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![Page 1: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/1.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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
![Page 2: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/2.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
Funding Sources
• Physician Services Incorporated
• Canadian Institutes for Health Research
![Page 3: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/3.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
![Page 4: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/4.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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
![Page 5: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/5.jpg)
Ontario1 in 3 Canadians
12 million residents
3 million children
60% urban
415,000 sq miles
3.5 persons/sq mile
Major cities: Toronto,Ottawa
![Page 6: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/6.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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
![Page 7: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/7.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
In the setting of universal coverage,how does the local primary care
supply influence children’s receipt of health services?
Research Question
![Page 8: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/8.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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
![Page 9: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/9.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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)
![Page 10: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/10.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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
![Page 11: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/11.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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
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Enhancing the effectiveness of health carefor Ontarians through research
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
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Description of Physician and Population by Physician Supply Category
1500-1999 (High MD supply)
2000-2499 2500-2999 3000-34993500+
(Low MD supply)
Total MDs 5654 2821 1108 501 190
Total FTE for kids
741 382 132 46 11
% FTE = pediatrician
26.6 11.2 13.6 4.0 0
# counties 7 15 15 8 4
# of kids 1.3 mill 865,000 365,000 152,000 44,000
Median Income
62k 48k 47k 46k 41k
%rural 0.61 14.2 33.5 46.6 83.4
![Page 14: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/14.jpg)
Access to primary care
% reporting access to a family doctor*
1500-1999
(high MD supply)94
2000-2499 94
2500-2999 93
3000-3499 90
>3500
(low MD supply) 67
*Among families with children in the home
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Recommended services missed
0%
10%
20%
30%
40%
50%
60%
70%
80%
1
# of kids per Primary Care FTE
% o
f ch
ildre
n Children not receiving primary care
Children not receiving preventativecare
Newborns without postpartum visits
1500 – 1999
High MD supply
2001 - 2500 2501- 3000 3001 - 3500 >3500
Low MD supply
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Adjusted rate ratios of children with no visits by supply
Supply No Preventive Care No Primary Care No Newborn Visits
1500 – 1999 1.00 (ref) 1.00 (ref) 1.00 (ref)
2000 – 2499 1.56 (1.54, 1.58) 1.27 (1.24, 1.31) 2.59 (2.46, 2.73)
2500 – 2999 1.91 (1.87, 1.94) 1.42 (1.38, 1.46) 3.19 (3.00, 3.40)
3000 – 3500 2.79 (2.70, 2.88) 1.69 (1.63, 1.76) 3.51 (3.25, 3.78)
>3500 5.22 (4.50, 6.06) 2.47 (2.14, 2.86) 7.44 (6.17, 8.96)
*adjusted for age, sex, income quintile
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Discretionary Utilization (visits per 1000 children)
Supply Visits for Colds
Follow up Visits for
Colds
Visits for Acne
1500-1999
(high supply)121.4 11.3 8.0
2000-249986.7 7.0 7.2
2500-299964.9 4.4 5.9
3000-349949.1 2.9 5.7
>3500
(low supply) 20.4 0.8 4.5
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Children’s ED visit rates by supply
0
50
100
150
200
250
300
350
400
450
500
1
# of kids per Primary Care FTE
Vis
its p
er
10
00
ch
ildre
n
All ED Visits per 1000 children All ED Visits with low acuity per 1000
1500 – 2000
High Supply
2000 - 2499 2500- 2999 3000 - 3499 >3500
Low supply
![Page 19: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/19.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
Hospitalizations for Ambulatory Care Sensitive Conditions
ACS Hospitalization Rates per 1000 children
0
10
20
30
40
50
1
# of kids per Primary Care FTE
Vis
its p
er 1
000
child
ren
ACS Acute Hospitalization per 1000 children ACS Asthma Hospitalization per 1000
ACS Diabetic Hospitalization per 1000
![Page 20: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/20.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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
![Page 21: Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care Supply in a Single Payer Health System Astrid Guttmann.](https://reader035.fdocuments.us/reader035/viewer/2022070410/56649f1f5503460f94c37e5f/html5/thumbnails/21.jpg)
Enhancing the effectiveness of health carefor Ontarians through research
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)
Highest supply
<1000 kids/doc
1000-2000 2001-3000 >3000
Lowest supplyNo docs
% US children
17.9 62.7 12.8 6.2 0.4
% Ontario children
0 45.4 40.8 13.8 0