Public policy and the supply of primary care physicians

The decline in general practice, the arrested growth of family medicine training programs, and the increased subspecialization of internal medicine and pediatrics are responsible for the continuing decrease in the proportion of physicians in the United States who practice a primary care specialty. Since 1963, the number of physicians has more than doubled, but the ratio of office-based primary care physicians to the national population has decreased. This trend has been especially pronounced in rural areas and impoverished urban communities. There is evidence that the proportion of young physicians entering primary care specialties is declining. Medical education has become increasingly reliant on service income, making it difficult to fund training in primary care specialties. Grants for graduate training in primary care specialties have not increased with inflation, and outright elimination of these programs is under consideration. Public programs that fund medical education must be reformed to improve the geographic and specialty distribution of physicians.     

Which medical schools produce rural physicians?

OBJECTIVE--To examine the hypothesis that medical schools vary systematically and predictably in the proportion of their graduates who enter rural practice. DESIGN--The December 1991 version of the American Medical Association Physician Masterfile was used to examine the rural and urban practice locations of physicians who graduated from American medical schools between 1976 and 1985. Selected characteristics of the medical schools--including location, ownership, and funding--were linked to the Physician Masterfile. MAIN OUTCOME MEASURES--The percentage of the graduates from each medical school who were practicing in rural areas in December 1991, disaggregated by physician specialty. RESULTS--Of the practicing graduates from our study, 12.6% were located in rural counties; family physicians were much more likely than members of other specialties to select rural practice, particularly in the smallest and most isolated rural counties. Women were much less likely than men to enter rural practice. Medical schools varied greatly in the percentage of their graduates who entered rural practice, ranging from 41.2% to 2.3% of the graduating classes studied. Twelve medical schools accounted for over one quarter of the physicians entering rural practice in this time period. Four variables were strongly associated with a tendency to produce rural graduates: location in a rural state, public ownership, production of family physicians, and smaller amounts of funding from the National Institutes of Health. DISCUSSION--The organization, location, and mission of medical schools is closely related to the propensity of their graduates to select rural practice. Increasing policy coordination among medical schools and state and federal governmental entities would most effectively address residual problems of rural physician shortages.     

Impact of the Medicare fee schedule on payments to physicians

Beginning in 1992, the Medicare program will pay physicians by the Medicare Fee Schedule, a system of geographically adjusted standardized payment rates based in part on the Resource-Based Relative Value Scale developed by Hsaio et al and in part on current Medicare payments. In our simulations of the Medicare Fee Schedule, we find that (1) redistributions of Medicare-allowed charges across specialities will be substantial but approximately only half the size projected by Hsaio, (2) there will be large redistributions among geographic areas that tend to compound the specialty redistributions, and (3) there will be wide variation within specialties as to how individual providers are affected. The majority of the redistributive impact of the Medicare Fee Schedule is attributable to implementation of a geographically adjusted system of standardized payments rather than to the particular work values developed by Hsiao et al in the Resource-Based Relative Value Scale.     

Profile of Canadian physicians: results of the 1990 Physician Resource Questionnaire.

OBJECTIVE: To determine the supply, mix and distribution of physicians in Canada and to compare data with those of the 1982 and 1986 physician surveys. DESIGN: National census mail survey. SETTING: Canada. PARTICIPANTS: All physicians licensed to practise medicine in Canada, excluding interns and residents. A total of 52,422 questionnaires were mailed, of which 771 were ineligible. There were 38,313 valid responses (response rate 74.2%). MAIN OUTCOME MEASURES: Activity status, workload, specialty certification, practice setting and demographic profiles. MAIN RESULTS: A total of 88.7% of the respondents were active physicians; 19.4% were women, compared with 16.8% in 1986. Physicians reported working on average 4.1 fewer hours per week in total activities than in 1986 and 5.7 fewer hours per week than in 1982. As was found in 1982, about 50% of active physicians were certified specialists; 30% of specialists and 21% of general/family practitioners were 55 years of age or more. Approximately 11% of active physicians were in rural practice, as was reported in 1986. Similar proportions of foreign graduates and Canadian graduates were located in rural areas (10.9% and 11.4% respectively). CONCLUSIONS: Factors such as aging and retirement will affect specific specialty groups (e.g., general surgery and obstetrics/gynecology) in the near future. Specialty groups must address the issue of the future supply of physicians and the demand for their services when developing targeted needs within their specialties. The increasing proportion of women in medicine is changing the specialty mix and practice profiles of physicians as a whole. The issues associated with the recruitment and retention of physicians in rural areas remain complex.     

The Minnesota Rural Physician Associate Program for medical students

The Rural Physician Associate Program (RPAP) at the University of Minnesota Medical School is a clinical education experience for third-year students that lasts nine to 12 months. In 1970 the Minnesota legislature required the medical school faculty to find an educational method to redistribute physicians into the medically underserved rural areas of Minnesota or lose state funds for the medical school. After 16 years of the program, all 87 counties in Minnesota have an acceptable ratio of general physicians for the first time in the state's history. RPAP students work directly with and are supervised by general physicians practicing in rural areas; these preceptors have an average age of 40 years, are board-certified, and have 12 years of clinical experience. They give their teaching services and a $2,500 stipend to the student; the state provides $7,000 to the student with no obligation that the student practice in rural Minnesota after training. The preceptors, RPAP staff members, and visiting university faculty members provide 50, 30, and 20 percent, respectively, of a student's grades for the program; the student receives six months of credit for the program. As of 1986, 57 percent of the former RPAP students in practice were practicing in rural communities, with a majority in Minnesota and a majority in towns with populations less than 10,000.     

The decline in bulk-billing and increase in out-of-pocket costs for general practice consultations in rural areas of Australia, 1995-2001

OBJECTIVE: To describe the changes in bulk-billing and out-of-pocket costs for Australian general practice consultations over the period 1995-2001. DESIGN: Retrospective analysis of 1996-2001 survey data from the Australian Longitudinal Study on Women's Health (ALSWH), linked with Medicare and Department of Veterans' Affairs (DVA) data on general practice consultations from 1995 to 2001. PARTICIPANTS: 22 633 women who gave consent to linkage of their ALSWH data with Medicare/DVA records. In 1996, women in the "young" cohort (n = 6219) were aged 18-23 years, those in the "mid-age" cohort (n = 8883) were aged 45-50 years, and those in the "older" cohort (n = 7531) were aged 70-75 years. OUTCOME MEASURES: Out-of-pocket costs paid by patients for general practice consultations, by calendar year, urban/rural area of residence, age, frequency of attendance, self-rated health, and education level. RESULTS: For each age group and year studied, the use of bulk-billing was lower in rural areas than in urban areas. For example, in 2000, the percentage of women in rural and urban areas, respectively, who had all their general practice consultations bulk-billed was 31% v 52% (young women), 24% v 45% (mid-age women) and 58% v 79% (older women). There has been a steady decline in bulk-billing for general practice consultations in rural areas since 1995. The average out-of-pocket cost per consultation for women in rural areas was higher than the cost for women living in urban areas. After adjusting for age, health and socioeconomic factors, women living in urban areas were more than twice as likely to have all their consultations bulk-billed as women living in rural areas: odds ratio (OR), 2.4 (95% CI, 2.1-2.7) (young women); OR, 2.5 (95% CI, 2.3-2.8) (mid-age women); OR, 2.6 (95% CI, 2.3-2.9) (older women). CONCLUSIONS: In Australia, the geographic differential in the cost of general practice consultations is widening. Policy changes are required to enable women in rural and remote areas to have access to affordable healthcare services.     

Mississippi's physician labor force: current status and future challenges

The literature review indicates that changes in Medicaid/Medicare reimbursement, large numbers of uninsured patients, the legal climate, and largely rural and chronically ill populations create a challenging environment for physicians practicing in Mississippi. As a largely rural state, many Mississippians find medical care to be physically distant, with most care being concentrated in a couple areas of the state. Given these factors, the legal climate in Mississippi and the top relocation decision factors, Mississippi will be further challenged in recruiting and retaining the numbers of general practitioners and specialists necessary to provide care to the state's population. The challenges that physicians are facing have led to challenges for health policy makers, in that physicians are difficult to recruit to Mississippi and, once here, difficult to retain as practitioners throughout their career. Four datasets were used in conjunction to analyze the demographic characteristics of Mississippi's physicians, including the age structure disaggregated by several other variables. Ultimately, the results were extended to impacts of recruitment, relocations, and retirement decisions of physicians who participated in the MSMDS. Briefly, demographic results indicate that Mississippi has a largely white physician population serving a nearly 40% minority population in Mississippi. The under representation of women within the medical profession in Mississippi means that women in the state might find it unusually challenging to find a female physician, particularly in rural areas where access to physicians is more limited in the first place. Mississippi has a high concentration of African-American patients with a low African-American physician presence. The proportion of physicians who are female is on the rise nationwide and within Mississippi, largely due to increasing enrollments of women in medical schools. Though variations exist within the groups of physicians identified as generalists, Mississippi is only slightly more likely than the nation to have specialists, rather than generalists (see Table Seven). Age structure analysis indicates that Delta physicians are older than physicians elsewhere in the state, that urban physicians are younger than rural physicians, and that our physician labor force is more highly concentrated between the ages of 35 and 54 than in the nation as a whole. Analyses concerning the future of the physician labor force indicate that a near majority of Mississippi's practicing physicians received their MD degree at UMC, but younger physicians are more likely to have been educated out-of-state than older physicians. Those who received their degrees elsewhere and chose to practice in Mississippi are more likely to be specialists (60%) than generalists (40%). Those physicians practicing in the state who were educated in-state are nearly equally as likely to be generalists (47%) as they are to be specialists (53%). Additionally, those approaching retirement are more likely to be generalists, yet the state is recruiting more generalists from recent medical school classes than in the past. Variations in intentions to recruit, relocate, and retire exist. However, most of the substantively important variation is across age groups and time in practice. There is little relevance of specialty or location within the state when examining variation in recruitment, relocation or retirement plans. Given the findings, policy research recommendations focus on improving the retention of UMC's graduates for practice in the state, improving retention of active physicians, increasing the recruitment of physicians from out of state, and easing difficulties associated with working part-time as a step toward retirement. With these changes in policy, it is possible that Mississippi can thwart a physician workforce shortage; however, without changes, with more physicians relocating, retiring early, or opting out of practicing in the state, the extant physician shortage will become more severe. Furthermore, without the data collection efforts mentioned here, there will be no means to assess whether policy changes are actually impacting the physician labor force.     

Migration of physicians from one specialty to another. A longitudinal study of US medical school graduates

To demonstrate the extent to which physicians change their specialty, randomized samples of the graduating classes of 1960, 1964, and 1968 were studied with respect to their self-designated specialties in 1971 and 1976. Of the 2,046 physicians in the three samples, 333 (16%) changed their specialty between 1971 and 1976. It was 8% for the 1960 cohort, 11% for 1964, and 29% for 1968. Of all the changes, 78% were from one specialty practice to another or back to a formal residency in a different specialty; 22% changed from one specialty residency to either practice or another residency in a different specialty. Between 1971 and 1976, a total of 127 (16%) of 783 primary care physicians changed their specialty. The magnitude of this change must be considered in planning for distribution of physicians by specialty.     

Physician supply in key medical specialties in West Virginia hospitals, 2001-2004

This article describes the development, implementation and analysis of an ongoing prospective physician supply survey of the largest acute care hospitals in West Virginia. This survey was designed to assess changes in availability of physicians in key specialties from 2001-2004, a period of years that included a "malpractice insurance crisis." The malpractice crisis in this article describes the period of time in 2001-2002 when medical malpractice insurance rates increased abruptly in West Virginia and a number of physicians publicized their departure from practice in the state. We calculated the absolute and relative percentage change in the median number of physicians in each specialty between 2001-2004, calculated percentage change for each specialty by year, and performed univariate analysis on the percentage changes among all hospitals. We also calculated univariate analysis on the percentage changes among all hospitals. The median number of staff physicians in these hospitals declined steadily from 2001-2004. Declines in the number of specialists (some statistically significant) occurred, especially early in the three-year period, notably among surgical specialties. The availability of nephrologists increased significantly from 2003-2004. Decreases in staff physician numbers may have leveled off, but there is no evidence of sustained growth.     

The Medical Association of Georgia's Impaired Physicians Program. Review of the first 1000 physicians: analysis of specialty

Risk factors for the disease of chemical dependence, or addiction to alcohol and/or drugs, for physicians have not been clearly defined. Yet chemical dependence is believed to be a leading occupational hazard for physicians. This study compares the specialties of a population of physicians assessed for the presence of impairment (study group, N = 1000) with the distribution of specialties for all US physicians. Only 21 of the total were found to be free of impairment from chemical dependence or psychiatric disease, while 920 physicians (92.0%) had a primary diagnosis of chemical dependence, and 59 (5.9%) had a major psychiatric illness. Anesthesia and family and general practice were found to be overrepresented in the population under study, as compared with all US physicians. There were significant differences between the study group and all US physicians with respect to age, sex, and practice activity status. The authors urge these apparent high-risk specialties, as well as the medical profession itself, to develop control or prevention strategies that will reduce risk for chemical dependence through education, early identification, intervention, and treatment of those individuals with the disease.     

国外农村基层医师医学培养项目实施现状、成效及评价的系统综述

背景　2010年我国农村订单定向医学生免费培养工作启动，旨在为农村地区培养具备本科学历的全科医生，缓解农村地区基层医师匮乏的现状。本研究通过系统综述了解国外类似项目的实施现状、成效及评价，为我国农村订单定向医学生培养工作评价和改善提供理论参考。目的　了解国外农村基层医师医学培养项目实施现状、成效及评价指标方法等。方法　2019年2-7月，采用系统综述的方法，以“医学教育”“医学教育+医学本科生”“医学院校教育”“医学生”“住院医师规范化培训”“医学专业+人力资源”“农村地区”“农村基层医疗服务”“医师执业地点”“农村基层医师”“农村基层医师培养”“农村医学实习”“农村临床见习”为检索词，检索Ovid MEDLINE、PubMed、Cochrane及Google Scholar主要英文数据库，获取2000-01-01至2019-01-01发表的关于全球农村基层医师院校教育及住院医师培训等项目的实施现状、成效及评价的英文文献。结果　最终纳入53篇文献，分别来自美国、加拿大、澳大利亚、日本、泰国及南非6个国家，包括20个院校教育项目和6个住院医师培训项目。文献显示各国农村基层医师培养项目均具有指向性招生策略、面向农村卫生和全科医学的临床课程体系、以农村执业的家庭医生为临床导师及农村地区临床实践基地等要素；培养项目学生选择家庭医学为执业专业、农村地区执业率和长期农村保留率均明显高于非培养项目学生，两者国家医疗执照考试成绩和通过率无明显差异。长期农村地区临床实践培训、招生策略倾斜农村成长背景学生及农村执业的家庭医生导师是影响项目最终效果的关键因素。结论　医学教育是解决农村基层医师匮乏的有效途径。国外农村基层医师培养项目的招生策略、临床课程体系设置、导师指导及评价可为我国农村订单定向医学生培养工作提供有益参考。     

Wisconsin's family physician shortage

This paper analyzes current and future needs for primary care physicians--particularly family practice physicians--in Wisconsin in light of predictions of a national physician glut by the year 1990. The current shortfall of family physicians is estimated to be at least 150, with the most severe deficits found in rural and underserved urban areas. Forty-nine to 79 family practice physicians will be needed each year to meet the growing demand and to replace losses due to retirement, speciality change, and other factors. At the current rate of training, 63 new family physicians will enter practice each year; it appears that the current deficit will be made up slowly, if at all. The number of primary care specialists appears unlikely to increase due to the declining interest in the speciality among medical students; only half the number of new family physicians entering practice each year will enter practice in 1994, resulting in an additional shortfall of about 30 to 50 family physicians each year. Programs should be undertaken at medical schools to bolster student interest in family practice and primary care.     

The economic impacts of Oklahoma's Family Medicine residency programs

The enactment of Medicare and Medicaid created a new demand for medical services in Oklahoma, particularly in rural areas. The state of Oklahoma responded by creating The Oklahoma Physician Manpower Training Commission in 1975. The overall purpose of the Commission was to increase the number of primary care physicians and influence distribution into non-metro areas. This analysis concerns the public policy value of this ongoing program. The PMTC has provided resident stipend funding to each of Oklahoma's publicly funded Family Medicine residency programs. Since 1975, the PMTC has provided over 139 million dollars in resident stipend funding and support; and there have been 749 program graduates with 431 practicing in Oklahoma. This model calculates that the Oklahoma-based physicians have created a cumulative 3.7 billion dollars of economic impact on the state; and conservatively estimates that only 10% of the practice decisions/locations were influenced by the PMTC. This creates an estimated return of 370 million dollars on an "investment" of 139 million dollars. Additionally the model demonstrates that the current cohort of physicians is annually responsible for 15,530 jobs and an associated payroll of 428 million dollars.     

Doctors' attitudes, medical philosophy, and political views

A survey of 507 British physicians in different specialties was conducted to investigate their attitudes on various medico-moral and practice issues. There were few substantial differences among the specialty groups in their responses to questions concerning specific bioethical and practical issues. However, the groups differed substantially in political outlook and general medical philosophy. Ranged from the most right wing and technological to the most left wing and humanistic were the following groups: surgeons, hospital physicians, women physicians, general practitioners, and psychiatrists.     

An evaluation of income incentives and board-certification trends.

In this paper the author examines income differentials between board-certified and non-board-certified physicians to determine whether the trend toward board certification is consistent with economic incentives. Although simple income comparisons indicate substantial differentials by certification status, after adjustments are made for specialty-mix, age distribution, and hours worked, the remaining differential is small. However, results by specialty indicate that physicians are most likely to become certified in specialties with the largest income differentials.     

State public policy: the impacts of Oklahoma's physician incentive programs

The enactment of Medicare and Medicaid created a sudden and significant increase in demand for physician services in Oklahoma. As a response, the Oklahoma Legislature established the Physician Manpower Training Commission in 1975. The intent was to provide incentives for graduating physicians to remain in Oklahoma, especially in rural areas. This analysis examines the retention rates experienced during the 25-year period of 1976-2001. It is observed that 82% of program physicians are currently practicing in Oklahoma. This retention proportion compares to only 36% for National Health Service Corps physicians who were obligated to practice in Oklahoma. Additionally, Oklahoma has experienced a 67% retention proportion in rural areas. During this period, 633 physicians have received an estimated dollar 19 million in loans and scholarships. This is an average of dollar 30,000 per recipient. In return, each of these physicians will create 34 jobs and almost dollar 1 million of annual income.     

临床医学八年制学生就业分析及其对人才培养的启示

目的 使用北京某高校临床医学八年制毕业生就业数据,对其就业情况及变化趋势进行分析,以期探讨对人才培养的启示。方法 采用描述性分析方法,所分析的指标包括就业人数、就业率、就业地域及专业分布。结果 在2009至2021年间,该校共有2 281名临床医学八年制毕业生。其中,毕业当年就业者2 188人,占比96.0%。在医疗机构就业者所占比例平均为90.8%（2 034/2 241）,但呈下降趋势。就业地域主要集中在东部经济发达省份,在北京就业者最多,占比78.7%（1 723/2 188）。在专业选择方面,以学习外科专业者最多,占比33.0% （753/2 281）;其次为内科学,占比24.4%（557/2 281）;选择儿科、精神病与精神卫生学等社会急需紧缺专业者极少。结论 临床医学八年制毕业生整体就业形式好,但也需要关注就业呈现的新趋势,进一步优化人才培养方案。在二级学科的选择中,需要进一步加强引导,为学科发展建立合理的人才梯队。需要加强课程思政教育,引导和激励毕业生为急需紧缺专业和边远地区卫生服务作出贡献。     

When is it appropriate to bill physician services using modifier -59?

Accurate coding of medical services is a constant challenge for physicians and could jeopardize a practice if not taken seriously. Insurance carriers use sophisticated claims-processing software that easily identifies coding trends by physicians and flags outliers within specialties. The Office of Inspector General (OIG) and the Center for Medicare and Medicaid Services (CMS) hire auditors to identify areas for review which are commonly miscoded. One area that has been flagged for review is billing with modifier -59 because misuse of this modifier has increased inappropriate reimbursement. Be cautious when using this modifier, due to the legal and compliance ramifications when documentation does not adequately support the "distinct procedural service" to justify the use of modifier -59.     

Women in medical specialty societies. An update

The question of whether women are joining medical specialty societies at the same rate as their male counterparts has not been studied. A questionnaire was mailed to 48 medical specialty societies representing the 37 specialties listed in the Physician Characteristics and Distribution in the U.S., 1986 Edition. The response rate was 79%. Twenty organizations were able to identify the sex of their members, including the 7 specialty societies that represent the 6 most frequently chosen specialties of women physicians. Only in the American Psychiatric Association and the American Academy of Family Physicians was the enrollment of potential female members equivalent to that of male members. If the medical specialty societies do not address the issue of women being underrepresented in their societies, they will lose a large potential resource of leadership, participation, and financial support. More important, the societies will not be truly representative of their specialties.     

Rural background and clinical rural rotations during medical training: effect on practice location

BACKGROUND: Providing health care services in rural communities in Canada remains a challenge. What affects a family medicine resident's decision concerning practice location? Does the resident's background or exposure to rural practice during clinical rotations affect that decision? METHODS: Cross-sectional mail survey of 159 physicians who graduated from the Family Medicine Program at Queen's University, Kingston, Ont., between 1977 and 1991. The outcome variables of interest were the size of community in which the graduate chose to practise on completion of training (rural [population less than 10,000] v. nonrural [population 10,000 or more]) and the size of community of practice when the survey was conducted (1993). The predictor or independent variables were age, sex, number of years in practice, exposure to rural practice during undergraduate and residency training, and size of hometown. RESULTS: Physicians who were raised in rural communities were 2.3 times more likely than those from nonrural communities to choose to practise in a rural community immediately after graduation (95% confidence interval 1.43-3.69, p = 0.001). They were also 2.5 times more likely to still be in rural practice at the time of the survey (95% confidence interval 1.53-4.01, p = 0.001). There was no association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community. INTERPRETATION: Physicians who have roots in rural Canada are more likely to practise in rural Canada than those without such a background.