Winston Liaw

Projecting US Primary Care Physician Workforce Needs: 2010-2025

PURPOSE We sought to project the number of primary care physicians required to meet US health care utilization needs through 2025 after passage of the Affordable Care Act. METHODS In this projection of workforce needs, we used the Medical Expenditure Panel Survey to calculate the use of office-based primary care in 2008. We used US Census Bureau projections to account for demographic changes and the American Medical Associations Masterfile to calculate the number of primary care physicians and determine the number of visits per physician. The main outcomes were the projected number of primary care visits through 2025 and the number of primary care physicians needed to conduct those visits. RESULTS Driven by population growth and aging, the total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. After incorporating insurance expansion, the United States will require nearly 52,000 additional primary care physicians by 2025. Population growth will be the largest driver, accounting for 33,000 additional physicians, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require more than 8,000 additional physicians, a 3% increase in the current workforce. CONCLUSIONS Population growth will be the greatest driver of expected increases in primary care utilization. Aging and insurance expansion will also contribute to utilization, but to a smaller extent.

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.

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.

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

The Impact of Insurance and a Usual Source of Care on Emergency Department Use in the United States

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.

Lessons for Primary Care from the First Ten Years of Medicare Coordinated Care Demonstration Projects

Background. Finding a usual source of care (USC) is difficult for certain populations. This analysis determines how insurance type and having a USC affect the settings in which patients seek care. Methods. In this cross-sectional study of the 2000–2011 Medical Expenditure Panel Surveys, we assessed the percentage of low-income persons with half or more of their ambulatory visits to the emergency department (ED). Respondents were stratified based on insurance type and presence of a USC. Results. In 2011, among Medicaid enrollees without USCs, 21.6% had half or more of their ambulatory visits to EDs compared to 8.1% for those with USCs. Among the uninsured without USCs, 24.1% went to an ED for half or more of their ambulatory visits compared to 8.8% for those with USCs in 2011. Among the privately insured without USCs, 7.8% went to an ED for half or more of their ambulatory visits compared to 5.0% for those with USCs in 2011. These differences remained in multivariate analyses. Conclusions. Those who lack USCs, particularly the uninsured and Medicaid enrollees, are more likely to rely on EDs.

Risk-Adjusted Comparison of Blood Pressure and Low-Density Lipoprotein (LDL) Noncontrol in Primary Care Offices

Over the past decade, Medicare has tested care coordination programs in an effort to achieve the triple aim of improving the patient experience, improving population health, and lowering costs. Although savings from this promising concept have not materialized, private payers are starting to offer blended payments to primary care. From these demonstrations, we propose 5 lessons for practices implementing care coordination: (1) minimize expenses by sharing resources and avoiding cost ineffective interventions; (2) concentrate on high utilizers; (3) foster relationships with both providers and patients; (4) track patients across the medical neighborhood in real time; and (5) extend rather than a duplicate the efforts of primary care practices.

Navigating payer heterogeneity in the United States: lessons for primary care

Objectives: Population-level control of modifiable cardiovascular disease (CVD) risk factors is suboptimal. The objectives of this study were (1) to demonstrate the use of electronically downloaded electronic health record (EHR) data to assess guideline concordance in a large cohort of primary care patients, (2) to provide a contemporary assessment of blood pressure (BP) and low-density lipoprotein (LDL) noncontrol in primary care, and (3) to demonstrate the effect of risk adjustment of rates of noncontrol of BP and LDL for differences in patient mix on these clinic-level performance measures. Methods: This was an observational comparative effectiveness study that included 232,172 adult patients ≥18 years old with ≥1 visit within 2 years in 33 primary care clinics with EHRs. The main measures were rates of BP and LDL noncontrol based on current guidelines and were calculated from electronically downloaded EHR data. Rates of noncontrol were risk-adjusted using multivariable models of patient-level variables. Results: Overall, 16.0% of the 227,122 patients with known BP and 14.9% of the 136,771 patients with known LDL were uncontrolled. Clinic-level, risk-adjusted BP noncontrol ranged from 7.7% to 26.5%, whereas that for LDL ranged from 5.8% to 23.6%. Rates of noncontrol exceeded an achievable benchmark for 85% (n = 28) and 79% (n = 26) of the 33 clinics for BP and LDL, respectively. Risk adjustment significantly influences clinic rank order for rate of noncontrol. Conclusions: We demonstrated that the use of electronic collection of data from a large cohort of patients from fee-for-service primary care clinics is feasible for the audit of and feedback on BP and LDL noncontrol. Rates of noncontrol for most clinics are substantially higher than those achievable. Risk adjustment of noncontrol rates results in a rank-order of clinics very different from that achieved with nonadjusted data.

When Do Primary Care Physicians Retire? Implications for Workforce Projections

With most providers accepting private and public funding, the US exemplifies hybridization, which results in both systemic benefits and harms. While this practice stimulates innovation, encourages practices to be efficient, and increases choice, it has also been linked to gaps in patient safety and overtreatment. We propose three lessons from the US for navigating a public and private system: hybridization allows for innovation; hybridization leads to administrative complexity; and if the costs of participation outweigh the benefits, practices may undergo dehybridization.

Privately insured adults in HDHP with higher deductibles reduce rates of primary care and preventive services

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.