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Biomedical subjects

D A Kindig

Publications and source records attributed to D A Kindig.

At least 19 recordsLinked to original sources
PubMed1998

Purchasing population health: aligning financial incentives to improve health outcomes.

OBJECTIVE: To review the concept of population health, including its definition, measurement, and determinants, and to suggest an approach for aligning financial incentives toward this goal. DATA SOURCE, STUDY DESIGN, DATA EXTRACTION. Literature review, policy analysis PRINCIPAL FINDINGS: The article presents the argument that a major reason for our slow progress toward health outcome improvement is that there is no operational definition of population health and that financial incentives are not aligned to this goal. Current attempts at process measures as indicators of quality or outcome are not adequate for the task. It is suggested that some measure of health-adjusted life expectancy be adopted for this purpose, and that integrated delivery systems and other agents responsible for nonmedical determinants be rewarded for improvement in this measure. This will require the development of an investment portfolio across the determinants of health based on relative marginal return to health, with horizontal integration strategies across sectoral boundaries. A 20-year three-phase development strategy is proposed, including components of research and acceptance, integrated health system implementation, and cross-sectoral integration. CONCLUSIONS: The U.S. healthcare system is a $1 trillion industry without a definition of its product. Until population outcome measures are developed and rewarded for, we will not solve the twenty-first century challenge of maximizing health outcome improvement for the resources available.

Cost-Benefit Analysis↗
PubMed1996

Domestic production vs international immigration: Options for the US physician workforce.

OBJECTIVE: To determine alternate combinations for reductions in US medical school graduates (USMGs), international medical graduate (IMG) immigration, and graduate medical education (GME) residencies, based on future physician supply targets. DESIGN: A demographic projection model of the physician supply was constructed and calibrated to fit observed American Medical Association Physician Masterfile data and current supply forecasts. Total annual input to GME was backcast from given future supply targets, adjusting for the portion of IMGs in GME who do not enter the US workforce. MAIN OUTCOME MEASURES: The annual number of new physicians added to supply from domestic or international sources needed to reach future physician-to-population ratio targets. RESULTS: Because of the low rate of attrition from the physician supply, it takes up to 50 years for workforce policy to effectively stabilize the physician-to-population ratio at a target level. All target ratios considered here would require immediate reductions in the total number of GME positions. These reductions must be followed by gradual annual increases to account for population growth. The size of USMG and IMG reductions are interrelated and depend critically on the percentage of IMG trainees who remain to practice in the United States. CONCLUSIONS: Reductions in future physician supply can come from either the IMG or USMG component of physician production, or both. The model developed here allows the estimation of multiple combinations of both GME components.

Demography↗
PubMed1996

The evolution of divergences in physician supply policy in Canada and the United States.

The size, geographic distribution, and specialty mix of the US physician workforce continue to interest American health policy analysts. Evidence suggests that the United States is on the verge of a serious oversupply of physicians, particularly nongeneralist physicians. Canada faces some of the same problems in physician supply, cost, and distribution as does the United States. Unlike the American states, however, the Canadian provinces, which have responsibility for financing health care, have in recent years made changes in their physician workforce policies that address these problems. Of particular note, Canadian provinces have developed policies that limit medical school enrollments, adjust the specialty training mix to better accord with needs, and establish physician practice location incentives. This article proceeds on the assumption that historical and contemporary similarities between medical care systems in Canada and the United States make comparisons between them potentially valuable. It offers a historical perspective on the evolution of workforce planning in the 2 countries and identifies 3 periods of policy development. It also compares and contrasts the relative size and specialty composition of the Canadian and US workforces and discusses how Canadian initiatives have diverged from American policy. Unless the United States devises its own coordinated workforce strategy, it will have considerable difficulty limiting physician workforce growth and influencing specialization and distribution in the future.

Canada↗
PubMed1995

Wisconsin's future requirements for generalist physicians: is the state's training capacity sufficient?

The need for expansion of generalist residency training programs in Wisconsin is considered, using population-based considerations and projection models that estimate the future statewide supply of and requirements for generalist physicians. In 1990, Wisconsin's generalist physician-to-population ratio was relatively low, at 59 per 100,000 population. The supply of generalists per 100,000 population was also highly variable across broad geographic areas of the state, with 16 of Wisconsin's 25 Health Service Areas having ratios which fell below 59 per 100,000 population. These patterns may not automatically translate into the need for expansion of Wisconsin's generalist residency training capacity, however. The projection model indicates that, even with no expansion of graduate medical education capacity for generalist physicians, the statewide supply could grow to more than 70 generalists per 100,000 population by the year 2015. Expansion of the state's generalist training capacity would also not guarantee that any additional generalist physicians trained in the state would actually locate in areas where they would be most needed. Policy efforts to provide incentives for generalist physicians to locate in under-served areas should continue to be supported.

Family Practice↗
PubMed1994

How will graduate medical education reform affect specialties and geographic areas?

OBJECTIVES: To project specialty and geographic impacts of workforce reform proposals on the practice output of graduate medical education (GME). DESIGN: A demographic life-table model to predict GME output was developed using 1987 cohort data from the Association of American Medical Colleges Annual GME Census. The 1992 GME cohort was used as a baseline to compare the simulated impact of alternate specialty and regional policies. SETTING: Allopathic and osteopathic GME programs in the United States. MAIN OUTCOME MEASURE: Projected number of physicians (MDs and DOs) entering nine categories of practice specialty at the conclusion of GME. RESULTS: If GME input is reduced to 110% of US medical graduates with 55% entering practice as generalists (including obstetrics and gynecology), then the total number of first-year positions will decline from 24,433 to 18,783, and the total number of residents in GME would decline from 103,858 to 80,699 at equilibrium. Even with a 110% restriction on GME input, the overall physician-to-population ratio will continue to grow, albeit at a much slower rate. The number of generalists leaving GME annually would increase by 742 (9%) and the number of specialists would decline by 6517 (44%). At the regional level, allocating GME positions by prorating to the current distribution results in less change than would prorating positions to regional populations. CONCLUSIONS: Achieving national goals of reduced aggregate physician production, reduced specialist supply, and generalist increases will require significant alterations in the GME pool. Adequate time and funding for resident substitution will be required for hospitals to develop alternate models of providing service to allow national workforce goals to be met.

Demography↗
PubMed1994

Graduate medical education reform. Service provision transition costs.

OBJECTIVE: To analyze the potential strategies and costs of house staff substitution under a reformed system of graduate medical education. DESIGN: An economic model using two scenarios for substitution of house staff (residents and fellows): (1) a lower-cost model under which nonphysician providers assume many house staff responsibilities, but additional aspects of their workload are taken over by staff physicians, nurses, and ancillary personnel; and (2) a higher-cost traditional model that relies more heavily on staff physicians to replace house officers. SETTING: US teaching hospitals. MAIN OUTCOME MEASURES: Projected net substitution costs of house staff on a per full-time equivalent basis and aggregate national cost estimates of substitution. RESULTS: Net annual house staff substitution costs were estimated to be $58,000 and $77,000 per replaced full-time equivalent house officer, respectively, under the two scenarios. Assuming elimination of approximately 23,200 house staff under a reformed system, total (net) substitution costs to teaching hospitals were estimated at approximately $1.4 billion to $1.8 billion nationally on an annual basis. CONCLUSIONS: Graduate medical education reform, while likely to result in substantial long-term cost savings, will necessitate transitions in service provision that are likely to generate some new costs in the short term.

Economics, Medical↗
PubMed1994

The value of the physician executive role to organizational effectiveness and performance.

With the growing importance of medical management as a component of health care delivery, it is important to understand the extent to which physician executives assist their organizations in the provision of health care that is efficient and of high quality. To date, research on the role of physician executives in large health care organizations has been limited. This research attempts to address some of the gaps in our understanding of the value of the role of the physician executive and explores the anticipated opportunities for expansion of that role as health care organizations attempt to respond to a rapidly changing health care environment.

Chi-Square Distribution↗
PubMed1993

The elusive generalist physician. Can we reach a 50% goal?

National attention has focused on the goal of attaining 50% primary care practitioners to facilitate patient access and cost-effectiveness. To determine how long it might take to achieve this goal, we used the Bureau of Health Professions' aggregate physician supply model to forecast the generalist-specialist balance. Assuming that 30% of graduates will enter generalist practice after 1993 (the percentage in the mid-1980s), the number of generalists would increase from 174,940 in 1990 to 232,000 in 2040 (77 per 100,000 population), but the percentage would remain at about 30%; specialists would continue to make up about 70% of all active physicians, but their total number would grow from 345,600 to 537,000 (178 per 100,000 population). If 50% of graduates were to enter generalist practices, by the year 2040 the number of generalists would grow to 373,000, or 124 per 100,000 (48.4% of all physicians). If entry into generalist practice falls to 20%, as suggested by recent medical student preferences, the number of generalists would peak at 192,000 (26.4%) in 2010 and would fall to 160,000 (21%) by 2040, resulting in 53 generalists and 201 specialists per 100,000 population. We discuss the implications of these findings on aggregate physician supply and on policy initiative affecting the ratio of generalists to specialists. Reform proposals affecting the specialty mix should clearly identify the desired future ratio of generalists and specialists per capita.

Family Practice↗
PubMed1993

Physician supply in rural areas with large minority populations.

While much research has been conducted into physician supply in rural areas, very little is known about physician supply in areas with heavy populations of ethnic minorities. This study finds that in 1990 the number of physicians per thousand residents was lower than the national average in counties with predominantly black and Hispanic populations. For counties largely populated by Native Americans, the mean number of physicians was slightly higher than the national average.

Health Services Needs and Demand↗
PubMed1992

Age distribution and turnover of physicians in nonmetropolitan counties of the United States.

Using data for 1975 to 1985 from the Area Resource File (ARF), net number changes in different age groups of physicians practicing in nonmetropolitan counties are examined. Small net increases are seen in the higher age groups in most county size categories but the most striking change is large increases in the age groups up to age 44. Family practitioners show a net decline in all county size categories for ages 45-54, but these are offset by increases in medical specialists. In counties of less than 25,000 population, the rate of turnover of physicians over the 1983-1988 period was 25 percent; physicians exiting these counties had a mean age of 52.3 years. The data indicate that aging of physicians in rural counties should not affect maintenance of current supply in the short run, but that increasing the physician-to-population ratio in areas with less adequate supply will be difficult, particularly if the rate of increase of younger physicians in nonmetropolitan counties does not continue.

Adult↗
PubMed1992

Physician responses to fee-for-service and capitation payment.

The ability to achieve reductions in health care costs is determined in part by physician payment mechanisms. This study observes the response to a change in the reimbursement mechanism by a group of physicians who participated in a fee-for-service plan and then formed an IPA using capitation payment for primary care physicians and a reduced fee schedule for specialists. Patient benefits were similar under the two plans. Analyses of data for a group of continuous enrollees show that the change in the physician payment mechanism was associated with a reduction in hospitalizations but increases in length of hospital stay and number of ambulatory visits. These increases may have occurred because capitation for primary care physicians and a reduced fee schedule for specialists led to a greater number of referrals with no incentive in place for reductions in length of stay for specialty admissions.

Ambulatory Care↗
PubMed1991

Uncompensated and discounted Medicaid care provided by physician group practices in Wisconsin.

A survey of a sample of physician group practices in Wisconsin was undertaken to determine the amounts of charity care, bad debt, and discounted Medicaid care that were provided in 1988. Overall, the physician group practices in the sample reported dollar amounts of uncompensated care and discounted Medicaid care that averaged approximately 7.6% of their total billings for the year (1.6% of charity care, 3.0% of bad debt, and 3.0% of discounted Medicaid care). From the dollar totals reported, it was calculated that the individual physicians represented by this sample of group practices were responsible for, on average, +4300 of charity care, +9100 of bad debt, and +7500 of Medicaid discounted services, for a yearly per-physician total of +20,900 of uncompensated care and discounted care provided to uninsured and indigent patients. The results indicate that a majority of the group practices provided more charity care in 1988 than they had 5 years earlier and suggest that the burden of providing uncompensated care tends to fall disproportionately on those group practices that are also providing relatively high levels of service to Medicaid recipients.

Charities↗
PubMed1991

Career paths of physician executives.

Survey data from a sample of physicians whose primary professional activity is administration were used to examine their previous administrative positions and career paths. Forty percent reported administrative positions in more than one type of health care organization, and time spent in administration increased with age and years in administration. Most responders with senior titles had four or more positions in a single type of organization or two positions in different types of organizations. These findings should be useful for further investigation on the physician executive role, as well as in career planning.

Career Mobility↗