Orthopedic surgeons' transition into full-time practice over the last 20 years: an analysis using Ministry of Health billing data.

BACKGROUND: Underemployment is a reality for many new graduates, who accept locum or part-time work as an alternative to unemployment because of lack of opportunities. We sought to analyze orthopedic surgeons' Ontario Health Insurance Program (OHIP) billing data over a 20-year period as a proxy of practice patterns and hypothesized that billing in the first 6 years of practice would be affected by underemployment and locum. METHODS: We analyzed the annual average billing totals of orthopedic surgeons, broken down by year of graduation, year of billings, and number of surgeons billing in that year. We analyzed public census data of the Ontario population size as a proxy of orthopedic demand. RESULTS: A 2019 cross-sectional analysis showed that around 15 surgeons per graduating year were billing in Ontario from the 1995 to 2016 cohorts, while 2017 and 2018 saw an increase to 30 and 36 actively billing surgeons, respectively. The number returned to more historical numbers in 2019, with 20 actively billing surgeons. For those surgeons billing in Ontario, billing trends have been roughly stable, with average billings increasing each year for the first 6 years in practice (p < 0.001). Year of graduation did not have an effect on the first 6 years of billings (p > 0.5). Billings were stable after 6 years in practice (p > 0.09). CONCLUSION: The Ontario health care system has not expanded to support more orthopedic surgeons despite the aging and growing population; despite our growing population, the number of surgeons being trained and retained has not matched this growth. Further research needs to be done to guide optimal health human resource decision-making.

Sex Disparities in Operating Room use Among Cataract Surgeons: A 10-Year Retrospective Population-Based Analysis.

PURPOSE: To evaluate sex differences in operating room (OR) time and case volumes among comprehensive cataract surgeons in Ontario, Canada's most populated province. DESIGN: Retrospective, population-based cohort study. METHODS: Physician billing data of active comprehensive cataract surgeons between 2010 and 2019 were analyzed to identify all cataract surgeries in this timeframe. The number of OR days and case volume were the primary outcomes. Data were stratified by surgeon sex and career stage. RESULTS: Between 2010 and 2019, approximately 1.05 million cataract surgeries were performed in Ontario. There were an average of 195 ± 3 comprehensive cataract surgeons per year, of which 39 ± 5 were female. The proportion of female surgeons increased from 16.8% of all surgeons in 2010 to 24.4% in 2019. The greatest proportion of male surgeons were in the late phase of their career, whereas the greatest proportion of female surgeons were in the early stage of their career. On average, male surgeons had 44.9 ± 1.90 OR days per year and females had 32 ± 1.90 OR days per year, resulting in female surgeons averaging 12.45 ± 1.90 fewer OR days per year. This OR distribution remained consistent across career stages. Average case volumes per OR day were similar across sexes, but male surgeons performed on average 172.7 ± 30.6 more surgeries per year. CONCLUSIONS: Despite performing similar average case volumes per OR day, female surgeons had less OR time compared to their male counterparts per year, and this remained consistent across career stages and over the 10-year period. Metrics for OR allocation and use should be well defined and transparent.

Referring and Specialist Physician Gender and Specialist Billing.

Importance: While a gender pay gap in medicine has been well documented, relatively little research has addressed mechanisms that mediate gender differences in referral income for specialists. Objective: To examine gender-based disparities in medical and surgical specialist referrals in Ontario, Canada. Design, Setting, and Participants: This cross-sectional study included referrals for specialist care ascertained from Ontario Health Insurance Plan physician billings for fiscal year 2018 to 2019. Participants were specialist physicians who received new patient consultations from April 1, 2018, to March 31, 2019, and the associated referring physicians. Data were analyzed from April 2018 to March 2020, including a 12-month follow-up period. Exposures: Specialist and referring physician gender (female or male). Main Outcomes and Measures: Revenue per referral was defined based on an episode-of-care approach as total billings for a 12-month period from the initial consultation. Mean total billings for female and male specialists were compared and the differential divided into the portion owing to referral volume vs referral revenue. Difference-in-differences multivariable regression analysis was used to estimate gender-based differences in revenue per referral. For each referring physician, gender-based differences in referral patterns were examined using case-control analysis, in which specialists who received a referral were compared with matched control specialists who did not receive a referral. This analysis considered the gender of the specialist and concordance between the gender of the referring physician and specialist, among other characteristics. Results: Of 7 621 365 new referrals, 32 824 referring physicians, of whom 13 512 (41.2%) were female (mean [SD] age, 46.3 [11.6] years) and 19 312 (58.8%) were male (mean [SD] age, 52.9 [13.5] years), made referrals to 13 582 specialists, of whom 4890 (36.0%) were female (mean [SD] age, 45.6 [11.0] years) and 8692 (64.0%) were male (mean [SD] age, 51.8 [13.0] years). Male specialists received more mean (SD) referrals than did female specialists (633 [666] vs 433 [515]), and the mean (SD) revenue per referral was higher for males ($350 [$474]) compared with females ($316 [$393]). Adjusted analysis demonstrated a -4.7% (95% CI, -4.9% to -4.5%) difference in the revenue per referral between male and female specialists. Multivariable regression analysis found that physicians referred more often to specialists of the same gender (odds ratio, 1.04; 95% CI, 1.03-1.04) but had higher odds of referring to male specialists (odds ratio, 1.10; 95% CI, 1.09-1.11). Conclusions and Relevance: In this cross-sectional study of the gender pay gap in specialist referral income, the number and revenue from referrals received differed by gender, as did the odds of receiving a referral from a physician of the same gender. Future research should examine the effectiveness of different policies to address this gap, such as a centralized, gender-blinded referral system.

Developing a dashboard to help measure and achieve the triple aim: a population-based cohort study.

BACKGROUND: Health system planners aim to pursue the three goals of Triple Aim: 1) reduce health care costs; 2) improve population health; and 3) improve the care experience. Moreover, they also need measures that can reliably predict future health care needs in order to manage effectively the health system performance. Yet few measures exist to assess Triple Aim and predict future needs at a health system level. The purpose of this study is to explore the novel application of a case-mix adjustment method in order to measure and help improve the Triple Aim of health system performance. METHODS: We applied a case-mix adjustment method to a population-based analysis to assess its usefulness as a measure of health system performance and Triple Aim. The study design was a retrospective, cohort study of adults from Ontario, Canada using administrative databases: individuals were assigned a predicted illness burden score using a case-mix adjustment system from diagnoses and health utilization data in 2008, and then followed forward to assess the actual health care utilization and costs in the following year (2009). We applied the Johns Hopkins Adjusted Clinical Group (ACG) Case-Mix System to categorize individuals into 60 levels of healthcare need, called ACGs. The outcomes were: 1) Number of individuals per ACG; 2) Total system costs per ACG; and 3) Mean cost per person per ACG, which together formed a health system "dashboard". RESULTS: We identified 11.4 million adults. 16.1% were aged 65 or older, 3.2 million (28%) did not use health care services that year, and 45,000 (0.4%) were in the highest acuity ACG category using 12 times more than an average adult. The sickest 1%, 5% and 15% of the population use about 10%, 30% and 50% of total health system costs respectively. The dashboard measures 2 dimensions of Triple Aim: 1) reduced costs: when total system costs per ACG or when average costs per person is reduced; and 2) improved population health: when more people move into healthier rather than sicker ACGs. It can help to achieve the third aim, improved care experience, when ACG utilization predictions are reported to providers to proactively develop care plans. CONCLUSIONS: The dashboard, developed via case-mix methods, measures 2 of the Triple Aim goals and can help health system planners better manage their health delivery systems.

Inclusion of persons with mental illness in patient-centred medical homes: cross-sectional findings from Ontario, Canada.

BACKGROUND: In Ontario, Canada, the patient-centred medical home is a model of primary care delivery that includes 3 model types of interest for this study: enhanced fee-for-service, blended capitation, and team-based blended capitation. All 3 models involve rostering of patients and have similar practice requirements but differ in method of physician reimbursement, with the blended capitation models incorporating adjustments for age and sex, but not case mix, of rostered patients. We evaluated the extent to which persons with mental illness were included in physicians' total practices (as rostered and non-rostered patients) and were included on physicians' rosters across types of medical homes in Ontario. METHODS: Using population-based administrative data, we considered 3 groups of patients: those with psychotic or bipolar diagnoses, those with other mental health diagnoses, and those with no mental health diagnoses. We modelled the prevalence of mental health diagnoses and the proportion of patients with such diagnoses who were rostered across the 3 medical home model types, controlling for demographic characteristics and case mix. RESULTS: Compared with enhanced fee-for-service practices, and relative to patients without mental illness, the proportions of patients with psychosis or bipolar disorders were not different in blended capitation and team-based blended capitation practices (rate ratio [RR] 0.91, 95% confidence interval [CI] 0.82-1.01; RR 1.06, 95% CI 0.96-1.17, respectively). However, there were fewer patients with other mental illnesses (RR 0.94, 95% CI 0.90-0.99; RR 0.89, 95% CI 0.85-0.94, respectively). Compared with expected proportions, practices based on both capitation models were significantly less likely than enhanced fee-for-service practices to roster patients with psychosis or bipolar disorders (for blended capitation, RR 0.92, 95% CI 0.90-0.93; for team-based capitation, RR 0.92, 95% CI 0.88-0.93) and also patients with other mental illnesses (for blended capitation, RR 0.94, 95% CI 0.92-0.95; for team-based capitation, RR 0.93, 95% CI 0.92-0.94). INTERPRETATION: Persons with mental illness were under-represented in the rosters of Ontario's capitation-based medical homes. These findings suggest a need to direct attention to the incentive structure for including patients with mental illness.

Evaluation of the equity of age-sex adjusted primary care capitation payments in Ontario, Canada.

OBJECTIVE: Several innovative primary care models have recently been introduced in Ontario, Canada. Two of these models are funded primarily through age-sex based capitation. There is concern that adjusting capitation rates for age and sex alone does not take into account the increased morbidity burden and health care needs that are associated with lower socioeconomic status. This study assesses the extent to which the current age-sex capitation rates in Ontario reflect health care needs of patients across socioeconomic status by comparing Ontario's age-sex adjusted capitation remuneration rate index with relative expected health care resource use by socioeconomic status (SES). METHODS: This study used administrative data collected by the Ontario Ministry of Health and Long-Term Care. The study sample was those patients who were enrolled to a FHN continuously from September 1, 2005 to August 31, 2006. Standardized expected health care utilization was calculated based on morbidity burden using The Johns Hopkins Adjusted Clinical Groups (ACG) Case-mix System and compared with standardized capitation rates across and within neighbourhood income quintiles. RESULTS: Among those in the lowest income group expected utilization was much higher than the age-sex capitation rates, while the opposite was true for those in the highest income group. CONCLUSIONS: The findings suggests that under the physician reimbursement system used in Family Health Networks in Ontario, physicians are under-compensated for the health care needs of low income patients and over-compensated for the needs of high income patients. Adjusting capitation rates for morbidity burden in addition to age and sex may reduce incentives to preferentially enrol patients with higher socioeconomic status.

An evaluation of access to health care services along the rural-urban continuum in Canada.

BACKGROUND: Studies comparing the access to health care of rural and urban populations have been contradictory and inconclusive. These studies are complicated by the influence of other factor which have been shown to be related to access and utilization. This study assesses the equity of access to health care services across the rural-urban continuum in Canada before and after taking other determinants of access into account. METHODS: This is a cross-sectional study of the population of the 10 provinces of Canada using data from the Canadian Community Health Survey (CCHS 2.1). Five different measures of access and utilization are compared across the continuum of rural-urban. Known determinants of utilization are taken into account according to Andersen's Health Behaviour Model (HBM); location of residence at the levels of province, health region, and community is also controlled for. RESULTS: This study found that residents of small cities not adjacent to major centres, had the highest reported utilisation rates of influenza vaccines and family physician services, were most likely to have a regular medical doctor, and were most likely to report unmet need. Among the rural categories there was a gradient with the most rural being least likely to have had a flu shot, use specialist physicians services, or have a regular medical doctor. Residents of the most urban centres were more likely to report using specialist physician services. Many of these differences are diminished or eliminated once other factors are accounted for. After adjusting for other factors those living in the most urban areas were more likely to have seen a specialist physician. Those in rural communities had a lower odds of receiving a flu shot and having a regular medical doctor. People residing in the most urban and most rural communities were less likely to have a regular medical doctor. Those in any of the rural categories were less likely to report unmet need. CONCLUSION: Inequities in access to care along the rural-urban continuum exist and can be masked when evaluation is done at a very large scale with gross indicators of rural-urban. Understanding the relationship between rural-urban and other determinants will help policy makers to target interventions appropriately: to specific demographic, provincial, community, or rural categories.

Risk adjustment using administrative data-based and survey-derived methods for explaining physician utilization.

OBJECTIVES: The objective of this study was to evaluate an administrative data-based risk adjustment method for predicting physician utilization and the contribution of survey-derived indicators of health status. The results of this study will support the use of administrative data for planning, reimbursement, and assessing equity of physician utilization. METHODS: The Ontario portion of the 2000-2001 Canadian Community Health Survey was linked with administrative physician claims data from 2002-2003 and 2003-2004. Explanatory models of family physician (FP) and specialist physician (SP) utilization were run using demographic information and The Johns Hopkins University Adjusted Clinical Groups (ACG) Case-mix System. Survey-based measures of health status were then added to the models. The coefficient of determination, R, indicated the models' explanatory power. RESULTS: The study sample consisted of 25,558 individuals aged 20 to 79 years representing approximately 7.8 million people. Over the 2 years of study period, 82.5% of the study population had a FP visit with a median of 6 visits and 53.2% had a SP visit with a median of 1 visit. The R values based on administrative data alone were 33% and 21% for the frequency of FP and SP visits and 16% and 35% for having one or more visit to an FPs and SPs, respectively. The addition of the survey-based measures to the administrative data-based models produced less than a 2% increase in explanatory power for any outcome. CONCLUSION: Administrative data-based measures of morbidity burden are valid and useful indicators of future physician utilization. The survey-derived measures used in this study did not contribute significantly to models on the basis of administrative data-based measures. These findings support the future use of administrative data-based data and Adjusted Clinical Groups for planning, reimbursement, and research.

The predictors of self-rated health and the relationship between self-rated health and health service needs are similar across socioeconomic groups in Canada.

OBJECTIVE: To examine if there are systematic differences in the predictors of self-rated health (SRH) and to examine the relationship between SRH and health care utilization across socioeconomic groups. STUDY DESIGN AND SETTING: We used cross-sectional data from the Canadian Community Health Survey linked to the Ontario Health Insurance Plan (N=17,109). We examined relative differences in the factors associated with different levels of SRH across socioeconomic groups (as assessed by education and household income) using probit models separately for men and women. We then examined differences in expected health care costs, as assessed by adjusted clinical group weights using administrative health care records, between socioeconomic groups within the same level of SRH. RESULTS: We found limited differences across the predictive ability of a broad range of physical, mental, health service/care utilization, and health behavior variables on SRH across socioeconomic groups. In addition, no differences were found in the expected health care utilization costs across socioeconomic groups within the same level of SRH. CONCLUSIONS: The results of this study suggest that SRH assesses a broad variety of factors, including physical health status, mental health status, health service/care utilization, and health behaviors, relatively equally across socioeconomic groups, measured as either education or income.

Universal health insurance and equity in primary care and specialist office visits: a population-based study.

PURPOSE: Universal coverage of physician services should serve to reduce socioeconomic disparities in care, but the degree to which a reduction occurs is unclear. We examined equity in use of physician services in Ontario, Canada, after controlling for health status using both self-reported and diagnosis-based measures. METHODS: Ontario respondents to the 2000-2001 Canadian Community Health Survey (CCHS) were linked with physician claim files in 2002-2003 and 2003-2004. Educational attainment and income were based on self-report. The CCHS was used for self-reported health status and Johns Hopkins Adjusted Clinical Groups was used for diagnosis-based health status. RESULTS: After adjustment, higher education was not associated with at least 1 primary care visit (odds ratio [OR] = 1.05; 95% confidence interval [CI], 0.87-1.24), but it was inversely associated with frequent visits (OR = 0.77; 95% CI, 0.65-0.88). Higher education was directly associated with at least 1 specialist visit (OR = 1.20; 95% CI, 1.07-1.34), with frequent specialist visits (OR = 1.21; 95% CI, 1.03-1.39), and with bypassing primary care to reach specialists (OR = 1.23, 95% CI 1.02-1.44). The largest inequities by education were found for dermatology and ophthalmology. Income was not independently associated with inequities in physician contact or frequency of visits. CONCLUSIONS: After adjusting for health status, we found equity in contact with primary care for educational attainment but inequity in specialist contact, frequent visits, and bypassing primary care. In this setting, universal health insurance appears to be successful in achieving income equity in physician visits. This strategy alone does not eliminate education-related gradients in specialist care.

Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation.

BACKGROUND: Primary care reform in Ontario, Canada, included the initiation of a blended capitation model in 2001-2002 and an enhanced fee-for-service model in 2003. Both models involve patient rostering, incentives for preventive care and requirements for after-hours care. We evaluated practice characteristics and patterns of care under both models. METHODS: Using administrative data, we identified physicians belonging to either the capitation or the enhanced fee-for-service group throughout the period from Sept. 1, 2005, to Aug. 31, 2006, and their enrolled patients. Practices were stratified by location (urban v. rural). We compared the groups in terms of practice characteristics and patterns of care, including comprehensiveness of care, continuity of care, after-hours care, visits to the emergency department and uptake of new patients. RESULTS: Patients in the capitation and enhanced fee-for-service practices had similar demographic characteristics. Patients in capitation practices had lower morbidity and comorbidity indices. Comprehensiveness and continuity of care were similar between the 2 groups. Compared with patients in enhanced fee-for-service practices, those in capitation practices had less after-hours care (adjusted rate ratio [RR] 0.68, 95% confidence interval [CI] 0.61-0.75) and more visits to emergency departments (adjusted RR 1.20, 95% CI 1.15-1.25). Overall, physicians in the capitation group enrolled fewer new patients than did physicians in the enhanced fee-for-service group (37.0 v. 52.0 per physician); the same was true of new graduates (60.3 v. 72.1 per physician). INTERPRETATION: Physicians enrolled in the capitation model had different practice characteristics than those in the enhanced fee-for-service model. These characteristics appeared to be pre-existing and not due to enrolment in a new model. Although the capitation model provides an alternative to fee-for-service practice, its characteristics should be the focus of future policy development and research.

Reasons for self-reported unmet healthcare needs in Canada: a population-based provincial comparison.

In this study, we compare self-perceived unmet need across Canadian provinces and assess how the reasons for unmet need - problems with availability, accessibility and acceptability - vary. This cross-sectional study uses data from the Canadian Community Health Survey (2.1) conducted in 2003. Overall, 11.7% perceived having had unmet healthcare needs in the previous 12 months. The adjusted provincial rates varied from 13.3% in Manitoba to 7.8% in Prince Edward Island. Among those reporting unmet health service needs, the leading reason was problems of availability of services (54.9%), followed by acceptability (42.8%) and accessibility related to cost or transportation (12.7%). Unmet need due to problems of availability was most likely in Quebec, Newfoundland and Manitoba, while Alberta and British Columbia had the highest likelihood of unmet need due to accessibility problems. Those in British Columbia, Saskatchewan and Manitoba were more likely to report problems of acceptability. The reasons for unmet need vary across provinces, with each reason having different policy implications.

Outcome of corneal transplantation: can a prioritisation system predict outcome?

BACKGROUND: In 1995 a prioritisation system for patients waiting for corneal transplantation surgery was adopted in British Columbia. In 1997 a routine outcome assessment programme was adopted. The authors sought to determine the outcomes of corneal transplant surgery in the province of British Columbia and to evaluate if they were associated with waiting list prioritisation. METHODS: Since May 1997 all patients who receive a corneal transplant are enrolled in the Eye Bank of British Columbia (EBBC) outcome assessment programme. Each patient fills out a visual function assessment (VFA) questionnaire before and 12 months after surgery. Data on visual acuity, pain, demographics, and other ocular complications are collected from both patients and surgeons before and after operation. RESULTS: 269 patients were enrolled in the programme between May 1997 and April 1998. 12 month follow up showed that visual acuity improved in 69.9% of patients, while it remained the same in 20.8%, and got worse in 5.9%. Overall, at follow up 16.6% of patients had intermittent pain and 5.0% had constant pain. 78.6% of patients who experienced intermittent or constant pain before surgery reported no pain at follow up. Visual function improved in 72.4% of patients, remained the same in 4.1%, and worsened in 23.5%. 88% of patients improved in at least one of the three outcome categories. Patients who had the greatest improvement had been assigned the highest priority for surgery. The 11% of patients who did not improve in any of the three categories (visual acuity, pain, or visual function) were more likely to have a preoperative visual acuity better than 20/60, most likely to have old trauma or Fuchs' dystrophy as their primary diagnosis, and to have had fewer points in the EBBC priority scoring system. CONCLUSION: The finding that patients who had a high preoperative priority score were more likely to have a good outcome suggests that the priority system was accurately identifying patients at greatest need for surgery. These findings also suggest that outcome from corneal transplant surgery is best measured as a combination of clinical indices and patient derived indices. A routine outcome assessment programme and prioritisation system can assist surgeons and eye banks in better case selection and in anticipating both objective and subjective improvement following surgery.