The future role of the family physician in the United States: a rigorous exercise in definition.

As the U.S. health care delivery system undergoes rapid transformation, there is an urgent need to define a comprehensive, evidence-based role for the family physician. A Role Definition Group made up of members of seven family medicine organizations developed a statement defining the family physician's role in meeting the needs of individuals, the health care system, and the country. The Role Definition Group surveyed more than 50 years of foundational manuscripts including published works from the Future of Family Medicine project and Keystone III conference, external reviews, and a recent Accreditation Council on Graduate Medical Education Family Medicine Milestones definition. They developed candidate definitions and a "foil" definition of what family medicine could become without change. The following definition was selected: "Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health." This definition will guide the second Future of Family Medicine project and provide direction as family physicians, academicians, clinical networks, and policy-makers negotiate roles in the evolving health system.

Communities of solution: partnerships for population health.

Communities of solution (COSs) are the key principle for improving population health. The 1967 Folsom Report explains that the COS concept arose from the recognition that complex political and administrative structures often hinder problem solving by creating barriers to communication and compromise. A 2012 reexamination of the Folsom Report resurrects the idea of the COS and presents 13 grand challenges that define the critical links among community, public health, and primary care and call for ongoing demonstrations of COSs grounded in patient-centered care. In this issue, examples of COSs from around the country demonstrate core principles and propose visions of the future. Essential themes of each COS are the crossing of "jurisdictional boundaries," community-led or -oriented initiatives, measurement of outcomes, and creating durable connections with public health.

The effects of health insurance and a usual source of care on a child's receipt of health care.

INTRODUCTION: Although recent health care reforms will expand insurance coverage for U.S. children, disparities regarding access to pediatric care persist, even among the insured. We investigated the separate and combined effects of having health insurance and a usual source of care (USC) on children's receipt of health care services. METHODS: We conducted secondary analysis of the nationally representative 2002-2007 Medical Expenditure Panel Survey data from children (≤ 18 years of age) who had at least one health care visit and needed any additional care, tests, or treatment in the preceding year (n = 20,817). RESULTS: Approximately 88.1% of the study population had both a USC and insurance; 1.1% had neither one; 7.6% had a USC only, and 3.2% had insurance only. Children with both insurance and a USC had the fewest unmet needs. Among insured children, those with no USC had higher rates of unmet needs than did those with a USC. DISCUSSION: Expansions in health insurance are essential; however, it is also important for every child to have a USC. New models of practice could help to concurrently achieve these goals.

Is health insurance enough? A usual source of care may be more important to ensure a child receives preventive health counseling.

Despite the promise of expanded health insurance coverage for children in the United States, a usual source of care (USC) may have a bigger impact on a child's receipt of preventive health counseling. We examined the effects of insurance versus USC on receipt of education and counseling regarding prevention of childhood injuries and disease. We conducted secondary analyses of 2002-2006 data from a nationally-representative sample of child participants (≤17 years) in the Medical Expenditure Panel Survey (n = 49,947). Children with both insurance and a USC had the lowest rates of missed counseling, and children with neither one had the highest rates. Children with only insurance were more likely than those with only a USC to have never received preventive health counseling from a health care provider regarding healthy eating (aRR 1.21, 95% CI 1.12-1.31); regular exercise (aRR 1.06, 95% CI 1.01-1.12), use of car safety devices (aRR 1.10, 95% CI 1.03-1.17), use of bicycle helmets (aRR 1.11, 95% CI 1.05-1.18), and risks of second hand smoke exposure (aRR 1.12, 95% CI 1.04-1.20). A USC may play an equally or more important role than insurance in improving access to health education and counseling for children. To better meet preventive counseling needs of children, a robust primary care workforce and improved delivery of care in medical homes must accompany expansions in insurance coverage.

The case for synergy between a usual source of care and health insurance coverage.

BACKGROUND: In 2010, the United States (US) passed health insurance reforms aimed at expanding coverage to the uninsured. Yet, disparities persist in access to health care services, even among the insured. OBJECTIVE: To examine the separate and combined association between having health insurance and/or a usual source of care (USC) and self-reported receipt of health care services. DESIGN/SETTING: Two-tailed, chi-square analyses and logistic regression models were used to analyze nationally representative pooled 2002-2007 data from the Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: US adults (≥18 years of age) in the MEPS population who had at least one health care visit and who needed any care, tests, or treatment in the past year (n = 62,067). MAIN OUTCOME MEASURES: We assessed the likelihood of an adult reporting unmet medical needs; unmet prescription needs; a problem getting care, tests, or treatment; and delayed care based on whether each individual had health insurance, a USC, both, or neither one. KEY RESULTS: Among adults who reported a doctor visit and a need for services in the past year, having both health insurance and a USC was associated with the lowest percentage of unmet medical needs, problems and delays in getting care while having neither one was associated with the highest unmet medical needs, problems and delays in care. After adjusting for potentially confounding covariates (age, race, ethnicity, employment, geographic residence, education, household income as a percent of federal poverty level, health status, and marital status), compared with insured adults who also had a USC, insured adults without a USC were more likely to have problems getting care, tests or treatment (adjusted relative risk [aRR] 1.27; 95% confidence interval [CI] 1.18-1.37); and also had a higher likelihood of experiencing a delay in urgent care (aRR 1.12; 95% CI 1.05-1.20). CONCLUSIONS: Amidst ongoing health care reform, these findings suggest the important role that both health insurance coverage and a usual source of care may play in facilitating individuals' access to care.

Family medicine residency training in community health centers: a national survey.

PURPOSE: For more than 25 years, family medicine residencies (FMRs) have worked with community health centers (CHCs) to train family physicians. In light of the long history and current policy focus on this training model, the authors sought to evaluate comprehensively the scope and extent of family physician training occurring in CHCs. METHOD: The authors conducted a cross-sectional survey of 439 U.S. FMR directors in 2007. FMR directors were asked to provide information regarding the number, type, location, and length of any CHC training affiliations and to rate their satisfaction with such affiliations. RESULTS: Of 354 respondents (80% response rate), 83 FMRs (23.4%) provided some type of CHC training experience; 32 (9%) had their main residency continuity training site in a CHC. Respondents reported that 10.5% (788) of family medicine residents were trained in a CHC continuity clinic. The average length of affiliation was 10.2 years. Residency directors reported high satisfaction with CHC training affiliations. CONCLUSIONS: Almost one-quarter of FMRs in 2007 provided some training in CHCs. However, the proportion of residencies providing continuity training in CHCs--the type of training associated with enhanced recruitment and retention of family medicine graduates in underserved areas--was limited and relatively unchanged since 1992.