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Defining and measuring full service family practice in BC, 1991-2006 Lavergne, Ruth; McGrail, Kimberlyn, 1966-; Peterson, Sandra; Sivananthan, Saskia Nikali, 1983-; McKendry, Rachael; Mooney, Dawn Aug 31, 2013

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Defining and Measuring Full Service  Family Practice in BC, 1991–2006Ruth Lavergne, Kimberlyn McGrail, Sandra Peterson, Saskia Sivanathan, Rachael McKendry, Dawn MooneyAugust 2013CHSPR.UBC.CA Advancing world-class health services and policy research,  training and data resources on issues that matter to Canadians. P A P E R SWORKINGBackgroundOngoing primary care reform in Canada is in part a response to concerns that Canadians lack timely access to a regular source of primary care. While the supply of general practice physicians per capita has been stable, changes in practice patterns including abandonment of specific areas of practice (such as obstetrics, anesthesia, or provi-sion of services in hospitals, homes, or long-term care facilities) and movement to walk-in style clinics may shape accessibility of primary care as perceived and experienced by patients. In British Columbia (BC), the General Prac-tice Services Committee (GPSC) has spearheaded reform efforts. Founded in 2003, the GPSC is a joint committee composed of the BC Ministry of Health, the BC Medical Association, and the Society of General Practitioners of BC. Its mandate is to support full service family practice and benefit patients. This report seeks to operationalize the GPSC definition of full service family practice using administrative data, and to track changes in physician practice patterns consistent with that definition over time.MethodsWe classified elements of the GPSC definition of full service family practice according to four features of primary care (first-contact access for each new need, long-term person-focused care, coordinated care, comprehensiveness for most health needs). We then determined which elements could be measured using administrative data available over the period from 1991/2 to 2005/6, and report changes over that period. We also describe physician characteristics associ-ated with a full service style of practice, and perform sensitivity analysis to confirm that any observed changes were not the result of a shift to alternate payment plans not captured in the fee-for-service data used in analysis.ResultsMarked declines were observed in first-contact, long-term person-focused, and coordinated care. Comprehensive-ness was roughly constant over time. While provision of maternity care fell markedly, scores on all other elements rose to compensate. Differences in provision of full service care are apparent by physician characteristics, with higher scores among male physicians, those in middle age, University of BC graduates, those practicing in the Interior and Northern health authorities, as well as in rural and small town settings. Declining trends persisted when adjusting for the possibility that full service physicians have moved to alternate payment plans.ConclusionA marked decline in the provision of full service family practice was observed over the period from 1991/92 to 2005/06 in BC. This was observed across all examined physician characteristics. UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS2ContentsBackground	3Full service family practice 3Primary care physician practice patterns 4Objectives and research questions 5Approach	 5Dimensions of primary care 5Data sources 6Measuring full service family practice 7First contact access for each new health need 7Long-term person-focused care 8Coordinated care 8Comprehensiveness for most health needs 8Exclusion criteria 9Producing a summary score 10Results	 10Physician characteristics over time 10Change in dimensions over time 10Change in the summary score over time 13Physician characteristics associated with full service family practice 13Sensitivity analysis 13Discussion	 14References	 14Appendix:	List	of	MSP	Service	Codes	 15UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS3BackgroundA stronger primary care system contributes to better outcomes for patients and a more efficient health care system (1). Starfield has described primary care services as having four main features:1. The first point of access to the health care system for each new need;2. Longitudinal care focused on the person, not the disease, implying the existence and use of a regular source of care over time;3. The part of the system that coordinates care provided elsewhere or by others, including both coordination by practitioners and through medical records. For some purposes, primary care is also described as being oriented toward family and community; and4. Comprehensive for most health needs, in that it can arrange for all types of services with referrals to other types and locations of care as appropriate (1,2).These four features are consistent with an earlier US Institute of Medicine definition of primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (3). In Canada, family physicians play a central role in providing primary care, and have been the focus of recent efforts to reform primary care in several provinces.Primary care reformReform has come in the face of concerns that increasing numbers of Canadians lack timely access to a regular source of primary care. Over the period from 2003 to 2010, the proportion of British Columbians reporting being without a regular medical doctor climbed from 10.6% to 14.3% (4). While the supply of general practice physicians per capita has been stable (5), primary care physicians report that they are providing fewer hours of direct patient care (6,7) and younger doctors are seeking a different work-life balance (8). At the same time, there has been concern about declining compre-hensiveness of family practice, as physicians move to walk-in clinics (9) or abandon specific areas of practice (such as obstetrics, anesthesia, or provision of services in hospitals, homes, or long-term care facilities) (10,11).This combination of factors has the potential to shape accessibility of primary care as perceived and expe-rienced by patients. However, changes over time and across multiple dimensions of care have not been described. This report seeks to address this gap. The underlying analyses represent one component of a larger project examining changes in the supply, avail-ability, and use of physicians services, motivated by an interest in understanding the shift from a general perception in Canada of a physician surplus in the early 1990s, to a shortage a half-decade later.Full service family practiceIn British Columbia (BC), recent efforts at primary care reform have been spearheaded by the General Prac-tice Services Committee (GPSC). Founded in 2003, the GPSC is a joint committee composed of the BC Ministry of Health, the BC Medical Association, and the Society of General Practitioners of BC. Its mandate is to “support full service family practice and benefit patients” (9). It has introduced incentive payments for patient care in areas such as chronic disease manage-ment, maternity care, mental health, care for the frail and elderly, and palliative care over the period from 2003-2008, as well as other support programs. Central to the GPSC’s approach to reform is the idea that the doctor-patient dyad is the critical component of primary care (12), and that this is best-supported by  full service family practice (FSFP). The GPSC defines FSFP as a style of practice that includes most of the following (13): • Health and health risk assessments• Co-ordination of patient care across the spectrum of primary, secondary, and tertiary care, including making referrals and acting on consultative adviceUBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS4• Longitudinal care of patients across the spectrum of their medical needs• Diagnosis and management of acute ailments• Chronic disease management, including implemen-tation of BC guidelines• Primary reproductive care including the organiza-tion of appropriate screening• The provision of or the arrangement with another provider for the provision of prenatal, obstetrical, postnatal, and newborn care• Primary mental health care• Primary palliative care• Care and support of the frail elderly• Support for hospital, home, rehabilitation and long-term care facilities• Patient education and preventive care• The maintenance of a longitudinal patient record• An association with other practitioners that provides patients with a designated provider to contact for medical advice and/or care as appro-priate both during and outside of office hours, an association that includes the use of call-group guidelines and protocols for patient follow-up• The future use of information technology systems as they become available to further enhance the co-ordination and provision of patient care.Since the GPSC reforms are predicated on a model of care in which the physician-patient dyad is central, physicians are responsible for the full range of primary care functions, providing comprehensive, continuous, and patient-centered care, and serving as the first point of contact between a patient and the health care system. This can be contrasted with team-based models in which the core functions of primary care are shared across a variety of service providers. It also stands in contrast to walk-in practices, which may provide accessible, first-contact services, without maintaining continuity over time, or fulfilling a coordinating role.Despite a focus on supporting the FSFP style of care, the degree to which family physicians practice within this model, their characteristics, and how provision of FSFP changed over the period leading up to the GPSC reforms is unknown. In order to examine this, it is necessary to operationalize the GPSC definition using administrative data, and then to track changes in physi-cian practice patterns consistent with that definition over time.Primary care physician practice patternsPrevious Canadian literature examining practice patterns with administrative data has focused on scope of practice, or the dimension of comprehensive-ness of care. A 2009 paper by Glazier et al. evaluated capitation and enhanced fee-for-service models in Ontario, and measured the mean number and percent of 21 services defined using Ontario Health Insur-ance Plan Billing codes (14). In the 2006 Manitoba report “Profiling Primary Care”, an Atypical Diagnostic Coding Index (ADCI) was used to summarize scope of service provision, in order to determine the extent to which primary care physicians were sub-specializing, implying less availability for general practice (15). This used the Johns Hopkins Expanded Diagnosis Clusters (EDCs) grouping system which sorts ICD-9 codes for each physician visit into 27 distinct groups. The authors determined an ‘expected proportion of codings’ using the actual distribution of each of the 27 groups in  the region.Survey data has also been used to examine practice patterns. Wong and Stewart used the 2001 National Family Physician Workforce Survey to identify factors associated with the scope of practice of FPs in office-based practice, based on 12 historically provided medical services (10). Earlier, Hutten-Czapski, Pitblado and Slade described the scope of family practice in rural and urban settings, using a practice breadth score based on survey responses to the 1997 National Family Physician Survey. This survey included 16 questions on procedures and eight on on-call activities (16). In BC, scope of practice has been examined using indi-vidual fee items grouped into categories (17), but  domains other than comprehensiveness were not meas- ured and the study did not examine changes over time. UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS5The Primary Care Assessment Tool (PCAT) is a survey tool including items dealing with primary care quality designed to measure each of the core domains of primary care as articulated by Starfield, as well as three other related domains (family centeredness, community orientation, and cultural competence) (18). However, in order to track changes over time, we needed to use existing administrative data, so this approach was  not feasible.Objectives and research questionsExisting approaches to describing family physician practice patterns do not consider all of the elements noted in the GPSC definition. The extent to which family physicians practice within this model, their char-acteristics, and how provision of FSFP changed over time remain unknown.Table 1 Measurement of full service family practice using BC administrative dataDimensions Attribute(s) from GPSC FSFP definition MeasurableFirst-contact access for each new need     First-contact care Health and health risk assessments No     Access both during and outside of       office hoursAn association with other practitioners that provides patients with a designated  provider to contact for medical advice and/or care as appropriate both during and  outside of office hoursYes     Support for alternate settings Support for hospital, home, rehabilitation and long-term care facilities YesLong-term person-focused care     Continuity Longitudinal care of patients across the spectrum of their medical needs YesCoordinated care     Coordination and referral Co-ordination of patient care across the spectrum of primary, secondary, and  tertiary care, including making referrals and acting upon consultative adviceYes     Record keeping The maintenance of a longitudinal patient record No     Information technology The future use of information technology to enhance the co-ordination and  provision of patient careNoComprehensive for most health needs     Service for both acute and       chronic conditionsDiagnosis and management of acute ailments. Chronic Disease Management,  including implementation of BC guidelines Yes     Reproductive care Primary reproductive care including the organization of appropriate screening Yes     Maternity care The provision of or the arrangement with another provider for the provision of  prenatal, obstetrical, postnatal, and newborn careYes     Mental health care Primary mental health care Yes     Palliative care Primary palliative care No     Geriatric care Care and support of the frail elderly Yes     Disease prevention Preventive care Yes     Health promotion and education Patient education NoWe first seek to operationalize the GPSC’s definition of FSFP using administrative data in BC. We then set out to answer the following questions:1. How has the provision of FSFP changed over the period from 1991 to 2006?2. What are the characteristics of family physicians who maintain full service practices?ApproachDimensions of primary careWe adopt the definition of FSFP articulated as part of the GPSC primary care policies in this analysis, and classify elements according to Starfield’s four features of primary care (9). We then determine if we can measure the dimension using administrative data available in BC in all four study years (see Table 1). A detailed explana-UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS6tion of each element and its measurement, or reasons why it could not be adequately measured using admin-istrative data, is provided in the following section.Watson et al. propose a logic model for primary health care that describes the inputs, activities, outputs, and expected outcomes of the primary care system in Canada, as well as the contexts that influence services (19). We focus only on outputs, described in the logic model as the volume, type (e.g. referral, prevention, curative, and palliative) and qualities of products and services. As such, our analysis informs only the clinical activities of providing primary health care in the context of the family practice. It does not describe the structure of the system in which such practices are embedded, nor does it capture outcomes (efficiency  or equity).Data sourcesThis report uses linked data developed by the BC Ministry of Health and provided through Population Data BC. The specific data files include BC’s Medical Services Plan registration and physician payment files, and physician-level information from the College of Physicians and Surgeons of BC. Access to these data was governed by a Research Data Access Framework that met all requirements of BC’s Freedom of Informa-tion and Protection of Privacy Act and other relevant legislation.Medical Services Plan (MSP) payment fileThis file includes data on all fee-for-service medical services claims paid to physicians, with anony-mous identifiers for both patients and physicians. It describes services used, and includes a patient diagnosis code for each encounter. Services are clas-sified by fee codes, five-digit codes which indicate the insured service for which the practitioner was paid. These fee codes are nested within service codes. Service codes are two-digit codes to indicate the type of service rendered by a practitioner. The Medical Services Plan (MSP) senior medical advisor is responsible for the assignment and maintenance of the service code for each fee item. The service code can be amended to reflect the status of the fee item established between MSP and the BC Medical Association (BCMA).College of Physicians and Surgeons of BCThis is the registering and licensing body for physi-cians in BC. Data available from the College provide information on physician characteristics including age, sex, year of graduation, province or country of training, practice location, and specialty, used in descriptive analyses.Medical Services Plan (MSP) registration fileThis includes a record for all BC residents who receive or are eligible to receive publicly-funded health care services, and contains individual demo-graphic information.All data were provided by Population Data BC with unique study identifiers that enabled us to connect records for individual patients and physicians across datasets and over time. These identifiers cannot be linked at an individual level to other data and cannot be used to identify specific individuals. We used four discrete years of data, covering a decade and a half of healthcare services use: 1991/2, 1995/6, 2001/2, and 2005/6.In this analysis all billings are adjusted to 2005/6 fees. Contacts are defined as unique combinations of patient, physician, and calendar date, regardless of how many fee codes were billed on that day. Telephone calls, completion of documentation/forms, and other indi-rect patient care that would not involve an in-person meeting were not included when determining contacts.UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS7Measuring	full	service	family	practiceFirst contact access for each new health needHealth and health risk assessmentsThis was not measured explicitly. The role of family physicians as first-contact care providers (performing health assessments, including history taking, physical exam, and diagnostic evaluation), is inherent to the structure of the Canadian health system, and so first contact being with a family physician is assumed. There will be exceptions, but these are likely to be rare. While completing health and health risk assessments are assumed to be basic elements of patient visits, these activities cannot be measured directly.Access both during and outside of office hoursArrangements for 24-hour, seven-day a week response could not be measured directly, as there are no provin-cial data on on-call groups, nor are there patient rosters corresponding to individual physicians. Physicians were classified as providing access to care both during and outside of office hours if they billed for any services designating care outside of office hours.Billings outside of office hours included service codes 09 or 49 (excluding fee codes 04432, 07043, and 07283). These capture premiums paid for care outside of office hours. Those with no billings outside of office hours received a score of 0. All others received a score of 100. Support for alternate settingsContacts were classified as having occurred in the following locations outside of the office during the study year:• Home• Long term care (LTC) facility• Hospital, emergency room (ER) specified• Hospital, ER not specifiedService and fee codes for home, LTC, and ER care specify the location of services. Codes reflecting hospital care either specify hospital as the location of Service codes Fee codesContacts in homes05 00103, 00104, 00361, 96859Contacts in long term care00114, 00115, 13114Contacts in hospital, ER specified06, 26, 6700112, 00111,* 00325, 19921, 96801, 96802, 96803, 96804, 96805, 96811, 96812, 96813, 96814, 96815, 96821, 96822, 96823, 96824, 96825, 01823Contacts in hospital, ER not specified27, 28, 30, 40, 41, 42 (NOT 04090, 04091, 04094, 14090, 14091, 14094), 43, 45, 46 (NOT 00361), 48, 9700013, 00016, 00017, 00018, 00019, 00024, 00025, 00026, 00027, 00028, 00040, 00046, 00105, 00108, 00109, 00105, 00113, 00116, 00118, 00119, 00123, 00127, 00128, 03100, 00319, 00370, 00371, 00393, 00394, 00525, 00526, 00641, 00700, 00702, 00703, 00704, 00705, 00706, 00707, 00708, 00709, 00710, 00711, 00719, 00720, 00721, 00722, 00723, 00724, 00726, 00727, 00728, 00729, 00731, 00733, 00734, 00735, 00736, 00738, 00737, 00739, 00740, 00741, 00742, 00746, 00747, 00749, 00750, 00751, 00752, 00754, 00755, 00759, 00760, 00807, 00808, 00977, 01018, 01094, 01095, 02420, 02144, 02444, 04005, 04008, 04049, 04403, 07138, 07142, 07143, 07430, 07528, 07560, 07561, 07783, 70552, 08265, 08583, 08591, 08606, 08607, 08608, 08617, 08620, 08626, 08627, 08690, 08691, 08692, 08693, 08694, 08695, 10733, 11215, 11245, 11645, 11845, 12148, 13108, 13127, 13128, 13148, 13228, 13229, 12148, 19921, 96858Contacts out of office, other12200, 12201, 12220, 13200, 13201, 13220, 16200, 16201, 16220, 17200, 17201, 17220, 18200, 18201, 18220, 96841, 96850, 96852Contacts in office (specified)23 00100, 00101, 00120, 04007, 04505, 04533, 08264, 12100, 12101, 12120, 13100, 14094, 16100, 16101, 16120, 17100, 17101, 17120, 18100, 18101, 18120, 96857, 04094, 14094, 08264, 13101, 13120, 00137*This code indicates the patient was encountered at home, and then moved to ER.services, or correspond to services that could not be provided in an office setting. Some services had no loca-tion specified, and could not otherwise be classified (e.g. intravenous injection, skin biopsy). Fee codes within service codes 02, 08, 09, 12, 19, 22, 44, 47, 49, 60, 66, 71, 93, 94, 95, 96, and 98 not mentioned elsewhere fell into the category of “location not specified.” (See Table 2).Physicians received a score of 100 if they provided care in all four identified non-office locations, 75 if they provided care in three of the four, 50 in two of the  four, and 25 in one of the four. They received a score of zero if all services were in office, or a location that was not specified.Table 2 Service and fee codes specifying settingUBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS8ADGs includedAcute ADG1 Time Limited: MinorADG2 Time Limited: Minor-Primary InfectionsADG3 Time Limited: MajorADG4 Time Limited: Major-Primary InfectionsADG23 Psychosocial: Time Limited, MinorADG21 Injuries/Adverse Effects: MinorADG22 Injuries/Adverse Effects: MajorADG7 Likely to Recur: DiscreteADG8 Likely to Recur: Discrete-InfectionChronic ADG5 AllergiesADG6 AsthmaADG9 Likely to Recur: ProgressiveADG10 Chronic Medical: StableADG11 Chronic Medical: UnstableADG12 Chronic Specialty: Stable-OrthopedicADG13 Chronic Specialty: Stable-Ear, Nose, ThroatADG14 Chronic Specialty: Stable-EyeADG16 Chronic Specialty: Unstable-OrthopedicADG17 Chronic Specialty: Unstable-Ear, Nose, ThroatADG18 Chronic Specialty: Unstable-EyeADG24 Psychosocial: Recurrent or Persistent, StableADG25 Psychosocial: Recurrent or Persistent, UnstableADG32 MalignancySigns/symptoms0ADG26 Signs/Symptoms: MinorADG27 Signs/Symptoms: UncertainADG28 Signs/Symptoms: MajorNot classified ADG15 No longer in useADG19 No longer in useADG20 DermatologicADG29 DiscretionaryADG31 Prevention/AdministrativeADG33 PregnancyADG34 DentalADG30 See and ReassureLong-term person-focused careContinuityThe majority source of care (MSOC) for each patient was the physician who provided >50% of GP contacts. Patients with one contact are considered to have a MSOC. Patients who had an equal number of contacts with two or more physicians could not be assigned.Physicians were given a score equal to the percent of the total number of patients they saw for whom they were the assigned MSOC. Coordinated careCoordination and referralDisorganized care was defined as patients seeing four or more GPs in the study year. The coordination score was assigned on the basis of the proportion of a physician’s patients not receiving disorganized care.Record keepingRecord keeping was not measured. While all  practices keep records for billing purposes, mainte-nance of a detailed and complete longitudinal record  is likely variable.Information technologyUse of information technology to enhance the  coordination and provision of patient care could not  be measured.Comprehensiveness for most health needsService for both acute and chronic conditionsDiagnosis and management of acute ailments and chronic diseases was captured using Aggregated Diag-nosis Groups (ADG), assigned based on ICD-9 codes. Care was classified as shown in Table 3.The score was calculated as the ratio of acute and chronic contacts, multiplied by 100 (the denominator was whichever number was largest). As such, a score of 100 corresponds to equal distribution of services for acute and chronic conditions, 50 reflects twice as many in one category than the other, 25 reflects four times as Table 3 Classification of acute and chronic conditionsmany in one category than the other, and 0 reflects no contacts for either acute or chronic conditions.Reproductive carePrimary reproductive care was measured as the percent of all women ages 18-74 seen by a physician in the study year, to which the physician administered a pelvic examination with pap smear. Since exams are not recommended annually, this value was multiplied by 3 and truncated at 100%. Note that the denominator is all women ages 18-74 seen by the physician. Many UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS9Fee codesContacts (#) maternity, not delivery 04090, 04091, 04094, 14090, 14091, 14094Contacts (#) maternity, delivery and post-natal care00118, 00119, 04000, 04014, 04017, 04018, 04022, 04023, 04024, 04025, 04026, 04050, 04052, 04092, 04093, 14104, 04107, 14108, 14109, 04118, 04119, 14199, 04038, 04021, 04104, 04105, 04108, 04109Fee codesGlucose, patients 45+ 15100, 91707, 09230, 09219Lipids, patients 45+ 91375, 92350, 91780, 09240, 09158, 09467Geriatric careThough the FSFP description specifies care and support of the frail elderly, we could not assess frailty from the available administrative databases. Physicians received a score of 100 if they were the usual provider of care to at least one patient age 75 and older who had three or more contacts.Disease preventionPreventive care was assessed on the basis of lipid and glucose screening (men and women age 45+). will have seen multiple physicians over the course of the year, and would therefore be included in multiple denominators, leading to the low overall percentage.Maternity careSince these screening measures are not indicated on an annual basis, the percent of patients receiving each test in a given year was multiplied by 3, truncated at 100, and then averaged across the two indicators.Patient educationPatient education could not be measured. No fee  codes correspond consistently and directly to  education activities.Exclusion	criteriaPhysicians were excluded if they:• Did not have at least one billing record in all four quarters. These physicians may be entering or leaving practice.• Claimed more than 15,000 unique patient contacts (unique physician/patient/date combinations). This corresponds to more than 250 unique patient contacts per week. The National Physician Survey shows that only 5% of family physicians see more than 200 patients per week. These are therefore likely to be primary care clinics with shared billings across multiple physicians. • Had more than 50% of contacts (with known loca-tion) in hospital. These physicians were assumed to be playing the role of “hospitalist” and were consid-Fee codesRoutine pelvic exam, women 18-74 04560, 14560The provision of pre/post-natal and obstetrical care was captured using the following fee codes: Physicians were assigned a value of 100 if they both performed deliveries and provided pre/post-natal care, 50 if they did one or the other (the vast majority did pre/post-natal care but not deliveries), and 0 if they did neither. We could not directly measure arrange-ments with another provider for the provision of some segment of maternity care.Mental health careContacts for which physicians recorded ICD-9 codes 290-319 were classified as mental health care. Physi-cians were assigned a score of 0 if they had no contacts for mental health conditions. All other physicians received a score of 100.Palliative carePalliative care could not be measured. Only a small subset of decedents received specialized care that corre-sponds to unique fee codes, and these have changed over the study period. Moreover, any given physician may experience only a handful of deaths from within his/her patients over the course of a year, which would be insufficient to capture provision of palliative services.UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS10ered unlikely to be maintaining a practice in the community. There is a clear bimodal distribution in the proportion of contacts in hospital. On average, 90% of physicians had fewer than 35% of contacts in hospital, and a small cluster of 5% of physicians had more than 95% of contacts in hospital.• Used shadow-billing codes associated with alter-nate payment plans (APPs). • Billed less than $50,000 in the year. These may be part-time physicians (approximately 0.3 FTE, based on a benchmark value of $170,000 over the study period), or physicians receiving a large proportion of their income from alternate payment plans.1991/2 1995/6 2001/2 2005/6Total physicians in data 3,726 4,176 4,446 4,759Exclusion criteria     No record in all quarters 593 554 639 631     >10,000 unique patient       contacts39 19 34 39     >50% of contacts in       hospital168 186 293 429     APP billings 0 0 0 62     <$50,000 in billings 194 228 270 347Total number excluded (APP payment plan/low billing)194 228 291 459Total number excluded (all reasons)994 986 1,257 1,558Number of physicians included in analysis2,732 3,190 3,189 3,201Table 4 Number of GP/FP physicians by exclusion category and yearSensitivity analyses performed to ensure that changes from fee-for-service to APPs did not affect conclusions over time are described below.Producing	a	summary	scoreAll physicians were assigned a score between 0 and 100 for each dimension. To produce a composite score, dimensions corresponding to first-contact, long-term person-focused, coordinated, and comprehensive were averaged and each dimension assigned a weight of 0.25. This weighting corresponds to Starfield’s definition of primary care (with comprehensiveness measured as one of four dimensions). Sensitivity analysis confirmed that while the scores differ with other approaches to weighting, conclusions about overall changes are robust to the weighting scheme used.ResultsPhysician	characteristics	over	timeThe total number of FP/GP physicians increased over the course of the study, as did fee-adjusted billings, total contacts per physician, and the number of patients per physician. The proportion of female physicians increased, as did the number of physicians falling into age categories 50 and above. Place of graduation was roughly constant over time, though a slight increase in international graduates is observed in 2005/6. Slight fluctuation in geographic location is observed, with a decrease in metro areas, and an increase in small urban areas. See Table 5.Change	in	dimensions	over	timeMarked declines were observed on all elements reflecting the dimensions of first-contact, long-term person-focused, and coordinated care. Notably, the percentage of physicians providing services outside office hours fell from 95.8% to 68.8% over the study period, while the percent providing care in all four alternate (non-office) settings fell from 64.6% to 34.7%. See Table 6. The summary score for comprehensiveness was  roughly constant over time. While provision of mater-nity care fell markedly, scores on all other elements rose to compensate.UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS1119 91/2 1996/7 2001/2 2005/6# physicians included 2,732 3,190 3,189 3,201Physician practice characteristics (mean, SD)Total billings ($) 209,946 (82,717) 202,950 (79,733) 204,503 (85,117) 209,292 (90,927)Total # of contacts 1,831 5,786 (2,471) 5,925 (2,627) 6,035 (2,832)# unique patients (867) 2,017 (1,112) 2,086 (1,184) 2,175 (1,305)# UPC patients* 467 (467) 427 (427) 428 (428) 417 (417)# MSOC patients** 754 (754) 718 (718) 716 (716) 698 (698)Physician demographics (n, %)Female 629 (23.0) 897 (28.1) 956 (29.8) 1018 (31.3)Age group    <40 1081 (39.6) 1110 (34.8) 815 (25.4) 570 (17.5)    40-44 546 (20.0) 591 (18.5) 583 (18.2) 556 (17.1)    45-49 444 (16.3) 570 (17.9) 563 (17.5) 583 (17.9)    50-54 218 (8.0) 437 (13.7) 529 (16.5) 537 (16.5)    55-59 201 (7.4) 197 (6.2) 392 (12.2) 494 (15.2)    60-64 143 (5.2) 161 (5.1) 162 (5.1) 307 (9.4)    65+ 99 (3.6) 123 (3.9) 166 (5.2) 203 (6.2)Years in practice    <5 404 (14.8) 307 (9.6) 159 (5.0) 95 (3.0)    6-10 437 (16.0) 613 (19.2) 422 (13.1) 292 (9.1)    11-20 1000 (36.6) 1047 (32.8) 1120 (34.9) 1073 (33.5)    21-30 540 (19.8) 842 (26.4) 975 (30.4) 970 (30.2)    31+ 350 (12.8) 379 (11.9) 534 (16.6) 777 (24.2)Place of graduation    University of BC 936 (34.3) 1092 (34.2) 1097 (34.2) 1035 (32.3)    Other Canadian medical school 1109 (40.6) 1326 (41.6) 1308 (40.8) 1273 (39.7)    International medical school 687 (25.2) 771 (24.2) 805 (25.1) 900 (28.1)Health Authority    Vancouver Coastal 462 (17.0) 549 (17.3) 562 (17.6) 613 (18.9)    Fraser Health 698 (25.7) 853 (26.9) 864 (27.1) 882 (27.2)    Vancouver Island 823 (30.3) 934 (29.5) 914 (28.7) 889 (27.5)    Interior 552 (20.3) 637 (20.1) 657 (20.6) 649 (20.0)    Northern 181 (6.7) 198 (6.2) 189 (5.9) 205 (6.3)Table 5 Physician characteristics over time*Usual Provider of Care. Physician provided two-thirds or more of GP contacts. Patients must have a minimum of        three contacts in the year.**Majority Source of Care. Physician provided 50% or more of GP contacts to the patient in question. Patients with     an equal number of contacts from two or more physicians cannot be assigned. Note: Data were missing for some physician characteristics. Age: 1 missing in 2005/6. Years in practice: 1 missing in 1991/2 and 2001/2, 44 in 2005/6. Place of graduation: 43 missing in 2005/6. Health Authority: 16 missing in 1991/2, 18 in 1996/7, 24 in 2001/2, and 13 in 2005/6.UBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS1219 91/2 1996/7 2001/2 2005/6First-contact	careAccess both during and outside of office hours    % billing at least one service provided outside office hours 95.8 90.9 79.4 68.8Services provided in alternate settings    % in homes 92.3 87.9 76.2 67.5    % in nursing homes 74.7 71.5 69.8 64.9    % in hospital (ER) 85.4 79.2 64.7 52.3    % in hospital (non-ER) 99.3 98.4 91.7 86.5    % office only 0.5 0.9 4.9 8.0    % in all four settings 64.6 58.7 45.8 34.7    Mean score 87.9 84.2 75.6 67.8Long-term	person-focused	careContinuity    % MSOC patients (continuity) 45.8 41.2 40.2 38.1Coordinated	careOrganized care    % patients seeing <4 GPs 67.6 63.0 61.2 58.0Comprehensive	for	most	health	needsService for both acute and chronic conditions    Mean % chronic contacts 23.7 24.5 27.2 29.0    Mean % acute contacts 36.5 34.7 31.1 30.7    Mean score (ratio low/high) 58.2 61.0 64.8 65.4Maternity care    % no obstetrical/maternity 13.3 16.7 26.0 33.5    % pre/post-natal & delivery 66.8 52.2 31.4 23.8    Mean score 76.7 67.8 52.7 45.2Mental health care    % with mental health contacts 98.0 97.8 98.1 98.3Geriatric care    % with “usual patients” aged 75+ years 94.4 94.7 93.0 92.2Reproductive care    % of female patients ages 18-74 receiving pelvic exams 23.5 23.4 25.0 26.1Disease prevention    % adults patients age 18-74 years receiving glucose and lipids tests 39.4 42.5 56.7 60.6Table 6 Change in the dimensions over timeUBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS13Change	in	the	summary	score		over	timeThe mean FSFP score fell from 67.6 to 57.2.1991/2 1995/6 2001/2 2005/6Gender    Female 65.4 62.8 59.2 55.3    Male 68.2 64.6 61.7 58.1Age group    39 and under 63.9 60.0 56.5 52.4    40-44 69.3 65.5 61.3 57.6    45-49 69.5 67.1 63.0 58.2    50-54 70.8 66.9 64.4 59.9    55-59 71.4 66.9 63.9 59.7    60-64 71.6 67.6 61.4 58.4    65+ 68.3 61.1 57.1 52.3Years in practice    <5 59.2 55.7 50.7 49.2    6-10 66.1 61.0 56.8 53.3    11-20 69.1 65.4 61.4 56.9    21-30 70.0 66.9 63.6 59.6    31+ 70.9 65.9 61.8 57.7Place of graduation    University of BC 68.4 65.3 62.7 59.4    Other Canadian school 66.4 62.9 59.6 55.5    International 68.2 64.5 60.9 57.6Health Authority    Vancouver Coastal 68.3 64.3 60.6 57.1    Fraser Valley 67.8 62.7 59.2 55.1    Vancouver Island 67.5 65.2 62.0 57.6    Interior 66.9 64.6 62.3 58.8    Northern 66.1 64.0 63.7 61.7Table 8 Mean FSFP score by physician characteristicsNote: Data were missing for some physician characteristics. Age: 1 missing in 2005/6. Years in practice: 1 missing in 1991/2 and 2001/2, 44 in 2005/6. Place of graduation: 43 missing in 2005/6. Health Authority: 16 missing in 1991/2, 18 in 1996/7, 24 in 2001/2, and 13 in 2005/6.Physician	characteristics	associated	with	full	service	family	practiceDifferences in mean scores are apparent by physician characteristics. In general, male physicians, and those in middle age had higher scores. University of BC gradu-ates had higher scores than those graduating elsewhere. Higher scores were also observed in the Interior and Northern health authorities, as well as in small urban, rural, and small town settings. See Table 8.Importantly, changes in physician characteristics did not explain falling scores over time, as scores fell within all categories of all variables. Sensitivity	analysisSensitivity analysis explored the question of whether the observed decline can be explained by the fact that physicians with full service practices have tended to move to APPS, and hence were more likely to have been excluded from our data in later years.To explore the impact of a shift toward APPs, we assumed that all physicians excluded with APP billings or total billings less than $50,000 would have received a score of 100. We then assumed, even more conserva-tively, that all physicians excluded for any reason would have received a score of 100. While mean scores are slightly attenuated, a clear declining trend persists. See Table 9.1991/2 1995/6 2001/2 2005/6Number of physicians included in analysis2,732 3,190 3,189 3,201Average summary score 67.6 64.1 61.0 57.21991/2 1995/6 2001/2 2005/6As calculated 67.6 64.1 61.0 57.2Sensitivity 1 – assuming APP / low billing excluded had scores = 10069.7 66.5 64.0 62.0Sensitivity 2 – assuming all excluded had scores = 10076.2 72.6 71.8 70.8Table 7 Mean summary scores over timeTable 9 Mean FSFP score sensitivity analysisUBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCHWORKING PAPER 2013:1WORKING PAPERS14DiscussionA marked decline in the provision of FSFP was observed over the period from 1991/92 to 2005/06 in BC. This was observed across all physician character-istics, and even when adjusting for the possibility that full service physicians have moved to alternate payment plans. This change was driven by declines in the dimensions reflecting first-contact, long-term, person-focused, and coordinated care, as well as provision of maternity care over time.The extent to which this change in practice affects patient outcomes remains unknown. In addition, policy reforms designed to emphasize FSFP in BC were rolled out over the period between 2003 and 2008. At the final time point in this analysis (2005/6) they had not yet come into full effect. Certainly we see no evidence in these data and analyses of a policy effect over the period 2001/02-2005/06. However, it may be unrealistic to expect an effect given the short time span and the incomplete roll-out by the end of our period of analysis. Future work will examine FSFP using more recent data, in order to observe if there has been any attenuation or reversal of the observed declines as a result of policies targeted at dimensions of FSFP.References1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly. 2005;83(3):457–502. 2. Starfield B. Primary Care: Balancing health needs, services, and technology. Oxford University Press; 1998. 3. Institute of Medicine. Primary care: America’s health in a new era. Washington, DC: National Academy Press, 1996. 4. Statistics Canada. Population with a regular medical doctor, by sex, provinces and territories. Available from: www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health76a-eng.htm5. Canadian Institute for Health Information. Supply, Distribution and Migration of Canadian Physicians. Ottawa: CIHI, 2010. Available from: publications.gc.ca/collections/collection_2012/icis-cihi/H115-23-2010-eng.pdf6. Watson DE, Slade S, Buske L, Tepper J. Intergen-erational differences in workloads among primary care physicians: a ten-year, population-based study. Health Affairs. 2006;25(6):1620–8. 7. Crossley TF, Hurley J, Jeon S-H. Physician labour supply in Canada: a cohort analysis. Health Economics. 2009;18(4):437–56. 8. CMA Bulletin. Attitudes of new MDs mean medi-cine is in for a change: survey. Canadian Medical Association Journal. 2011;183(17). Available from: cma.ca/multimedia/CMA/Content_Images/Policy_Advocacy/Policy_Research/22-Bulletin-nov22-rev.pdf9. Tregillus VHF, Cavers WJ. General Practice Services Committee: Improving Primary Care for BC Physicians and Patients. Healthcare Quarterly. 2011;14:1–6. 10. Wong E, Stewart M. Predicting the scope of practice of family physicians. Canadian Family Physician. 2010;56(6):e219–25. 11. Chan BTB. The declining comprehensiveness of primary care. Canadian Medical Association Journal. 2002;166(4):429–34. 12. Mazowita G, Cavers WJ. Issues in International Health Policy: Reviving Full-Service Family Practice in British Columbia. New York: The Commonwealth Fund, 2011. Available from: www.commonwealthfund.org/~/media/Files/Publications/Issue Brief/2011/Aug/1538_Mazowita_restoring_fullservice_family_practice_BC_intl_brief_v3_CORRECTED_20110906.pdf13. General Practice Services Committee. MSP - Full Service Family Practice Incentive Program. Avail-able from: www.health.gov.bc.ca/msp/legislation/bcmaagree_faqs_fsfp.htmlUBC CENTRE FOR HEALTH SERVICES AND POLICY RESEARCH WORKING PAPERSCHSPR.UBC.CA Advancing world-class health services and policy research,  training and data resources on issues that matter to Canadians.14. Hutten-Czapski P, Pitblado R, Slade S. Short report: Scope of family practice in rural and urban settings. Canadian Family Physician. 2004;50:1548–50. 15. Glazier RH, Klein-Geltink J, Kopp A, Sibley LM. Capitation and enhanced fee-for-service models for primary care reform: a population-based evalu-ation. Canadian Medical Association Journal. 2009;180(11):72–81. 16. Frohlich N, Katz A, Coster C De, Dik N, Soodeen R, Watson D, et al. Profiling Primary Care Physi-cian Practice in Manitoba. Winnipeg: Manitoba Centre For Health Policy, 2006. Available from: mchp-appserv.cpe.umanitoba.ca/reference/primary.profiling.pdf17. Olatunde S, Leduc ER, Berkowitz J. Different practice patterns of rural and urban general practitioners are predicted by the General Practice Rurality Index. Canadian Journal of Rural Medi-cine. 2007;12(2):73–80. 18. Shi L, Starfield B, Cu J. Validating the Adult Primary Care Assessment Tool. Journal of Family Practice. 2001;50(2):161. 19. Watson D, Broemeling A-M, Reid R, Black C. A results-based logic model for primary health care: laying an evidence-based foundation to guide performance measurement, monitoring and evalu-ation. Vancouver: Centre for Health Services and Policy Research, 2004.Appendix:	List	of	MSP	Service	Codes01. Regional Examinations02. Consultation03. Complete Examinations04. Counseling05. Home Visits06. Emergency Visits07. Institutional Visits08. Miscellaneous and Other Visits (GP)09. Visit Premiums11. Prolonged or extended visit12. Incentive payments/premiums13. Midwifery19. No Charge Referral22. Consultation (full minor repeat, specialist)23. Subsequent Visits (specialist) 24. Counseling Psychotherapy (specialist)25. Home Visits (specialist)26. Emergency Visits (specialist)27. Institutional Visits (specialist)28. Miscellaneous and Other Visits (specialist)29. Visit Premiums30. Critical Care Services (specialist)40. Anesthesia41. Cardiovascular Listing42. Obstetrics43. Surgery (non-minor, excisional)44. Minor Surgery, Minor Therapeutic Procedures45. Unlisted Miscellaneous Surgery46. Dialysis/Transfusions47. General Services (non-invasive tests, procedures)48. Therapeutic Radiation49. Procedural Premiums60. Form Fees71. Tray Service Items89. Diagnostic Ophthalmology 90. Diagnostic Radiology91. Diagnostic Ultrasound92. Nuclear Medicine93. Pathology (category 1)94. Pathology (beyond category 1)95. Pulmonary Function96. Electrodiagnosis97. Procedural Cardiology98. Other (needle biopsies, Ox99, etc.)99. Diagnostic Premiums

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