The Gender Wage Gap Among Early-Career Family Physicians

PURPOSE

Numerous studies have documented salary differences between male and female physicians. For many specialties, this wage gap has been explored by controlling for measurable factors that influence pay such as productivity, work-life balance, and practice patterns. In family medicine where practice activities differ widely between physicians, it is important to understand what measurable factors may be contributing to the gender wage gap, so that employers and policymakers and can address unjust disparities.

METHODS

We used data from the 2017 to 2020 American Board of Family Medicine (ABFM) National Graduate Survey (NGS) which is administered to family physicians 3 years after residency (n = 8608; response rate = 63.9%, 56.2% female). The survey collects clinical income and practice patterns. Multiple linear regression analysis was performed, which included variables on hours worked, degree type, principal professional activity, rural/urban, and region.

RESULTS

Although early-career family physician incomes averaged $225,278, female respondents reported incomes that were $43,566 (17%) lower than those of male respondents (P = .001). Generally, female respondents tended toward lower-earning principal professional activities and US regions; worked fewer hours (2.9 per week); and tended to work more frequently in urban settings. However, in adjusted models, this gap in income only fell to $31,804 (13% lower than male respondents, P = .001).

CONCLUSION

Even after controlling for measurable factors such as hours worked, degree type, principal professional activity, population density, and region, a significant wage gap persists. Interventions should be taken to eliminate gender bias in wage determinations for family physicians.

Does Community- or University-Based Residency Sponsorship Affect Graduate Perceived Preparation or Performance?

BACKGROUND

Residency training occurs in varied settings. Whether there are differences in the training received by graduates of community- or medical school-based programs has been the subject of debate.

OBJECTIVE

This study examined the perceived preparation for practice, scope of practice, and American Board of Family Medicine (ABFM) board examination pass rates of family physicians in relation to the type of residency program (community, medical school, or partnership) in which they trained.

METHODS

Predetermined survey responses were abstracted from the 2016 and 2017 National Family Medicine Graduate Survey of ABFM and linked to data about residency programs obtained from the websites of national organizations. Descriptive statistics were used to summarize the data and logistic regression to examine differences between survey results based on type of residency training: community, medical school, or partnership.

RESULTS

Differences in the perception of preparation as well as current scope of practice were noted for the 3 residency types. The differences in perception were mainly noted in hospital-based skills, such as intubation and ventilator management, and in women's health and family planning services, with different program types increasing preparedness perception in different domains.

CONCLUSIONS

In general, graduates of family medicine community-based, non-affiliated, and partnership programs perceived they were prepared for and were providing more of the services queried in the survey than graduates of medical school-based programs.

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.

Decline of Empathy after the First Internship: Towards a More Functional Empathy?

Research has shown a decline in empathy as medical studies progress. Among various hypotheses, an explanation track evoked is the first contact with the internship. Objectives This quasi-experimental study was designed to examine the impact of the first internship in medical students. Our research question was: "to what extent the first internship may decreased the empathy's scores of our 3d year medical students?" Methods We measured the empathy of 220 third year medical students before and after their first internship (3 weeks) in family medicine. Using online surveys methodology, we collected data about empathy ("Interpersonal Reactivity Index": IRI), epidemiology, professional orientation choices. Results Statistical analyses revealed a small but significant decrease in IRI's "fantasy," "empathic concern" and "personal distress" subscales. Conclusion These results suggest a potential impact of the first internship on empathic skills. The fact that the students' score for the "personal distress" subscale (which characterizes a difficulty in managing their emotions) decreases is actually a rather good thing. These data raise the question of the "function" of this loss of empathy. The fact that this score decreases after first internship, may indicate a positive change for these medical students: towards better emotional regulation and more functional affective empathy.

The Cost-Effectiveness Analysis of Cervical Cancer Screening Using a Systematic Invitation System in Lithuania

In Lithuania, cytological screening of cervical cancer (CC) is largely opportunistic. Absence of standardized systematic invitation practice might be the reason for low participation rates. The study aimed to assess the cost-effectiveness of systematic invitation approach in CC screening programme from the perspective of a healthcare provider. A decision tree was used to compare an opportunistic invitation by a family doctor, a personal postal invitation letter with appointment time and place, and a personal postal invitation letter with appointment time and place with one reminder letter. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) per one additionally screened woman and per one additional abnormal Pap smear test detected. The ICER of one personal postal invitation letter was €9.67 per one additionally screened woman and €55.21 per one additional abnormal Pap smear test detected in comparison with the current screening practice. The ICER of a personal invitation letter with an additional reminder letter compared to one invitation letter was €13.47 and €86.88 respectively. Conclusions: A personal invitation letter approach is more effective in increasing the participation rate in CC screening and the number of detected abnormal Pap smears; however, it incurs additional expenses compared with current invitation practice.

Relationship between general practice capitation funding and the quality of primary care in England: a cross-sectional, 3-year study

OBJECTIVE

To explore the relationship between general practice capitation funding and quality ratings based on general practice inspections.

DESIGN

Cross-sectional study pooling 3 years of primary care administrative data.

SETTING

UK primary care.

PARTICIPANTS

7310 practices (95% of all practices) in England which underwent Care Quality Commission (CQC) inspections between November 2014 and December 2017.

MAIN OUTCOME MEASURES

CQC ratings. Ordered logistic regression methods were used to predict the relationship between practice capitation funding and CQC ratings in each of five domains of quality: caring, effective, responsive, safe and well led, together with an overall practice rating.

RESULTS

Higher capitation funding per patient was significantly associated with higher CQC ratings across all five quality domains: caring (OR 1.14, 95% CI 1.04 to 1.23), effective (OR 1.08, 95% CI 1.00 to 1.16), responsive (OR 1.09, 95% CI 1.02 to 1.17), safe (OR 1.11, 95% CI 1.05 to 1.18), well led (OR 1.13, 95% CI 1.06 to 1.20) and overall rating (OR 1.13, 95% CI 1.06 to 1.19).

CONCLUSION

Higher capitation funding was consistently associated with higher ratings across all CQC domains and in the overall practice rating. This study suggests that measured dimensions of the quality of care are related to the underlying capitation funding allocated to each general practice, implying that additional capitation funding may be associated with higher levels of primary care quality.

[Cost to ambulatory care for schizophrenia in Family Medicine]

BACKGROUND

The groups related to ambulatory care (GRAA, according to its initials in Spanish) are a classification of clinical diagnoses performed on patients receiving medical care in primary care; it is a comprehensive treatment for one year.

OBJECTIVE

To determine the costs of ambulatory care and sociodemographic characteristics of patients with schizophrenia attended in Family Medicine (FM).

MATERIAL AND METHODS

Cross-sectional study which included adult patients with complete electronic clinical record, who had confirmed diagnosis of schizophrenia and received medical attention in a FM unit from January to December 2017. The variables were: age, sex, sociodemographic data, drug addiction and employment status. To determine the annual cost of schizophrenia based on GRAA, the economic medical card was applied, which includes family medicine consultations, inter-consultations, medications, medical supplies, and the time of use of installed capacity for one year.

RESULTS

Out of all patients, 56.2% were men (n = 172). Age was 48.42 ± 14.4 years. Of women, 21.2% were married and 21.2% homemakers, 4.2% smokers, and 1.3% alcohol drinkers. Of men, 30.4% were unmarried, 15% unemployed, 13.1% smokers, and 6.9% alcohol drinkers. The total annual cost of schizophrenia for FGRAA-MH for men was $ 7 613 236.00.

CONCLUSIONS

The use of FGRAA-MH revealed the total annual cost for the care of schizophrenia in the medical unit, which provides important information for better understanding the magnitude of this health problem in that area, and will improve planning and economic medical management.

How often do both core competencies of shared decision making occur in family medicine teaching clinics?

OBJECTIVE

To assess how often risk communication and values clarification occur in routine family medicine practice and to explore factors associated with their occurrence.

DESIGN

Qualitative and quantitative cross-sectional study.

SETTING

Five university-affiliated family medicine teaching clinics across Quebec.

PARTICIPANTS

Seventy-one health professionals (55% physicians, 35% residents, 10% nurses or dietitians) and 238 patients (76% women; age range 16 to 82 years old).

MAIN OUTCOME MEASURES

The presence or absence of risk communication and values clarification during visits in which decisions were made was determined. Factors associated with the primary outcome (both competencies together) were identified. The OPTION5 (observing patient involvement in decision making) instrument was used to validate the dichotomous outcome.

RESULTS

The presence of risk communication and values clarification during visits was associated with OPTION5 scores (area under the curve of 0.80, 95% CI 0.75 to 0.86, P < .001). Both core competencies of shared decision making occurred in 150 of 238 (63%) visits (95% CI 54% to 70%). Such an occurrence was more likely when the visit included discussion about beginning something new, treatment options, or postponing a decision, as well as when health professionals preferred a collaborative decision-making style and when the visit included more decisions or was longer. Alone, risk communication occurred in 203 of 238 (85%) visits (95% CI 82% to 96%) and values clarification in 162 of 238 (68%) visits (95% CI 61% to 75%).

CONCLUSION

Health professionals in family medicine are making an effort to engage patients in shared decision making in routine daily practice, especially when there is time to do so. The greatest potential for improvement might lie in values clarification; that is, discussing what matters to patients and families.

Debt and the Emerging Physician Workforce: The Relationship Between Educational Debt and Family Medicine Residents' Practice and Fellowship Intentions

PURPOSE

Educational debt is increasing and may affect physicians' career choices. High debt may influence family medicine residents' initial practice setting and fellowship training decisions, adversely affecting the distribution of primary care physicians. The purpose of this study was to determine whether debt was associated with graduating family medicine residents' practice and fellowship intentions.

METHOD

The authors completed a cross-sectional secondary analysis of 2014 and 2015 American Board of Family Medicine (ABFM) examination registration questionnaire data and ABFM administrative data. They used multivariate logistic regression to determine whether educational debt was associated with graduating residents' practice (ownership and type) and fellowship intentions.

RESULTS

Most residents (89.7%; 3,368) intended to pursue an employed position, but this intention was not associated with their debt. Residents with high debt ($150,000-$249,999) had lower odds of intending to work for a government organization (odds ratio [OR] 0.57; confidence interval [CI] 0.41-0.79). Those with high or very high debt (> $250,000) had lower odds of choosing academic practice (OR 0.55, CI 0.36-0.85 and OR 0.62, CI 0.40-0.96, respectively) or a geriatrics fellowship (OR 0.36, CI 0.20-0.67 and OR 0.29, CI 0.15-0.55, respectively).

CONCLUSIONS

High educational debt may contribute to national shortages of academic primary care physicians and geriatricians. Existing National Health Service Corps loan repayment opportunities may not offer adequate incentives to primary care physicians with high debt. The medical community should advocate for policies that better align financial incentives with workforce needs.

Family medicine in the service of internal security: morbidity and cost of prescriptions

BACKGROUND

The study of morbidity and cost of drug prescriptions generated by the primary care physician, with specific populations directs Quality Improvement strategies of care.

AIM

To identify acute pathologies in primary care medicine forces for internal security and to study the cost of drug prescription .

METHODS

This is a cross-sectional survey during which, we analyzed the medical records (MR) and medical prescriptions (MP)for patients older than 5 years, presenting for acute pathologies, at the first online consultation polyclinic of the internal security forces(ISF) of Mahdia, during the year 2014. Data were collected using a standardized form. We opted for a two-stage sampling the first agreement by taking the second month of each season, the second systematic taking MR from one day to two.

RESULTS

We analyzed 701 MR. The average age of the consultants was 37 years with a sex ratio de1,34. Systems, respiratory, digestive, musculoskeletal, skin and cardiovascular, were accumulating 88.3% of acute morbidity diagnosed. The most prescribed therapeutic classes were antipyretics / analgesics (61.6%), antibiotics (42.7%), local treatments oto-rhino-laryngological and throat (28.6%), cough (13.6%), the non steroidal anti inflammatory (12.2%) and mucolytics (11.7%). The median cost of the prescription was 12.070 Tunisian Dinar (TD). The contribution of the patients served at the polyclinic of the FIS of Mahdia, in drug costs, was 35.1%.

CONCLUSION

we were able to highlight the specificities of morbidity in the front line at the polyclinic of the FSI of Mahdia , the nature and cost of drug prescription that was equivalent to that of the general population but with better contribution third party payers.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors

BACKGROUND

It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.

METHODS

Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.

RESULTS

Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.

CONCLUSION

Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Nurses as substitutes for doctors in primary care

BACKGROUND

Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005.

OBJECTIVES

Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'.

SELECTION CRITERIA

Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis.

MAIN RESULTS

For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low.

AUTHORS' CONCLUSIONS

This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.

Billing by residents and attending physicians in family medicine: the effects of the provider, patient, and visit factors

BACKGROUND

Medical billing and coding are critical components of residency programs since they determine the revenues and vitality of residencies. It has been suggested that residents are less likely to bill higher evaluation and management (E/M) codes compared with attending physicians. The purpose of this study is to assess the variation in billing patterns between residents and attending physicians, considering provider, patient, and visit characteristics.

METHOD

A retrospective cohort study of all established outpatient visits at a family medicine residency clinic over a 5-year period was performed. We employed the logistic regression methodology to identify residents' and attending physicians' variations in coding E/M service levels. We also employed Poisson regression to test the sensitivity of our result.

RESULTS

Between January 5, 2009 and September 25, 2015, 98,601 visits to 116 residents and 18 attending physicians were reviewed. After adjusting for provider, patient, and visit characteristics, residents billed higher E/M codes less often compared with attending physicians for comparable visits. In comparison with attending physicians, the odds ratios for billing higher E/M codes were 0.58 (p = 0.01), 0.56 (p = 0.01), and 0.63 (p = 0.01) for the third, second, and first years of postgraduate training, respectively. In addition to the main factors of patient age, medical conditions, and number of addressed problems, the gender of the provider was also implicated in the billing variations.

CONCLUSION

Residents are less likely to bill higher E/M codes than attending physicians are for similar visits. While these variations are known to contribute to lost revenues, further studies are required to explore their effect on patient care in relation to attendings' direct involvement in higher E/M-coded versus their indirect involvement in lower E/M-coded visits.

General Practitioners and Mammographic Screening Uptake: Influence of Different Modalities of General Practitioner Participation

Aims and background

To compare the impact of different modalities of general practitioner (GP) involvement, including the introduction of target payments, on the attendance rate of organized population-based screening programs for breast cancer in Italy.

Study design

The study was conducted between 1994 and 1996 in four Italian cities where mammographic screening programs are active: Caltanissetta (CL), Firenze (Fl), Modena (MO) and Torino (TO). The impact on attendance rate of different invitation strategies based on active GP involvement was tested in each center. The additional effect of economic incentives was also assessed. The incentives were proportional to the level of compliance attained by each GP and weighted by the size of his eligible patients’ list.

Results

In the Firenze project, an invitation signed by the GP and the project co-ordinator attained a statistically significant higher participation (difference: 4.2%, χ2 = 7.42, P = 0.006). In Caltanissetta and Torino there was a significant increase of about 7% in the response rate to the postal reminder in the groups contacted by the GPs. No difference was observed in the Modena project between the two groups.

Conclusions

The main contributions of GP involvement can be: “cleaning up'’ the invitation lists, especially when computerized archives with the mammographic history of the target population are not available; increasing the women's participation by signing the invitation letter, by counseling and active participation in the invitation phase; co-operating in the reminder phase by recalling women non responders at first invitation. The offer of target payment had a certain impact on the screening uptake, but not easily distinguishable from GP signature of the invitation letter; further studies of appropriate design should be planned. Organizational factors, such as availability of a list of non-responders, might be crucial in order to enhance the effect of the GPs’ action.

The impact of team-based primary care on health care services utilization and costs: Quebec's family medicine groups

We investigate the effects on health care costs and utilization of team-based primary care delivery: Quebec's Family Medicine Groups (FMGs). FMGs include extended hours, patient enrolment and multidisciplinary teams, but they maintain the same remuneration scheme (fee-for-service) as outside FMGs. In contrast to previous studies, we examine the impacts of organizational changes in primary care settings in the absence of changes to provider payment and outside integrated care systems. We built a panel of administrative data of the population of elderly and chronically ill patients, characterizing all individuals as FMG enrollees or not. Participation in FMGs is voluntary and we address potential selection bias by matching on GP propensity scores, using inverse probability of treatment weights at the patient level, and then estimating difference-in-differences models. We also use appropriate modelling strategies to account for the distributions of health care cost and utilization data. We find that FMGs significantly decrease patients' health care services utilization and costs in outpatient settings relative to patients not in FMGs. The number of primary care visits decreased by 11% per patient per year among FMG enrolees and specialist visits declined by 6%. The declines in costs were of roughly equal magnitude. We found no evidence of an effect on hospitalizations, their associated costs, or the costs of ED visits. These results provide support for the idea that primary care organizational reforms can have impacts on the health care system in the absence of changes to physician payment mechanisms. The extent to which the decline in GP visits represents substitution with other primary care providers warrants further investigation.

The Net Present Value and Other Economic Implications of a Medical Career

College graduates' career choices are driven by a complex mixture of factors, one of which is economics. The author comments on the report by Marcu and colleagues in this issue, which focuses strictly on the economics of this decision. Specifically, Marcu and colleagues modeled career choices as long-term financial investments in human capital, which consists of the knowledge and clinical skills physicians gain in undergraduate and graduate medical education. They distill the numerous factors that shape the economics of career choice into a commonly used criterion for long-term financial investments of any kind-namely, the so-called net present value (NPV) of the investment. For them, that investment is the decision to pursue a medical career rather than the next best nonmedical, alternative career. This NPV calculation determines the increase or decrease in wealth, relative to that of the next best alternative career, that a college graduate is thought to experience as of the moment she or he enters medical school simply by choosing a medical career rather than the next best alternative. Marcu and colleagues use this human capital model to explore how different plans to finance a medical school education impact the NPV, all other parameters being equal. The author of this Commentary explains in layman's terms how the NPV is calculated and then raises a number of other issues concerning the economics of a medical career, including medical school tuition, residents' salaries, and investments in human capital as tax deductible.

Differences in medical services in Nordic general practice: a comparative survey from the QUALICOPC study

OBJECTIVE

We aim to describe medical services provided by Nordic general practitioners (GPs), and to explore possible differences between the countries.

DESIGN AND SETTING

We did a comparative analysis of selected data from the Nordic part of the study Quality and Costs of Primary Care in Europe (QUALICOPC).

SUBJECTS

A total of 875 Nordic GPs (198 Norwegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answered identical questionnaires regarding their practices.

MAIN OUTCOME MEASURES

The GPs indicated which equipment they used in practice, which procedures that were carried out, and to what extent they were involved in treatment/follow-up of a selection of diagnoses.

RESULTS

The Danish GPs performed minor surgical procedures significantly less frequent than GPs in all other countries, although they inserted IUDs significantly more often than GPs in Iceland, Sweden and Finland. Finnish GPs performed a majority of the medical procedures more frequently than GPs in the other countries. The GPs in Iceland reported involvement in a more narrow selection of conditions than the GPs in the other countries. The Finnish GPs had more advanced technical equipment than GPs in all other Nordic countries.

CONCLUSIONS

GPs in all Nordic countries are well equipped and offer a wide range of medical services, yet with a substantial variation between countries. There was no clear pattern of GPs in one country doing consistently more procedures, having consistently more equipment and treating a larger diversity of medical conditions than GPs in the other countries. However, structural factors seemed to affect the services offered.

Medical Student Teaching and Recruiting: 50 Years of Balancing Two Educational Aims

Family medicine (FM) undergraduate medical educators have had two distinct missions, to increase the knowledge, skills, and attitudes of all students while also striving to attract students to the field of family medicine. A five decade literature search was conducted gathering FM curricular innovations and the parallel trends in FM medical student interest. Student interest in FM had a rapid first-decade rise to 14%, a second 1990's surge, followed by a drop to the current plateau of 8-9%. This falls far short of the 30-50% generalist benchmark needed to fill the country's health care needs. Curricular innovations fall into three periods: Charismatic Leaders &amp; Clinical Exposures (1965-1978), Creation of Clerkships of FM (1979-1998) and Curricular Innovations (1998-present). There is good evidence that having a required third-year clerkship positively impacts student interest in the field, however there is little research regarding the recruitment impact of specific clerkship curricula. Other tools associated with student interest include programming geared towards primary care or rural training and extracurricular opportunities such as FM Interest Groups. Strategic plans to improve the primary care work force should focus funding and legislative efforts on effective methods such as: establishing and maintaining FM clerkships, admitting students with rural and underserved backgrounds or primary care interest, developing longitudinal primary care tracks, and supporting extracurricular FM activities. Rigorous research is needed to assess how best to utilize limited educational resources to ensure that all students graduate with a core set of FM competence as well as an increased FM matriculation.

Financing of Vaccine Delivery in Primary Care Practices

OBJECTIVE

Vaccines represent a significant portion of primary care practice expenses. Our objectives were to determine among pediatric (Ped) and family medicine (FM) practices: 1) relative payment for vaccine purchase and administration and estimated profit margin according to payer type, 2) strategies used to reduce vaccine purchase costs and increase payment, and 3) whether practices have stopped providing vaccines because of finances.

METHODS

A national survey conducted from April through September 2011 among Ped and FM practitioners in private, single-specialty practices.

RESULTS

The response rate was 51% (221 of 430). Depending on payer type, 61% to 79% of practices reported that payment for vaccine purchase was at least 100% of purchase price and 34% to 74% reported that payment for vaccine administration was at least $11. Reported strategies to reduce vaccine purchase cost were online purchasing (81% Ped, 36% FM), prompt pay (78% Ped, 49% FM), and bulk order (65% Ped, 49% FM) discounts. Fewer than half of practices used strategies to increase payment; in a multivariable analysis, practices with ≥5 providers were more likely to use strategies compared with practices with fewer providers (adjusted odds ratio, 2.65; 95% confidence interval, 1.51-4.62). When asked if they had stopped purchasing vaccines because of financial concerns, 12% of Ped practices and 23% of FM practices responded 'yes,' and 24% of Ped and 26% of FM practices responded 'no, but have seriously considered.'

CONCLUSIONS

Practices report variable payment for vaccination services from different payer types. Practices might benefit from increased use of strategies to reduce vaccine purchase costs and increase payment for vaccine delivery.

Pricing of general practice in Australia: some recent proposals to reform Medicare

In the Australian Medicare system, general practitioners (GPs) are paid on a fee-for-service basis. A practitioner can choose to bill the government directly (termed bulk billing) and receive 85% of a regulated fee as full payment. Bulk billed consultations are free to the patient. However, GPs are free to charge above the regulated fee. The patient can then claim a rebate from the government but only the equivalent of 85% of the regulated Medicare fee. Such co-payments for GP consultations cannot be covered by private health insurance.

In the ten years following the introduction of Medicare in 1984, the bulk billing rate for GP consultations steadily increased to 84%. Since then the rate has fallen to below 68%. In April 2003 the Minister for Health announced a reform package under the title A Fairer Medicare which aimed, among other things, to increase the availability of bulk billing for some patients. A key feature of the proposal involved changes to the way that GPs are reimbursed. Following political opposition that would have prevented it passing both houses of the federal parliament, a revised version, MedicarePlus, was released in November 2003. This paper describes the factors influencing a GP's choice to bulk bill and examines the two proposals, in this context.

Results of the 2016 National Resident Matching Program®: 1986-2016: A Comparison of Family Medicine, E-ROADs, and Other Select Specialties

This article is a continuation in a series of national studies conducted by the American Academy of Family Physicians that reports the performance of family medicine and other primary care specialties in the National Residency Matching Program® (NRMP) Main Residency Match, hereafter called the Match. Match data from 1986-2016 were analyzed to compare the numbers of positions offered and filled in family medicine, other primary care specialties, emergency medicine, diagnostic radiology, ophthalmology, anesthesiology, and dermatology (E-ROAD), and other select specialties. Of the 10 largest specialties defined by the greatest number of positions offered in the 2016 Match, all but one (general surgery) have experienced growth since 1986.Overall, the total number of positions offered in the Match grew by an average of 226 positions per year. At the same time, primary care specialties grew 19 positions per year, and E-ROAD specialties grew by 72 positions per year. The disproportionate growth of subspecialties overall, notably the E-ROAD subspecialties, relative to the modest growth of primary care specialties, makes the goal of better health care harder to achieve. The GME portion of physician workforce pipeline is mismatched to the health needs of the nation, and this mismatch is worsening.

The benefits of doing ultrasound exams in your office

Family medicine ultrasound is more accurate, more cost-effective, and less time-consuming than you might imagine. Here's how it can improve your care.

Cost-utility of exercise therapy in patients with hip osteoarthritis in primary care

OBJECTIVE

To determine the cost-effectiveness (CE) of exercise therapy (intervention group) compared to 'general practitioner (GP) care' (control group) in patients with hip osteoarthritis (OA) in primary care.

METHOD

This cost-utility analysis was conducted with 120 GPs in the Netherlands from the societal and healthcare perspective. Data on direct medical costs, productivity costs and quality of life (QoL) was collected using standardised questionnaires which were sent to the patients at baseline and at 6, 13, 26, 39 and 52 weeks follow-up. All costs were based on Euro 2011 cost data.

RESULTS

A total of 203 patients were included. The annual direct medical costs per patient were significantly lower for the intervention group (€ 1233) compared to the control group (€ 1331). The average annual societal costs per patient were lower in the intervention group (€ 2634 vs € 3241). Productivity costs were higher than direct medical costs. There was a very small adjusted difference in QoL of 0.006 in favour of the control group (95% CI: -0.04 to +0.02).

CONCLUSION

Our study revealed that exercise therapy is probably cost saving, without the risk of noteworthy negative health effects.

TRIAL REGISTRATION NUMBER

NTR1462.

Family medicine in Denmark: Are there lessons for Botswana and Africa?

Family medicine is a new specialty in Botswana and many African countries and its definition and scope are still evolving. In this region, healthcare is constrained by resource limitation and inefficiencies in resource utilisation. Experiences in countries with good health indicators can help inform discussions on the future of family medicine in Africa. Observations made during a visit to family physicians (FPs) in Denmark showed that the training of FPs, the practice of family medicine and the role of support staff in a family practice were often different and sometimes unimaginable by African standards. Danish family practices were friendly and enmeshed in an egalitarian and efficient health system, which is supported by an effective information technology network. There was a lot of task shifting and nurses and clerical staff attended to simple or uncomplicated aspects of patient care whilst FPs attended to more complicated patient problems. Higher taxation and higher health expenditure seemed to undergird the effective health system. An egalitarian relationship amongst patients and healthcare workers (HCW) may help improve patient care in Botswana. Task shifting should be formalised, and all sectors of primary healthcare should have fast and effective information technology systems. HCW training and roles should be revised. Higher health expenditure is necessary to achieve good health indicators.

Impact of the Primary Care Exception on Family Medicine Resident Coding

BACKGROUND AND OBJECTIVES

The Medicare Primary Care Exception (PCE) allows residents to see and bill for less-complex patients independently in the primary care setting, requiring attending physicians only to see patients for higher-level visits and complete physical exams in order to bill for them as such. Primary care residencies apply the PCE in various ways. We investigated the impact of the PCE on resident coding practices.

METHODS

Family medicine residency directors in a five-state region completed a survey regarding interpretation and application of the PCE, including the number of established patient evaluation and management codes entered by residents and attending faculty at their institution. The percentage of high-level codes was compared between residencies using chi-square tests.

RESULTS

We analyzed coding data for 125,016 visits from 337 residents and 172 faculty physicians in 15 of 18 eligible family medicine residencies. Among programs applying the PCE criteria to all patients, residents billed 86.7% low-mid complexity and 13.3% high-complexity visits. In programs that only applied the PCE to Medicare patients, residents billed 74.9% low-mid complexity visits and 25.2% high-complexity visits. Attending physicians coded more high-complexity visits at both types of programs. The estimated revenue loss over the 1,650 RRC-required outpatient visits was $2,558.66 per resident and $57,569.85 per year for the average residency in our sample.

CONCLUSIONS

Residents at family medicine programs that apply the PCE to all patients bill significantly fewer high-complexity visits. This finding leads to compliance and regulatory concerns and suggests significant revenue loss. Further study is required to determine whether this discrepancy also reflects inaccuracy in coding.