Downsizing the physician workforce.

OBJECTIVE: To estimate the need for downsizing the physician workforce in a changing health care environment. METHODS: First assuming that 1993 physician-to-population ratios would be maintained, the authors derived downsizing estimates by determining the annual growth in the supply of specialists necessary to maintain these ratios (sum of losses from death and retirement plus increase necessary to parallel population growth) and compared them with an estimate of the number of new physicians being produced (average annual number of board certificates issued between 1990 and 1994). Then, assuming that workforce needs would change in a system increasingly dominated by managed care, the authors estimated specialty-specific downsizing needs for a managed care dominated environment using data from several sources. RESULTS: To maintain the 1993 199.6 active physicians per 100,000 population ratio, 14,644 new physicians would be needed each year. Given that an average of 20,655 physicians were certified each year between 1990 and 1994, at least 6011 fewer new physicians were needed annually to maintain 1993 levels. To maintain the 132.2 ratio of active non-primary care physicians per 100,000 population, the system needed to produce 9698 non-primary care physicians per year, because an average of 14,527 new non-primary care physicians entered the workforce between 1990 and 1994, downsizing by 4829, or 33%, was needed. To maintain the 66.8 active primary care physicians per 100,000 population ratio, 4946 new primary care physicians were needed per year, since primary care averaged 6128 new certifications per year, a downsizing of 1182, or 20% was indicated. Only family practice, neurosurgery, otolaryngology, and urology did not require downsizing. Seventeen medical and hospital-based specialties, including 7 of 10 internal medicine subspecialties, needed downsizing by at least 40%. Less downsizing in general was needed in the surgical specialties and in psychiatry. A managed care dominated-system would call for greater downsizing in most of the non-primary care specialties. CONCLUSION: These data support the need for downsizing the nation's physician supply, especially in the internal medicine subspecialties and hospital support specialties and to a lesser extent among surgeons and primary care physicians.

Networking for educational resources in a rural community.

Four community organizations in a geographically isolated area shared resources and collaborated in providing a continuing education program on trauma care to meet the needs of the healthcare community. The process, from initial needs assessment and educational design through the steps involved in program planning and implementation among coproviders, is outlined. Response was overwhelmingly positive from the participants.

Identifying primary care disciplines by analyzing the diagnostic content of ambulatory care.

BACKGROUND: There is considerable controversy about which medical specialties are primary care disciplines. This paper addresses this issue by examining the extent to which the major physician disciplines provide comprehensive ambulatory care to large segments of the population, a characteristic central to the provision of primary care. METHODS: The study is based on ambulatory visits to office-based physicians recorded in the 1980-81 and 1989-90 versions of the National Ambulatory Medical Care Survey. Each diagnosis is aggregated into one of 120 mutually exclusive diagnostic clusters. A primary care encounter is defined as a nonreferred ambulatory visit for one of the top 20 clusters. RESULTS: Family medicine, general internal medicine, and general pediatrics provide the majority of nonreferred ambulatory care for common conditions in the United States. All three of these disciplines provide a comprehensive range of ambulatory care to large segments of the population. Obstetrician-gynecologists are an important source of care for women of childbearing age, but they tend to limit their care to obstetric and gynecologic problems; most care for adult women is provided by family physicians and general internists. CONCLUSIONS: Although most specialties provide outpatient services to different segments of the population, only the traditional primary care disciplines of family practice, general internal medicine, and general pediatrics provide comprehensive ambulatory care to broad population groups.

Patterns of sealant delivery under variable third party requirements.

Despite evidence indicating dental sealants to be effective in preventing caries on the pit and fissure surfaces of teeth, only 8 percent of school-aged US children had received sealants as of 1986-87. While many rationales have been suggested and scientifically answered for this low level of utilization, issues of cost and cost effectiveness remain considerable barriers to many insurers and public programs. This study reports dentist behavior when sealants were added with few restrictions as a new benefit to an existing third party system of care. Results are compared to another third party program with stricter reimbursement policies. Overall, sealants were provided in a reasonable fashion to both groups of patients, relative to teeth selected for sealing and costs. Only a small proportion of patients receiving sealants were under age six or above age 19. Even under the most liberal program, sealants were predominantly targeted to teeth at highest risk to decay. Still, for both groups, a significant proportion of the sealants were placed in teeth at points in time quite distant from expected eruption patterns and, thus, their periods of highest risk to decay. Overall, dentists appeared to use sealants only minimally in their practices. These data suggest that sealants can be added to third party dental programs with little overall risk of inappropriate use or abuse. They also suggest that specific efforts are merited to educate providers as to the most effective times at which to provide sealants for preventing the maximum amount of decay in a population.