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Effects of Primary Care Supply in a Single Payer Health System

Effects of Primary Care Supply in a Single Payer Health System. Astrid Guttmann MDCM, MSc 1,2,3,4 Scott A. Shipman MD, MPH 5 Kelvin Lam MSc 1 David Goodman MD, MSc 5 Therese Stukel PhD 1,4,5 1 Institute for the Evaluative Clinical Sciences, Toronto, ON Canada

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Effects of Primary Care Supply in a Single Payer Health System

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  1. Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann MDCM, MSc1,2,3,4 Scott A. Shipman MD, MPH5 Kelvin Lam MSc1 David Goodman MD, MSc5 Therese Stukel PhD1,4,5 1 Institute for the Evaluative Clinical Sciences, Toronto, ON Canada 2 Paediatric Medicine, Hospital for Sick Children 3 Dept of Paediatrics, University of Toronto 4 Dept. of Health Policy, Management and Evaluation, University of Toronto 5 Center for Health Policy Research, The Dartmouth Institute for Health Policy and Clinical Practice

  2. Funding Sources • Physician Services Incorporated • Canadian Institutes for Health Research

  3. Objectives • Set the context of primary care delivery for children in Ontario • Present preliminary work on the association between primary care physician supply and health services access and utilization • Consider findings in light of U.S. healthcare system and current policy discussions

  4. Ontario 1 in 3 Canadians 12 million residents 3 million children 60% urban 415,000 sq miles 3.5 persons/sq mile Major cities: Toronto, Ottawa

  5. Primary care for children in Ontario • Universal insurance coverage • Primary care delivered mainly by GPs/FPs • Proportion provided by pediatricians increasing from 1990s to 2004 • Small increase in number of GPs but seeing fewer kids • Number of pediatricians increased slightly • Increasing proportion of practice devoted to primary care • Declining overall primary care visit rates for children • Disproportionately among low income children

  6. Research Question In the setting of universal coverage,how does the local primary care supply influence children’s receipt of health services?

  7. Calculating primary care physician supply (FTEs) • Examined physician-level claims for all care delivered in the province of Ontario, 2003-2005 • GP’s -- Defined the % of their overall activity that was primary care for children 0-17 yrs X overall FTE • General Pediatricians • Defined % of billings that used primary care fee codes (non-consultative office based visits) • % of overall activity X overall FTE

  8. Calculating supply (cont’d) • Used county as the local geographic measure • Calculated supply using GP, Ped head count as well as primary care FTE • Population = all children in Ontario ages 0-17 yrs • Categorized per capita supply at the county level in increments of 500 children/ 1 primary care FTE (1500-1999, 2000-2499, 2500-2999, 3000-3499, >3500)

  9. Outcomes assessed • Self-reported access to primary care • Primary Care Access Survey by Ontario Ministry of Health, 2006 • Recommended utilization rates • Newborn visit within 1 week of discharge (per Canadian consensus guidelines) • Preventive care (in first 2 years) – well baby, annual exams, immunizations • Any primary care over 2 years (for all children) • Emergency department utilization rates

  10. Outcomes, continued • Discretionary utilization • Visit rates for URI/ common cold • Follow-up visits for URI/common cold • Visits for acne • Admissions for ambulatory care sensitive conditions • For chronic  in prevalent population only

  11. Analysis • Unit of analysis : dissemination area • Age group/sex adjusted strata • Controlled for neighbourhood income • Also bed supply for hospitalization models • Poisson regression to model outcomes by supply category

  12. Description of Physician and Population by Physician Supply Category

  13. Access to primary care *Among families with children in the home

  14. Recommended services missed 1500 – 1999 High MD supply 2001 - 2500 2501- 3000 3001 - 3500 >3500 Low MD supply

  15. Adjusted rate ratios of children with no visits by supply *adjusted for age, sex, income quintile

  16. Discretionary Utilization(visits per 1000 children)

  17. Children’s ED visit rates by supply 1500 – 2000 High Supply 3000 - 3499 2000 - 2499 2500- 2999 >3500 Low supply

  18. Hospitalizations for Ambulatory Care Sensitive Conditions

  19. Conclusions • Self-reported access only really impacted when fewer than 1 FTE MD per 3500 or more children • Utilization (both recommended and discretionary) consistently increases as local primary care physician supply increases • ED utilization is markedly affected by local primary care supply • Some impact on ACS hospitalizations --?morbidity vs utilization

  20. In a U.S. Context. . . • U.S. has far more primary care physicians per capita, and worse maldistribution • U.S. might best improve access for children by first providing universal coverage for them • With universal coverage, it does appear that desired utilization patterns are improved as local primary care supply increases (? whether this continues beyond with more than 1 MD per 1700 children)

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