Mobility of US Rural Primary Care Physicians During 2000-2014.

PURPOSE: Despite considerable investment in increasing the number of primary care physicians in rural shortage areas, little is known about their movement rates and factors influencing their mobility. We aimed to characterize geographic mobility among rural primary care physicians, and to identify location and individual factors that influence such mobility. METHODS: Using data from the American Medical Association Physician Masterfile for each clinically active US physician, we created seven 2-year (biennial) mobility periods during 2000-2014. These periods were merged with county-level "rurality," physician supply, economic characteristics, key demographic measures, and individual physician characteristics. We computed (1) mobility rates of physicians by rurality; (2) linear regression models of county-level rural nonretention (departure); and (3) logit models of physicians leaving rural practice. RESULTS: Biennial turnover was about 17% among physicians aged 45 and younger, compared with 9% among physicians aged 46 to 65, with little difference between rural and metropolitan groups. County-level physician mobility was higher for counties that lacked a hospital (absolute increase = 5.7%), had a smaller population size, and had lower primary care physician supply, but area-level economic and demographic factors had little impact. Female physicians (odds ratios = 1.24 and 1.46 for those aged 45 or younger and those aged 46 to 65, respectively) and physicians born in a metropolitan area (odds ratios = 1.75 and 1.56 for those aged 45 or younger and those aged 46 to 65, respectively) were more likely to leave rural practice. CONCLUSIONS: These flndings provide national-level evidence of rural physician mobility rates and factors associated with both county-level retention and individual-level departures. Outcomes were notably poorer in the most remote locations and those already having poorer physician supply and professional support. Rural health workforce planners and policymakers must be cognizant of these key factors to more effectively target retention policies and to take into account the additional support needed by these more vulnerable communities.

Measuring the attractiveness of rural communities in accounting for differences of rural primary care workforce supply.

INTRODUCTION: Many rural communities continue to experience an undersupply of primary care doctor services. While key professional factors relating to difficulties of recruitment and retention of rural primary care doctors are widely identified, less attention has been given to the role of community and place aspects on supply. Place-related attributes contribute to a community's overall amenity or attractiveness, which arguably influence both rural recruitment and retention relocation decisions of doctors. This bi-national study of Australia and the USA, two developed nations with similar geographic and rural access profiles, investigates the extent to which variations in community amenity indicators are associated with spatial variations in the supply of rural primary care doctors. METHODS: Measures from two dimensions of community amenity: geographic location, specifically isolation/proximity; and economics and sociodemographics were included in this study, along with a proxy measure (jurisdiction) of a third dimension, environmental amenity. Data were chiefly collated from the American Community Survey and the Australian Census of Population and Housing, with additional calculated proximity measures. Rural primary care supply was measured using provider-to-population ratios in 1949 US rural counties and in 370 Australian rural local government areas. Additionally, the more sophisticated two-step floating catchment area method was used to measure Australian rural primary care supply in 1116 rural towns, with population sizes ranging from 500 to 50 000. Associations between supply and community amenity indicators were examined using Pearson's correlation coefficients and ordinary least squares multiple linear regression models. RESULTS: It was found that increased population size, having a hospital in the county, increased house prices and affluence, and a more educated and older population were all significantly associated with increased workforce supply across rural areas of both countries. While remote areas were strongly linked with poorer supply in Australia, geographical remoteness was not significant after accounting for other indicators of amenity such as the positive association between workforce supply and coastal location. Workforce supply in the USA was negatively associated with fringe rural area locations adjacent to larger metropolitan areas and characterised by long work commutes. The US model captured 49% of the variation of workforce supply between rural counties, while the Australian models captured 35-39% of rural supply variation. CONCLUSIONS: These data support the idea that the rural medical workforce is maldistributed with a skew towards locating in more affluent and educated areas, and against locating in smaller, poorer and more isolated rural towns, which struggle to attract an adequate supply of primary care services. This evidence is important in understanding the role of place characteristics and rural population dynamics in the recruitment and retention of rural doctors. Future primary care workforce policies need to place a greater focus on rural communities that, for a variety of reasons, may be less attractive to doctors looking to begin or remain working there.

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

PURPOSE: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: Regions with greater primary care physician involvement in end-of-life care have overall less intensive end-of-life care.

The Effects of Training Institution Practice Costs, Quality, and Other Characteristics on Future Practice.

PURPOSE: Medicare beneficiary spending patterns reflect those of the 306 Hospital Referral Regions where physicians train, but whether this holds true for smaller areas or for quality is uncertain. This study assesses whether cost and quality imprinting can be detected within the 3,436 Hospital Service Areas (HSAs), 82.4 percent of which have only 1 teaching hospital, and whether sponsoring institution characteristics are associated. METHODS: We conducted a secondary, multi-level, multivariable analysis of 2011 Medicare claims and American Medical Association Masterfile data for a random, nationally representative sample of family physicians and general internists who completed residency between 1992 and 2010 and had more than 40 Medicare patients (3,075 physicians providing care to 503,109 beneficiaries). Practice and training locations were matched with Dartmouth Atlas HSAs and categorized into low-, average-, and high-cost spending groups. Practice and training HSAs were assessed for differences in 4 diabetes quality measures. Institutional characteristics included training volume and percentage of graduates in rural practice and primary care. RESULTS: The unadjusted, annual, per-beneficiary spending difference between physicians trained in high- and low-cost HSAs was $1,644 (95% CI, $1,253-$2,034), and the difference remained significant after controlling for patient and physician characteristics. No significant relationship was found for diabetes quality measures. General internists were significantly more likely than family physicians to train in high-cost HSAs. Institutions with more graduates in rural practice and primary care produced lower-spending physicians. CONCLUSIONS: The "imprint" of training spending patterns on physicians is strong and enduring, without discernible quality effects, and, along with identified institutional features, supports measures and policy options for improved graduate medical education outcomes.

Retirement Age Ranges from Clinical Practice of Maternal-Fetal Medicine Physicians.

Objectives Retirement of "baby boomer" physicians is a matter of growing concern in light of the shortage of certain physician groups. The objectives of this investigation were to define what constitutes a customary retirement age range of maternal-fetal medicine (MFM) physicians and examine how that compares with other obstetrician-gynecologist (ob-gyn) specialists. Study Design This descriptive study was based on American Medical Association Masterfile survey data from 2010 to 2014. Data from the National Provider Identifier were used to correct for upward bias in reporting retirement ages. Only physicians engaged in direct patient care between ages 55 and 80 years were included. Primary outcomes involved comparisons of retirement ages of male and female physicians with other ob-gyn specialties. Results Interquartile ranges of retirement ages were similar between specialists in MFM (64.1-71.1), gynecologic oncology (62.1-68.9), reproductive endocrinology and infertility (64.1-71.7), and general ob-gyn (61.5-67.9). In every specialty, women retired earlier, while males in MFM were most likely to retire at the oldest age (median 70.0). Conclusion MFM physicians usually retired from clinical practice between ages 64 and 71 years, which is similar to other ob-gyn specialists. Females retired earlier, however, which may impact the overall supply as more females pursue MFM careers.

Office Visits for Women Aged 45-64 Years According to Physician Specialties.

BACKGROUND: The increase in access to healthcare through the Affordable Care Act highlights the need to track where women seek their office-based care. The objectives of this study were to examine the types of physicians sought by women beyond their customary reproductive years and before being elderly. METHODS: This retrospective cohort study involved an analysis of national data from the Medical Expenditure Panel Survey (MEPS) between 2002 and 2012. Women between 45 and 64 years old (n = 44,830) were interviewed, and reviews of corresponding office visits (n = 330,114) were undertaken. RESULTS: In 2002, women aged 45-64 years (62%) went to a family or internal medicine physician only and this reached 72% in 2012. The percentage of women who went to an obstetrician-gynecologist (ob-gyn) only decreased from 20% in 2002 to 12% in 2012. Most went to a family physician or general internist for a general checkup or for diagnosis or treatment. By contrast, visits to ob-gyn physicians were predominantly for general checkups. Those who went to an ob-gyn office were more likely to have a higher family income, live in the Northeast, and describe their overall health as being excellent. CONCLUSIONS: Women aged 45-64 years were substantially more likely to obtain care exclusively at offices of family physicians or general internists than of ob-gyn physicians. Overlap in care provided at more than one physician's office requires continued surveillance in minimizing redundant cost and optimizing resource utilization.

When Do Primary Care Physicians Retire? Implications for Workforce Projections.

PURPOSE: Retirement of primary care physicians is a matter of increasing concern in light of physician shortages. The joint purposes of this investigation were to identify the ages when the majority of primary care physicians retire and to compare this with the retirement ages of practitioners in other specialties. METHODS: This descriptive study was based on AMA Physician Masterfile data from the most recent 5 years (2010-2014). We also compared 2008 Masterfile data with data from the National Plan and Provider Enumeration System to calculate an adjustment for upward bias in retirement ages when using the Masterfile alone. The main analysis defined retirement as leaving clinical practice. The primary outcome was construction of a retirement curve. Secondary outcomes involved comparisons of retirement interquartile ranges (IQRs) by sex and practice location across specialties. RESULTS: The 2014 Masterfile included 77,987 clinically active primary care physicians between ages 55 and 80 years. The median age of retirement from clinical activity of all primary care physicians who retired in the period from 2010 to 2014 was 64.9 years, (IQR, 61.4-68.3); the median age of retirement from any activity was 66.1 years (IQR, 62.6-69.5). However measured, retirement ages were generally similar across primary care specialties. Females had a median retirement about 1 year earlier than males. There were no substantive differences in retirement ages between rural and urban primary care physicians. CONCLUSIONS: Primary care physicians in our data tended to retire in their mid-60s. Relatively small differences across sex, practice location, and time suggest that changes in the composition of the primary care workforce will not have a remarkable impact on overall retirement rates in the near future.

Solo and Small Practices: A Vital, Diverse Part of Primary Care.

PURPOSE: Solo and small practices are facing growing pressure to consolidate. Our objectives were to determine (1) the percentage of family physicians in solo and small practices, and (2) the characteristics of and services provided by these practices. METHODS: A total of 10,888 family physicians seeking certification through the American Board of Family Medicine in 2013 completed a demographic survey. Their practices were split into categories by size: solo, small (2 to 5 providers), medium (6 to 20 providers), and large (more than 20 providers). We also determined the rurality of the county where the physicians practiced. We developed 2 logistic regression models: one assessed predictors of practicing in a solo or small practice, while the other was restricted to solo and small practices and assessed predictors of practicing in a solo practice. RESULTS: More than one-half of respondents worked in solo or small practices. Small practices were the largest group (36%) and were the most likely to be located in a rural setting (20%). The likelihood of having a care coordinator and medical home certification increased with practice size. Physicians were more likely to be practicing in small or solo practices (vs medium-sized or large ones) if they were African American or Hispanic, had been working for more than 30 years, and worked in rural areas. Physicians were more likely to be practicing in small practices (vs solo ones) if they worked in highly rural areas. CONCLUSIONS: Family physicians in solo and small practices comprised the majority among all family physicians seeking board certification and were more likely to work in rural geographies. Extension programs and community health teams have the potential to support transformation within these practices.

Not Near Enough: Racial and Ethnic Disparities in Access to Nearby Behavioral Health Care and Primary Care.

BACKGROUND: Racial, ethnic, and geographical health disparities have been widely documented in the United States. However, little attention has been directed towards disparities associated with integrated behavioral health and primary care services. METHODS: Access to behavioral health professionals among primary care physicians was examined using multinomial logistic regression analyses with 2010 National Plan and Provider Enumeration System, American Medical Association Physician Masterfile, and American Community Survey data. RESULTS: Primary care providers practicing in neighborhoods with higher percentages of African Americans and Hispanics were less likely to have geographically proximate behavioral health professionals. Primary care providers in rural areas were less likely to have geographically proximate behavioral health professionals. CONCLUSION: Neighborhood-level factors are associated with access to nearby behavioral health and primary care. Additional behavioral health professionals are needed in racial/ethnic minority neighborhoods and rural areas to provide access to behavioral health services, and to progress toward more integrated primary care.

Considerations about retirement from clinical practice by obstetrician-gynecologists.

Retirement of obstetrician-gynecologists is becoming a matter of increasing concern in light of an expected shortage of practicing physicians. Determining a retirement age is often complex. We address what constitutes a usual retirement age range from general clinical practice for an obstetrician-gynecologist, compare this with practitioners in other specialties, and suggest factors of importance to obstetrician-gynecologists before retirement. Although the proportion of obstetrician-gynecologists ≥55 years old is similar to other specialists, obstetrician-gynecologists retire at younger ages than male or female physicians in other specialties. A customary age range of retirement from obstetrician-gynecologist practice would be 59-69 years (median, 64 years). Women, who constitute a growing proportion of obstetrician-gynecologists in practice, retire earlier than men. The large cohort of "baby boomer" physicians who are approaching retirement (approximately 15,000 obstetrician-gynecologists) deserves tracking while an investigation of integrated women's health care delivery models is conducted. Relevant considerations would include strategies to extend the work longevity of those who are considering early retirement or desiring part-time employment. Likewise volunteer work in underserved community clinics or teaching medical students and residents offers continuing personal satisfaction for many retirees and preservation of self-esteem and medical knowledge.

Estimating the residency expansion required to avoid projected primary care physician shortages by 2035.

PURPOSE: The purpose of this study was to calculate the projected primary care physician shortage, determine the amount and composition of residency growth needed, and estimate the impact of retirement age and panel size changes. METHODS: We used the 2010 National Ambulatory Medical Care Survey to calculate utilization of ambulatory primary care services and the US Census Bureau to project demographic changes. To determine the baseline number of primary care physicians and the number retiring at 66 years, we used the 2014 American Medical Association Masterfile. Using specialty board and American Osteopathic Association figures, we estimated the annual production of primary care residents. To calculate shortages, we subtracted the accumulated primary care physician production from the accumulated number of primary care physicians needed for each year from 2015 to 2035. RESULTS: More than 44,000 primary care physicians will be needed by 2035. Current primary care production rates will be unable to meet demand, resulting in a shortage in excess of 33,000 primary care physicians. Given current production, an additional 1,700 primary care residency slots will be necessary by 2035. A 10% reduction in the ratio of population per primary care physician would require more than 3,000 additional slots by 2035, whereas changing the expected retirement age from 66 years to 64 years would require more than 2,400 additional slots. CONCLUSIONS: To eliminate projected shortages in 2035, primary care residency production must increase by 21% compared with current production. Delivery models that shift toward smaller ratios of population to primary care physicians may substantially increase the shortage.

A retrospective analysis of the relationship between medical student debt and primary care practice in the United States.

PURPOSE: We undertook a study to reexamine the relationship between educational debt and primary care practice, accounting for the potentially confounding effect of medical student socioeconomic status. METHODS: We performed retrospective multivariate analyses of data from 136,232 physicians who graduated from allopathic US medical schools between 1988 and 2000, obtained from the American Association of Medical Colleges Graduate Questionnaire, the American Medical Association Physician Masterfile, and other sources. Need-based loans were used as markers for socioeconomic status of physicians' families of origin. We examined 2 outcomes: primary care practice and family medicine practice in 2010. RESULTS: Physicians who graduated from public schools were most likely to practice primary care and family medicine at graduating educational debt levels of $50,000 to $100,000 (2010 dollars; P <.01). This relationship between debt and primary care practice persisted when physicians from different socioeconomic status groups, as approximated by loan type, were examined separately. At higher debt, graduates' odds of practicing primary care or family medicine declined. In contrast, private school graduates were not less likely to practice primary care or family medicine as debt levels increased. CONCLUSIONS: High educational debt deters graduates of public medical schools from choosing primary care, but does not appear to influence private school graduates in the same way. Students from relatively lower income families are more strongly influenced by debt. Reducing debt of selected medical students may be effective in promoting a larger primary care physician workforce.

Trends in office-based care for reproductive-aged women according to physician specialty: a ten-year study.

BACKGROUND: The anticipated increase in access to health care has prompted an interest in where women go for their office-based care. The objectives of this study were to examine which types of office site are chosen by reproductive-aged women for their health care and to compare the reasons for their visits among these sites. METHODS: This descriptive study involved an analysis of national data from the Medical Expenditure Panel Survey between 2002 and 2011. We restricted the analysis to a nationally representative group of women between 19 and 39 years old (n=45,133). Interviews with patients were used to identify the patient's demographics, type of physician seen, and main reason for each self-reported office visit (n=208,814). RESULTS: One in four women did not go to a physician's office each year. Nearly all who sought some sort of office-based care went to family physicians, ob-gyns, or a combination. For the women who did go to a physician's office, going only to a family physician's office was most common (42.6%). In contrast, 28.6% of these women visited only an ob-gyn office, and an additional 21.5% went to offices of a family physician or general internist as well as an ob-gyn physician. Visits only to offices of ob-gyns were highest among women who were married and healthy. Compared with family physicians or internists, the percentages of office visits to an ob-gyn were more likely for pregnancy (57.0% vs. 2.8%), about the same for a general check-up (23.6% vs. 29.2%), and less for diagnosis or treatment (13.7% vs. 55.5%). Those who went to ob-gyn offices were most apt to return for several visits per year. CONCLUSION: Almost all health care sought by women aged 19 to 39 in a year is to ob-gyns or family physicians, and significant sharing of care exists across these provider groups. While most visits to family physicians were for diagnosis or treatment, the majority of visits to ob-gyn were for pregnancy-related care.

Cost, utilization, and quality of care: an evaluation of illinois' medicaid primary care case management program.

PURPOSE: In 2006, Illinois established Illinois Health Connect (IHC), a primary care case management program for Medicaid that offered enhanced fee-for-service, capitation payments, performance incentives, and practice support. Illinois also implemented a complementary disease management program, Your Healthcare Plus (YHP). This external evaluation explored outcomes associated with these programs. METHODS: We analyzed Medicaid claims and enrollment data from 2004 to 2010, covering both pre- and post-implementation. The base year was 2006, and 2006-2010 eligibility criteria were applied to 2004-2005 data to allow comparison. We studied costs and utilization trends, overall and by service and setting. We studied quality by incorporating Healthcare Effectiveness Data and Information Set (HEDIS) measures and IHC performance payment criteria. RESULTS: Illinois Medicaid expanded considerably between 2006 (2,095,699 full-year equivalents) and 2010 (2,692,123). Annual savings were 6.5% for IHC and 8.6% for YHP by the fourth year, with cumulative Medicaid savings of $1.46 billion. Per-beneficiary annual costs fell in Illinois over this period compared to those in states with similar Medicaid programs. Quality improved for nearly all metrics under IHC, and most prevention measures more than doubled in frequency. Medicaid inpatient costs fell by 30.3%, and outpatient costs rose by 24.9% to 45.7% across programs. Avoidable hospitalizations fell by 16.8% for YHP, and bed-days fell by 15.6% for IHC. Emergency department visits declined by 5% by 2010. CONCLUSIONS: The Illinois Medicaid IHC and YHP programs were associated with substantial savings, reductions in inpatient and emergency care, and improvements in quality measures. This experience is not typical of other states implementing some, but not all, of these same policies. Although specific features of the Illinois reforms may have accounted for its better outcomes, the limited evaluation design calls for caution in making causal inferences.

Factors influencing family physicians' contribution to the child health care workforce.

PURPOSE: We wanted to explore demographic and geographic factors associated with family physicians' provision of care to children. METHODS: We analyzed the proportion of family physicians providing care to children using survey data collected by the American Board of Family Medicine from 2006 to 2009. Using a cross-sectional study design and logistic regression analysis, we examined the association of various physician demographic and geographic factors and providing care of children. RESULTS: Younger age, female sex, and rural location are positive predictors of family physicians providing care to children: odds ratio (OR) = 0.97 (95% CI, 0.97-0.98), 1.19 (1.12-1.25), and 1.50 (1.39-1.62), respectively. Family physicians practicing in a partnership are more likely to provide care to children than those in group practice: OR = 1.53 (95% CI, 1.40-1.68). Family physicians practicing in areas with higher density of children are more likely to provide care to children: OR = 1.04 (95% CI, 1.03-1.05), while those in high-poverty areas are less likely 0.10 (95% CI, 0.10-0.10). Family physicians located in areas with no pediatricians are more likely to provide care to children than those in areas with higher pediatrician density: OR = 1.80 (95% CI, 1.59-2.01). CONCLUSIONS: Various demographic and geographic factors influence the likelihood of family physicians providing care to children, findings that have important implications to policy efforts aimed at ensuring access to care for children.