or older (OR, 0.29; 95% CI, 0.19-0.44). Except for those specializing in OBGYN, being an IMG was associated with lower odds of providing hormonal contraceptive service (family medicine IMGs: OR, 0.80 [95% CI, 0.73-0.88]; internal medicine IMGs: OR, 0.85 [95% CI, 0.77-0.93]; and pediatric IMGs: OR, 0.85 [95% CI, 0.78-0.93]). Practicing in a state that expanded Medicaid by 2016 was associated with higher odds of prescribing hormonal contraception for family medicine (OR 1.50; 95% CI, 1.06-2.12) and internal medicine (OR, 1.71; 95% CI, 1.18-2.48) physicians but not for physicians from other specialties. Conclusions and Relevance: In this cross-sectional study of primary care physicians, physician- and community-level factors, such as specialty, age, and the Medicaid expansion status of their state, were significantly associated with how they provided contraceptive services to Medicaid beneficiaries. However, the existence of associations varied across clinical specialties. Ensuring access to contraception among Medicaid beneficiaries may therefore require policy and program approaches tailored for different physician types.

Changes in the Clinical Workforce Providing Contraception and Abortion Care in the US, 2019-2021.

This cross-sectional study investigates changes in the workforce providing contraception and abortion services from before to during the COVID-19 pandemic.

A Mixed-Methods Study of Teaching Health Center Residents' Experiences of Mentorship, Career Planning, and Postresidency Practice Environments.

PURPOSE: The Teaching Health Center (THC) Graduate Medical Education program enables primary care physicians to train in community-based, underserved settings by shifting the payment structure and training environment for graduate medical education. To understand how THCs have successfully trained primary care physicians who practice in community-based settings, the authors conducted a mixed-methods exploratory study to examine THC residency graduates' experiences of mentorship and career planning during their residencies, perceptions of preparation for postresidency practice, and how these experiences were related to postresidency practice environments. METHOD: Surveys were conducted for all 804 graduating THC residents nationally, 2014-2017 (533 respondents, 66% response rate). Three quantitative outcomes were measured: graduates' perceptions of preparation for practice after residency (Likert scale), satisfaction with mentorship and career planning (Likert scale), and characteristics of postresidency practice environment (open-ended). A qualitative analysis of open-text survey answers, using thematic content analysis, was also conducted. RESULTS: Most THC graduates (68%) were satisfied with their mentorship and career planning experience and generally felt prepared for postresidency practice in multiple settings (78%-93%). Of the 533 THC graduates who provided information about their practice environment, 445 (84%) were practicing in primary care; nationally, 64% of physicians who completed primary care residencies practiced in primary care. Of the 445 THC graduates practicing in primary care, 12% practiced in rural areas, compared with 7% of all physicians. Just over half of THC graduates (51%) practiced in medically underserved areas, compared with 39% of all physicians. CONCLUSIONS: This study offers early evidence that the THC model produces and retains primary care physicians who are well prepared to practice in underserved areas. Given these promising findings, there appears to be a substantial benefit to growing the THC program. However, the program continues to face uncertainty around ongoing, stable funding.

Who is providing contraception care in the United States? An observational study of the contraception workforce.

BACKGROUND: Contraception care is essential to providing comprehensive healthcare; however, little is known nationally about the contraception workforce. Previous research has examined the supply, distribution, and adequacy of the health workforce providing contraception services, but this research has faced a series of data limitations, relying on surveys or focusing on a subset of practitioners and resulting in an incomplete picture of contraception practitioners in the United States. OBJECTIVE: This study aimed to construct a comprehensive database of the contraceptive workforce in the United States that provides the following 6 types of highly effective contraception: intrauterine device, implant, shot (depot medroxyprogesterone acetate), oral contraception, hormonal patch, and vaginal ring. In addition, we aimed to examine the difference in supply, distribution, the types of contraception services offered, and Medicaid participation. STUDY DESIGN: We constructed a national database of contraceptive service providers using multiple data sets: IQVIA prescription claims, preadjudicated medical claims, and the OneKey healthcare provider data set; the National Plan and Provider Enumeration System data set; and the Census Bureau's American Community Survey data on population demographics. All statistical analyses were descriptive, including chi-squared tests for groupwise differences and pairwise post hoc tests with Bonferroni corrections for multiple comparisons. RESULTS: Although 73.1% of obstetrician-gynecologists and 72.6% of nurse-midwives prescribed the pill, patch, or ring, only 51.4% of family medicine physicians, 32.4% of pediatricians, and 19.8% of internal medicine physicians do so. The ratio of all primary care providers prescribing contraception to the female population of reproductive age (ages, 15-44 years) varied substantially across states, with a range of 27.9 providers per 10,000 population in New Jersey to 74.2 providers per 10,000 population in Maine. In addition, there are substantial differences across states for Medicaid acceptance. Of the obstetrician-gynecologists providing contraception, the percentage of providers who prescribe contraception to Medicaid patients ranged from 83.9% (District of Columbia) to 100% (North Dakota); for family medicine physicians, it ranged from 49.7% (Florida) to 91.1% (Massachusetts); and for internal medicine physicians, it ranged from 25.0% (Texas) to 75.9% (Delaware). For in-person contraception, there were large differences in the proportion of providers offering the 3 different contraceptive method types (intrauterine device, implant, and shot) by provider specialty. CONCLUSION: This study found a significant difference in the distribution, types of contraception, and Medicaid participation of the contraception workforce. In addition to obstetrician-gynecologists and nurse-midwives, family medicine physicians, internal medicine physicians, pediatricians, advanced practice nurses, and physician assistants are important contraception providers. However, large gaps remain in the provision of highly effective services such as intrauterine devices and implants. Future research should examine provider characteristics, programs, and policies associated with the provision of different contraception services.

Community Health Centers' Practices, Barriers, and Facilitators for Providing a 1-Year Supply of Oral Contraception on Site.

INTRODUCTION: High-quality family planning services help women to achieve their preferred family size and birth spacing, which in turn leads to improved health outcomes and better quality of life. This study investigates whether women have access to a 1-year supply of oral contraceptives (OCs) on site when they receive care at community health centers and whether states require coverage for a 1-year supply. METHODS: This study used a concurrent, mixed-methods approach, with a single phase of quantitative research (survey of health centers) and two phases of qualitative research (50-state policy environment scan and in-depth interviews). RESULTS: Only three states require coverage for a 1-year supply of OCs under all Medicaid and private insurance coverage mechanisms; the majority of states limit it through at least one mechanism. The survey found that 50.9% of health centers provided OCs on site, and of these, only 29.9% offered up to a 1-year supply at a time. An analysis of interviews revealed that clinician and pharmacist preferences and the organization's overall approach to family planning played a role in these practices. CONCLUSION: This study finds that that only a minority of health centers provide a 1-year supply on site and that a minority of states have rules requiring coverage for a 1-year supply of OCs. To remedy these gaps, change is needed at multiple levels, including health center practices, clinician knowledge and beliefs, federal agency guidance, and state-level insurance policy.

Predicting the Impact of Transforming the Medicaid Program on Health Centers' Revenues and Capacity to Serve Medically Underserved Communities.

Policy Points Recent federal proposals to use block grants or per capita caps to fund Medicaid would likely lead to cuts in Medicaid funding for health centers, which are an important source of care for Medicaid enrollees. Recent Medicaid §1115 waivers are seeking to change state-level enrollment and eligibility requirements in ways that are expected to adversely affect health center revenues. Proposed Medicaid funding cuts are expected to lead to reductions in service capacity across all health centers over the long term. State policymakers should understand the likely impacts of proposed Medicaid program changes on health centers in their states and allocate funding to help offset lost federal financing. CONTEXT: In 2017, Congress considered implementing block grants or per capita caps to significantly reduce federal financing of the Medicaid program. Medicaid plays a key role in supporting health centers in their provision of care to patients with Medicaid coverage. Consequently, changes to the program could have serious implications for health centers and their ability to fulfill their mission. METHODS: We used a mixed-methods approach to (a) test a model simulating the effect of block grants and per capita caps on health centers' total revenues and general service capacity, and (b) augment model assumptions by using information collected from official Medicaid documents and interviews with health center leadership staff. Data came from the Uniform Data Systems (UDS), state- and county-level population projections, structured analyses of waiver documents, and interviews with health center leaders in seven states with approved or pending Medicaid §1115 waivers. FINDINGS: By 2024, in states where Medicaid coverage was expanded under the Affordable Care Act, block grant funding for Medicaid would decrease total health center revenues for the expansion population by 92%, and by 58% for traditional enrollees. In nonexpansion states, block grants would decrease health center revenues for traditional Medicaid enrollees by 38%. In expansion states, a per capita cap would, by 2024, decrease health center revenues for the expansion population by 78%, and for traditional Medicaid enrollees by 3%. The per capita cap would reduce health center revenues for traditional Medicaid enrollees in nonexpansion states by 2%. Eliminating the Medicaid expansion population would not fully compensate for health center revenue deficits in expansion states. Health center executives in all sample states expressed significant uncertainty around federal plans to reduce Medicaid funding as well as the financial implications of §1115 waiver requirements. Many interviewees anticipate cutting back on services and/or staff as a result. CONCLUSIONS: Both block grants and per capita caps would have a detrimental effect on health centers. Although health center leaders anticipate a reduction in services and/or staff, the uncertainty around federal and state proposals hinders health centers from making concrete strategic plans. States should prioritize communicating changes to health centers in a timely manner and be prepared to set aside dedicated funding to address anticipated shortfalls.

Primary Care Residents in Teaching Health Centers: Their Intentions to Practice in Underserved Settings After Residency Training.

PURPOSE: To describe the residents who chose to train in teaching health centers (THCs), which are community-based ambulatory patient care sites that sponsor primary care residencies, and their intentions to practice in underserved settings. METHOD: The authors surveyed all THC residents training in academic years 2013-2014, 2014-2015, and 2015-2016, comparing their demographic characteristics with data for residents nationally, and examined THC residents' intentions to practice in underserved settings using logistic regression analysis. RESULTS: The overall survey response rate was 89% (1,031/1,153). THC resident respondents were similar to residents nationally in family medicine, geriatrics, internal medicine, obstetrics-gynecology, pediatrics, and psychiatry in terms of gender, age, race, and ethnicity. Twenty-nine percent (283) of respondents came from a rural background, and 46% (454) had an educationally and/or economically disadvantaged background. More than half (524; 55%) intended to practice in an underserved setting on completion of their training. Respondents were more likely to intend to practice in an underserved area if they came from a rural background (odds ratio 1.58; 95% confidence interval 1.08, 2.32) or disadvantaged background (odds ratio 2.81; 95% confidence interval 1.91, 4.13). CONCLUSIONS: THCs attract residents from rural and/or disadvantaged backgrounds who seem to be more inclined to practice in underserved areas than those from urban and economically advantaged roots. THC residents' intentions to practice in underserved areas indicate that primary care training programs sponsored by community-based ambulatory patient care sites represent a promising strategy to improve the U.S. health care workforce distribution.

A comparison of alternative methods for measuring cigarette prices.

BACKGROUND: Government agencies, public health organisations and tobacco control researchers rely on accurate estimates of cigarette prices for a variety of purposes. Since the 1950s, the Tax Burden on Tobacco (TBOT) has served as the most widely used source of this price data despite its limitations. PURPOSE: This paper compares the prices and collection methods of the TBOT retail-based data and the 2003 and 2006/2007 waves of the population-based Tobacco Use Supplement to the Current Population Survey (TUS-CPS). METHODS: From the TUS-CPS, we constructed multiple state-level measures of cigarette prices, including weighted average prices per pack (based on average prices for single-pack purchases and average prices for carton purchases) and compared these with the weighted average price data reported in the TBOT. We also constructed several measures of tax avoidance from the TUS-CPS self-reported data. RESULTS: For the 2003 wave, the average TUS-CPS price was 71 cents per pack less than the average TBOT price; for the 2006/2007 wave, the difference was 47 cents. TUS-CPS and TBOT prices were also significantly different at the state level. However, these differences varied widely by state due to tax avoidance opportunities, such as cross-border purchasing. CONCLUSIONS: The TUS-CPS can be used to construct valid measures of cigarette prices. Unlike the TBOT, the TUS-CPS captures the effect of price-reducing marketing strategies, as well as tax avoidance practices and non-traditional types of purchasing. Thus, self-reported data like TUS-CPS appear to have advantages over TBOT in estimating the 'real' price that smokers face.