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

2. Enhancing the effectiveness of health care for Ontarians through research Funding Sources Physician Services Incorporated Canadian Institutes for Health Research

3. Enhancing the effectiveness of health care for Ontarians through research

4. Enhancing the effectiveness of health care for 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

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

6. Enhancing the effectiveness of health care for 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

7. Enhancing the effectiveness of health care for 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

8. Enhancing the effectiveness of health care for 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

9. Enhancing the effectiveness of health care for 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)

10. Enhancing the effectiveness of health care for 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

11. Enhancing the effectiveness of health care for 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

12. Enhancing the effectiveness of health care for 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

13. Description of Physician and Population by Physician Supply Category 1500-1999 (High MD supply) 2000-24992500-29993000-3499 3500+ (Low MD supply) Total MDs 565428211108501190 Total FTE for kids 7413821324611 % FTE = pediatrician 26.611.213.64.00 # counties 715 84 # of kids 1.3 mill865,000365,000152,00044,000 Median Income 62k48k47k46k41k %rural 0.6114.233.546.683.4

14. 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

15. Recommended services missed 1500 – 1999 High MD supply 2001 - 25002501- 30003001 - 3500 >3500 Low MD supply

16. Adjusted rate ratios of children with no visits by supply SupplyNo Preventive CareNo Primary CareNo Newborn Visits 1500 – 19991.00 (ref) 2000 – 24991.56 (1.54, 1.58)1.27 (1.24, 1.31)2.59 (2.46, 2.73) 2500 – 29991.91 (1.87, 1.94)1.42 (1.38, 1.46)3.19 (3.00, 3.40) 3000 – 35002.79 (2.70, 2.88)1.69 (1.63, 1.76)3.51 (3.25, 3.78) >35005.22 (4.50, 6.06)2.47 (2.14, 2.86)7.44 (6.17, 8.96) *adjusted for age, sex, income quintile

17. Discretionary Utilization (visits per 1000 children) SupplyVisits for Colds Follow up Visits for Colds Visits for Acne 1500-1999 (high supply) 121.411.38.0 2000-2499 86.77.07.2 2500-2999 64.94.45.9 3000-3499 49.12.95.7 >3500 (low supply) 20.40.84.5

18. Children’s ED visit rates by supply 1500 – 2000 High Supply 2000 - 24992500- 2999 3000 - 3499 >3500 Low supply

19. Enhancing the effectiveness of health care for Ontarians through research Hospitalizations for Ambulatory Care Sensitive Conditions

20. Enhancing the effectiveness of health care for 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

21. Enhancing the effectiveness of health care for 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 1000-20002001-3000>3000 Lowest supply No docs % US children 17.962.712.86.20.4 % Ontario children 045.440.813.80