Demographic and temporal trends in mental health and substance use services provided by primary care physicians in British Columbia, Canada.

BACKGROUND: As the demand for mental health and substance use (MHSU) services increases, there will be an even greater need for health human resources to deliver this care. This study investigates how family physicians' (FP) contact volume, and more specifically, MHSU contact volume, is shaped by demographic trends among FPs in British Columbia, Canada. METHODS: We used annual physician-level administrative billing data and demographic information on FPs in British Columbia between 1996 and 2017. This study analyzes trends in primary care service provision among graduating cohorts of FPs, FPs of different ages (as measured by years since graduation), and FPs practicing during different time periods. Additionally, analyses are stratified by FP sex to account for potential differences in labour supply patterns between male and female FPs. RESULTS: Our results show that while FPs' overall contacts with patients decreased between 1996 and 2017, their annual number of MHSU contacts increased, which was largely driven by an increase in substance use visits. Demographically, the proportion of female FPs in the labour force rose over time. Observed trends were similar, though not identical in male and female FPs, as males tended to have higher overall contact volume (both total contacts and MHSU), but also steeper declines in contact volume in later careers. The number of contacts (both total and MHSU) changed across career stage - rising steadily from start to mid-career, peaking at 20-30 years in practice, and decreasing steadily thereafter. This was evident for all cohorts and consistent over the 21-year study period but flattened in amplitude over time. Our findings also point to potential cohort effects on labour supply. The inverse U-shaped career trend extended to MHSU contacts, but its peak seems to have shifted to a later career stage (peaking at 30-40 years of practice) over time. CONCLUSIONS: Our study shows changing dynamics in MHSU service delivery among FPs over time, across the life span and between FP sexes that are likely to influence access to care beyond simply the number of FPs. Given the healthcare needs of the population, these findings point to potential future changes in provision of MHSU services.

Accelerated competency-based education in primary care (ACE-PC): a 3-year UC Davis and Kaiser permanente partnership to meet California's primary care physician workforce needs.

PROBLEM: Our nation faces an urgent need for more primary care (PC) physicians, yet interest in PC careers is dwindling. Students from underrepresented in medicine (UIM) backgrounds are more likely to choose PC and practice in underserved areas yet their representation has declined. Accelerated PC programs have the potential to address workforce needs, lower educational debt, and diversify the physician workforce to advance health equity. APPROACH: With support from Kaiser Permanente Northern California (KPNC) and the American Medical Association's Accelerating Change in Medical Education initiative, University of California School of Medicine (UC Davis) implemented the Accelerated Competency-based Education in Primary Care (ACE-PC) program - a six-year pathway from medical school to residency for students committed to health equity and careers in family medicine or PC-internal medicine. ACE-PC accepts 6-10 students per year using the same holistic admissions process as the 4-year MD program with an additional panel interview that includes affiliated residency program faculty from UC Davis and KPNC. The undergraduate curriculum features: PC continuity clinic with a single preceptor throughout medical school; a 9-month longitudinal integrated clerkship; supportive PC faculty and culture; markedly reduced student debt with full-tuition scholarships; weekly PC didactics; and clinical rotations in affiliated residency programs with the opportunity to match into specific ACE-PC residency tracks. OUTCOMES: Since 2014, 70 students have matriculated to ACE-PC, 71% from UIM groups, 64% are first-generation college students. Of the graduates, 48% have entered residency in family medicine and 52% in PC-internal medicine. In 2020, the first graduates entered the PC workforce; all are practicing in California, including 66% at federally qualified health centers, key providers of underserved care.

Primary Care Physician Network Overlap Between Medicaid and the Patient Protection and Affordable Care Act Marketplace.

This cross-sectional study quantifies Medicaid and the Patient Protection and Affordable Care Act (ACA) Marketplace overlap among primary care physicians.

Setting the Target: Comparing Family Medicine Among US Allopathic Target Schools.

BACKGROUND AND OBJECTIVES: Despite the persistent primary care physician shortage over 2 decades of allopathic medical school expansion, some medical schools are absent a department of family medicine; these schools are designated as "target" schools. These absences are important because evidence has demonstrated the association between structured exposure to family medicine during medical school and the proportion of students who ultimately select a career in family medicine. In this study, we aimed to address part of this gap by defining and characterizing the current landscape of US allopathic target schools. METHODS: We identified allopathic target schools by reviewing all Liaison Committee of Medical Education (LCME) accredited institutions for the presence of a family medicine department. To compare these schools in terms of family medicine representation and outcomes, we curated descriptive data from publicly available websites, previously published family medicine match results, and school rankings for primary care. RESULTS: We identified 12 target schools (8.7% of all US allopathic accredited medical schools) with considerable heterogeneity in opportunities for family medicine engagement, leadership, and training. Target schools with greater family medicine representation had increased outcomes for family medicine workforce and primary care opportunities. CONCLUSION: With growing primary care workforce gaps, target schools have a responsibility to enhance family medicine presence and representation at their institutions. We provide recommendations at the institutional, specialty, and national level to increase family medicine representation at target schools, with the goal that all schools eventually establish a department of family medicine.

Primary Care in the United States: Past, Present and Future.

Even though a well-functioning primary care system is widely acknowledged as critical to population health, the number of primary care physicians (PCPs) practicing in the United States has steadily declined, and PCPs are in short supply. The reasons are multiple and include inadequate income relative to other specialties, excessive administrative demands on PCPs and the lack of respect given to primary care specialties during medical school and residency. Advanced practice nurses can augment the services of primary care physicians but cannot substitute for them. To change this situation, we need action on several fronts. Medical schools should give preference to students who are more likely to enter the primary care specialties. The income gap between primary care and other specialties should be narrowed. The administrative load placed on PCPs, including cumbersome electronic medical records, must be lessened. Insurers, including Medicare and Medicaid, must provide the resources to allow primary care physicians to act as leaders of multidisciplinary teams.

Primary care doctors retirements in the context of an ageing population in Italy.

Background: Ongoing shortages in primary care doctors/primary care paediatricians and increasing healthcare needs due to ageing of the population represent a great challenge for healthcare providers, managers, and policymakers. To support planning of primary healthcare resource allocation we analyzed the geographic distribution of primary care doctors/primary care paediatricians across Italian regions, accounting for area-specific number and age of the population. Additionally, we estimated the number of primary care doctors/primary care paediatricians expected to retire over the next 25 years, with a focus on the next five years. Study design: Ecological study. Methods: We gathered the list of Italian general practitioners and primary care paediatricians and combined them with the data from the National Federation of Medical Doctors, Surgeons and Dentists. Using data from the National Institutes of Statistics, we calculated the average number of patients per doctor for each region using the number of residents above and under 14 years of age for general practitioners and primary care paediatricians respectively. We also calculated the number of residents over-65 and over-75 years of age per general practitioner, as elderly patients typically have higher healthcare needs. Results: On average the number of patients per general practitioner was 1,447 (SD: 190), while for paediatricians it was 1,139 (SD: 241), with six regions above the threshold of 1,500 patients per general practitioner and only one region under the threshold of 880 patients per paediatrician. We estimated that on average 2,228 general practitioners and 444 paediatricians are going to retire each year for the next five years, reaching more than 70% among the current workforce for some southern regions. The number of elderly patients per general practitioner varies substantially between regions, with two regions having >15% more patients aged over 65 years compared to the expected number. Conclusions: over 65 years compared to the expected number. Conclusions. The study highlighted that some regions do not currently have the required primary care workforce, and the expec-ted retirements and the ageing of the population will exacerbate the pressure on the already over-stretched healthcare services. A response from healthcare administrations and policymakers is urgently required to allow equitable access to quality primary care across the country.

A retomada do Programa Mais Médicos em 2023 / La reanudación del Programa Mais Médicos en 2023 / The resumption of the Mais Médicos Program in 2023

RESUMO: Os vazios assistenciais e a demanda por médicos no Sistema Único de Saúde são problemas crônicos, principalmente nas regiões mais vulneráveis do Norte e Nordeste e em áreas periféricas de centros urbanos. Frente a essa necessidade, o governo federal está recompondo o Programa Mais Médicos para o Brasil, por meio dos ministérios da Saúde, da Educação e da Fazenda. Os principais eixos do programa são a provisão de médicos na Atenção Primária em Saúde e a formação desses profissionais, nessa versão associados à especialização e mestrado profissional, tendo como referência a concepção de Atenção Primária à Saúde integral. Nesta nota de conjuntura, trazemos informações sobre a trajetória oficial deste movimento de retomada, recuperando brevemente características e avanços proporcionados por essa política - instituída primeiramente em 2013 - e apresentando peculiaridades da versão atual, proposta pewla medida provisória n. 1.165, de 20 de março de 2023, convertida em lei (n. 14.621/2023) e sancionada em julho deste ano.

RESUMEN: Las brechas de asistencia y la demanda de médicos en el Sistema Único de Salud son problemas crónicos, especialmente en las regiones más vulnerables del Norte y del Noreste y en las zonas periféricas de los centros urbanos. Ante esta necesidad, el gobierno federal está recomponiendo el Programa Mais Médicos para Brasil, a través de los ministerios de Salud, Educación y Hacienda. Los principales ejes del programa son la provisión de médicos en Atención Primaria de Salud y la formación de estos profesionales, en esta versión asociada a la especialización y maestría profesional, con referencia al concepto de atención primaria para la salud integral. En esta nota de coyuntura, traemos información sobre la trayectoria oficial de este movimiento de reanudación, recuperando brevemente las características y los avances proporcionados por esta política - establecida por primera vez en 2013 - y presentando las peculiaridades de la versión actual, propuesta por la medida provisional n. 1.165, del 20 de marzo de 2023, convertida en ley (n. 14.621/2023) y sancionado en julio de este año.

ABSTRACT: Healthcare gaps and the demand for physicians in the Brazilian Health System are chronic problems, especially in the most vulnerable regions of the North and Northeast and in peripheral areas of urban centers. In view of this need, the federal government is recomposing the Mais Médicos Program for Brazil, through the ministries of Health, Education and Finance. The main axes of the program are the provision of doctors in Primary Health Care and the training of these professionals, in this version associated with specialization and professional master's, with reference to the concept of primary care for integral health. In this note of conjuncture, we bring information about the official trajectory of this recovery movement, briefly recovering characteristics and advances provided by this policy - first established in 2013 - and presenting peculiarities of the current version, proposed by provisional measure n. 1.165, of March 20th, 2023, converted into law (n. 14.621/2023) and sanctioned in July of this year.

Primary Care Physician Supply by County-Level Characteristics, 2010-2019.

This study evaluates and compares US trends between 2010 and 2019 in per-capita primary care physician supply by county-level racial and ethnic minority concentration, poverty, rurality, and region.

Dual-eligible beneficiaries and inadequate access to primary care.

OBJECTIVES: To determine whether enough primary care providers are in close proximity to where dual-eligible beneficiaries live to provide the capacity needed for integrated care models. STUDY DESIGN: Secondary data analysis using dual-eligible enrollment data and health care workforce data. METHODS: We determined the density of dual-eligible beneficiaries per 1000 population in 2017 for each of 3142 US counties. County-level supply of primary care physicians (PCPs), primary care nurse practitioners, and physician assistants was determined. RESULTS: One-third of the 791 counties with the highest density of dual-eligible beneficiaries had PCP shortages. Counties with the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type were concentrated in Southeastern states. These areas also had some of the highest coronavirus disease 2019 outbreaks within their states. CONCLUSIONS: States in the Southeastern region of the United States with some of the most restrictive scope-of-practice laws have an inadequate supply of primary care providers to serve a high concentration of dual-eligible beneficiaries. The fragmented care of the dually eligible population leads to extremely high costs, prompting policy makers to consider integrated delivery models that emphasize primary care. However, primary care workforce shortages will be an enduring challenge without scope-of-practice reforms.

Estimated Effect on Life Expectancy of Alleviating Primary Care Shortages in the United States.

BACKGROUND: Prior studies have reported that greater numbers of primary care physicians (PCPs) per population are associated with reduced population mortality, but the effect of increasing PCP density in areas of low density is poorly understood. OBJECTIVE: To estimate how alleviating PCP shortages might change life expectancy and mortality. DESIGN: Generalized additive models, mixed-effects models, and generalized estimating equations. SETTING: 3104 U.S. counties from 2010 to 2017. PARTICIPANTS: Children and adults. MEASUREMENTS: Age-adjusted life expectancy; all-cause mortality; and mortality due to cardiovascular disease, cancer, infectious disease, respiratory disease, and substance use or injury. RESULTS: Persons living in counties with less than 1 physician per 3500 persons in 2017 had a mean life expectancy that was 310.9 days shorter than for persons living in counties above that threshold. In the low-density counties (n = 1218), increasing the density of PCPs above the 1:3500 threshold would be expected to increase mean life expectancy by 22.4 days (median, 19.4 days [95% CI, 0.9 to 45.6 days]), and all such counties would require 17 651 more physicians, or about 14.5 more physicians per shortage county. If counties with less than 1 physician per 1500 persons (n = 2636) were to reach the 1:1500 threshold, life expectancy would be expected to increase by 56.3 days (median, 55.6 days [CI, 4.2 to 105.6 days]), and all such counties would require 95 754 more physicians, or about 36.3 more physicians per shortage county. LIMITATION: Some projections are based on extrapolations of the actual data. CONCLUSION: In counties with fewer PCPs per population, increases in PCP density would be expected to substantially improve life expectancy. PRIMARY FUNDING SOURCE: None.

Fully Integrated Readiness for Service Training (FIRST): An Accelerated Medical Training Program for Rural and Underserved North Carolina.

PROBLEM: The U.S. primary care workforce remains inadequate to meet the health needs of the U.S. population. Effective programs are needed to provide workforce development for rural and other underserved areas. APPROACH: At the University of North Carolina (UNC) School of Medicine (SOM), between November 2014 and July 2015, the authors developed and implemented the Fully Integrated Readiness for Service Training (FIRST) Program, an accelerated curriculum focused on rural and underserved care that links 3 years of medical school with a conditional acceptance into UNC's 3-year family medicine residency, followed by 3 years of practice support post-graduation. Students are recruited to the FIRST Program during the fall of their first year of medical school. The FIRST Program promotes close faculty mentorship and familiarity with the health care system, includes a longitudinal quality improvement project with an assigned patient panel, includes early integration into the clinic, and fosters a close cohort of fellow students. OUTCOMES: As of March 2020, the FIRST Program had successfully recruited 5 classes of medical students, and 3 of those classes had matched into residency. In total, as of March 2020, 18 students had participated in the FIRST Program. NEXT STEPS: The FIRST Program will be expanded to additional clinical sites across North Carolina and to specialties beyond family medicine, including pediatrics, general surgery, and psychiatry.

Beyond the COVID-19 Pandemic: The Urgent Need to Expand Primary Care and Family Medicine.

The COVID-19 pandemic, together with its resultant economic downturn, has unmasked serious problems of access, costs, quality of care, inequities, and disparities of US health care. It has exposed a serious primary care shortage, the unreliability of employer-sponsored health insurance, systemic racism, and other dysfunctions of a system turned on its head without a primary care base. Fundamental reform is urgently needed to bring affordable health care that is accessible to all Americans. Over the last 40-plus years, our supposed system has been taken over by corporate stakeholders with the presumption that a competitive unfettered marketplace will achieve the needed goal of affordable, accessible care. That theory has been thoroughly disproven by experience as the ranks of more than 30 million uninsured and 87 million underinsured demonstrates. Three main reform alternatives before us are: (1) to build on the Affordable Care Act; (2) to implement some kind of a public option; and (3) to enact single-payer Medicare for All. It is only the third option that can make affordable, comprehensive health care accessible for our entire population. As the debate goes forward over these alternatives during this election season, the likelihood of major change through a new system of national health insurance is becoming increasingly realistic. Rebuilding primary care and public health is a high priority as we face a new normal in US health care that places the public interest above that of corporate stakeholders and Wall Street investors. Primary care, and especially family medicine, should become the foundation of a reformed health care system.

Changes in Health Care Use and Outcomes After Turnover in Primary Care.

Importance: Disruptions of continuity of care may harm patient outcomes, but existing studies of continuity disruption are limited by an inability to separate the association of continuity disruption from that of other physician-related factors. Objectives: To examine changes in health care use and outcomes among patients whose primary care physician (PCP) exited the workforce and to directly measure the association of this primary care turnover with patients' health care use and outcomes. Design, Setting, and Participants: This cohort study used nationally representative Medicare billing claims for a random sample of 359 470 Medicare fee-for-service beneficiaries with at least 1 PCP evaluation and management visit from January 1, 2008, to December 31, 2017. Primary care physicians who stopped practicing were identified and matched with PCPs who remained in practice. A difference-in-differences analysis compared health care use and clinical outcomes for patients who did lose PCPs with those who did not lose PCPs using subgroup analyses by practice size. Subgroup analyses were done on visits from January 1, 2008, to December 31, 2017. Exposure: Patients' loss of a PCP. Main Outcomes and Measures: Primary care, specialty care, urgent care, emergency department, and inpatient visits, as well as overall spending for patients, were the primary outcomes. Receipt of appropriate preventive care and prescription fills were also examined. Results: During the study period, 9491 of 90 953 PCPs (10.4%) exited Medicare. We matched 169 870 beneficiaries whose PCP exited (37.2% women; mean [SD] age, 71.4 [6.1] years) with 189 600 beneficiaries whose PCP did not exit (36.9% women; mean [SD] age, 72.0 [5.0] years). The year after PCP exit, beneficiaries whose PCP exited had 18.4% (95% CI, -19.8% to -16.9%) fewer primary care visits and 6.2% (95% CI, 5.4%-7.0%) more specialty care visits compared with beneficiaries who did not lose a PCP. This outcome persisted 2 years after PCP exit. Beneficiaries whose PCP exited also had 17.8% (95% CI, 6.0%-29.7%) more urgent care visits, 3.1% (95% CI, 1.6%-4.6%) more emergency department visits, and greater spending ($189 [95% CI, $30-$347]) per beneficiary-year after PCP exit. These shifts were most pronounced for patients of exiting PCPs in solo practice, whose beneficiaries had 21.5% (95% CI, -23.8% to -19.3%) fewer primary care visits, 8.8% (95% CI, 7.6%-10.0%) more specialty care visits, 4.4% more emergency department visits (95% CI, 2.1%-6.7%), and $260 (95% CI, $12-$509) in increased spending. Conclusions and Relevance: Loss of a PCP was associated with lower use of primary care and increased use of specialty, urgent, and emergency care among Medicare beneficiaries. Interrupting primary care relationships may negatively impact health outcomes and future engagement with primary care.

Calculating physician supply using a service day method and the income percentiles method: a descriptive analysis.

BACKGROUND: It is important to have an accurate count of physicians and a measurable understanding of their service provision for physician resource planning. Our objective was to compare 2 methods (income percentiles [IP] and service day activities [SVD]) for calculating the supply of full-time (FT) and part-time (PT) primary care physicians (PCPs) as measures of both physician supply counts and level of provider continuity. METHODS: Using an observational study design, we compared 2 methods of calculating the supply of PT and FT PCPs for 2011-2015. For the IP approach, the Canadian Institute for Health Information's method was applied to Alberta Health billing data. The SVD method calculated annual service days for fee-for-service PCPs. A simple descriptive analysis was conducted of the supply of PT and FT PCPs. RESULTS: The 2 methods agreed on the FT versus PT status of 85.2% of PCPs in 2015 but disagreed on the status of 490 PCPs. A total of 239 PCPs were classified as working FT by the IP method but PT by the SVD method. Two hundred and fifty-one PCPs were classified as working PT according by the IP method but FT by the SVD method. The former group of 239 PCPs worked fewer days per week (3.22 v. 4.1) and fewer weekend days per year (8.6 v. 24.1), billed more per year ($300 327 v. $201 834) and saw more patients per day (26.8 v. 17.8) with less continuity of care (38.0% v. 72.0%) than the latter group of 251 PCPs. INTERPRETATION: The SVD method provides a valid alternative to calculating GP supply that distinguishes groups of physicians that the standard IP methodology does not. Those groups provide very different service; policy-makers may benefit from distinguishing them.

Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities.

BACKGROUND: Investing in human resources for health (HRH) is vital for achieving universal health care and the Sustainable Development Goals. The Programa Mais Médicos (PMM) (More Doctors Programme) provided 17,000 doctors, predominantly from Cuba, to work in Brazilian primary care. This study assesses whether PMM doctor allocation to municipalities was consistent with programme criteria and associated impacts on amenable mortality. METHODS: Difference-in-differences regression analysis, exploiting variation in PMM introduction across 5565 municipalities over the period 2008-2017, was employed to examine programme impacts on doctor density and mortality amenable to healthcare. Heterogeneity in effects was explored with respect to doctor allocation criteria and municipal doctor density prior to PMM introduction. RESULTS: After starting in 2013, PMM was associated with an increase in PMM-contracted primary care doctors of 15.1 per 100,000 population. However, largescale substitution of existing primary care doctors resulting in a net increase of only 5.7 per 100,000. Increases in both PMM and total primary care doctors were lower in priority municipalities due to lower allocation of PMM doctors and greater substitution effects. The PMM led to amenable mortality reductions of - 1.06 per 100,000 (95%CI: - 1.78 to - 0.34) annually - with greater benefits in municipalities prioritised for doctor allocation and where doctor density was low before programme implementation. CONCLUSIONS: PMM potential health benefits were undermined due to widespread allocation of doctors to non-priority areas and local substitution effects. Policies seeking to strengthen HRH should develop and implement needs-based criteria for resource allocation.

The Neighborhood Deprivation Index and Provider Geocoding Identify Critical Catchment Areas for Diabetes Outreach.

PURPOSE: In designing a Project ECHO™ type 1 diabetes (T1D) program in Florida and California, the Neighborhood Deprivation Index (NDI) was used in conjunction with geocoding of primary care providers (PCPs) and endocrinologists in each state to concurrently identify areas with low endocrinology provider density and high health risk/poverty areas. The NDI measures many aspects of poverty proven to be critical indicators of health outcomes. METHODS: The data from the 2013-2017 American Community Survey (ACS) 5-year estimates were used to create NDI maps for California and Florida. In addition, geocoding and 30-minute drive-time buffers were performed using publicly available provider directories for PCPs and endocrinologists in both states by Google Geocoding API and the TravelTime Search Application Programming Interface (API). RESULTS: Based on these findings, we defined high-need catchment areas as areas with (1) more than a 30-minute drive to the nearest endocrinologist but within a 30-minute drive to the nearest PCP; (2) an NDI in the highest quartile; and (3) a population above the median (5199 for census tracts, and 1394 for census block groups). Out of the 12 181 census tracts and 34 490 census block groups in California and Florida, we identified 57 tracts and 215 block groups meeting these criteria as high-need catchment areas. CONCLUSION: Geospatial analysis provides an important initial methodologic step to effectively focus outreach efforts in diabetes program development. The integration of the NDI with geocoded provider directories enables more cost-effective and targeted interventions to reach the most vulnerable populations living with T1D.