In this module:
- Family Physicians as a Source of Women’s Health Services
- Primary Care Physicians as a Source of Behavioral Health Services
In most medical specialties, care is provided by teams that often include physicians, nurse practitioners (NP), physician assistants (PAs), and a variety of other occupations. Separate modules document how the Health Workforce Simulation Model (HWSM) models supply and demand for physicians, advanced practice providers, behavioral health providers, and other health occupations. Health workers often are defined by both their occupation and specialty.
In this module we discuss two topics not covered in other modules:
- The role of family physicians as a source of women’s health services, and
- The role of primary care physicians as a source of behavior health services.
The focus on physicians is in large part due to data limitations with quantifying the role of other care providers (e.g., NPs and PAs) in delivering care outside their typical scope of practice.
Family Physicians as a Source of Women’s Health Services
Women’s unique health needs extend well beyond just gender-specific, reproductive health services, and primary care physicians play a critical role in closing the many health disparities that women face. However, primary care physicians also deliver many reproductive health services as well. This can include, among other services, the provision of birth control, cervical cancer screening, prenatal care, and the management of chronic conditions during pregnancy. However, within the group of primary care providers, those specializing in family medicine are also uniquely trained to deliver obstetrical care. In line with this competency area, and its overlap with the skills of the obstetricians/gynecologists (OB-GYNs) and certified nurse midwives discussed in other modules, the role of family medicine physicians in delivering women’s health services is explored further within the context of this module.
This analysis combines the 2015 and 2016 National Ambulatory Medical Care Survey (NAMCS) data files to increase sample size. The 2016 NAMCS is the latest public use file available that provides detailed physician specialty. NAMCS is based on a representative sample of physician office visits. For each participating physician practice, information is collected for a random sample of patient visits obtained through record extraction. Among the information collected for each visit are the type of physician seen, the length of time (in minutes) the physician spent with the patient, and up to five diagnosis codes.
We first analyzed ICD-10 diagnosis and procedure codes (2016 NAMCS) and ICD-9 codes (2015 NAMCS) from office visits to OB-GYNs to identify codes and screening exams associated with the provision of women’s health services in an office setting.1 We then analyzed visits to family medicine physicians and identified visits where women’s health services were provided. Family physicians provide testing for sexually transmitted diseases for both males and females. For purposes of this analysis, we excluded such testing as specifically a women’s health service.
NAMCS reports the number of minutes the physician spent visiting with the patient. For patients with multiple diagnoses or exams/screening for the visit, there is insufficient information to know what proportion of physician time is spent providing women’s health services. Consequently, the visit time is pro-rated by dividing (a) the sum total of diagnosis codes and exams during the visit identified as women’s health services, by (b) the sum total of all diagnosis codes and exams provided during the visit. This approach implicitly assumes that addressing each diagnosis code and each exam takes approximately the same amount of time. If a 20-minute visit had one diagnosis code, and that code is for women’s health, then 100% of the visit time is assumed for women’s health services. If there are two diagnosis/procedure codes and one is for women’s health services, then we assumed 50% (10 minutes) of the visit time is to provide women’s health services.
Summing physician time across all patients and using NAMCS sample weights, we calculate that 3.9% of family physician time in direct patient care is spent providing women’s health services. For visits where the patient is a women or adolescent girl aged 13 or older, 7.0% of the visit time is spent providing women’s health services, on average. This includes 6.6% of time spent providing services to women and adolescent girls in metropolitan areas and 9.4% of time during visits in nonmetropolitan areas.
In 2020 approximately 4,350 full time equivalent (FTE) family physicians provided women’s health services—where FTE is defined as 40 hours per week of professional services. The 4,060 figure is calculated by multiplying the 3.9% estimate by the estimated 111,500 FTE family physicians identified using the 2020 American Medical Association Masterfile. An estimated 3,220 FTEs serve women and adolescents in metropolitan areas, and 1,130 FTEs are in nonmetropolitan areas.
Between 2020 and 2035, demand for OB-GYNs is projected to increase by 6.2% in metropolitan areas and decrease by 6.2% in nonmetropolitan areas. These projections are associated with changing demographics. If we apply the 6.2% increase in metropolitan areas and the 6.2% decline in nonmetropolitan areas to the FTE family physician numbers in 2020 providing women’s health services, we calculate that by 2035 this would be equivalent to 1,060 FTE family physicians providing women’s health services in nonmetropolitan areas and 3,420 FTEs in metropolitan areas. Given the level of demand for obstetrical care in nonmetropolitan areas and the larger role for family medicine physicians in delivering it, training on obstetrics and for the management of other complex women’s health issues will remain an important component for family medicine residency training programs in the future.2 3
The main implication of this analysis for HWSM modeling is that estimates of supply adequacy for primary care providers should be considered in the context of estimated supply adequacy for women’s health providers. The greater the shortfall of women’s health providers in less densely populated areas, the more primary care providers will be called on to address this shortfall.
Primary Care Physicians as a Source of Behavioral Health Services
Primary care providers increasingly are involved in delivering behavioral health services.4 5 6 We analyzed the role of primary care physicians in the delivery of behavioral health services where such activities include:
- Screening: Primary care is often the entry point to the health care system. Primary care providers help screen patients and identify the need for behavioral health treatment. The US Preventive Services Task Force (USPSTF) recommends that primary care providers screen children, adolescents and young adults for behavioral health outcomes.7 8 USPSTF also recommends screening and counseling in primary care settings for adults regarding excessive alcohol use and depression.9 10
- Treatment: Primary care providers sometimes are involved in the direct treatment of patients. This is especially seen in medically underserved areas without adequate behavioral health infrastructure to refer patients to other providers. Treatment includes counseling, prescribing medications for depression and anxiety, and prescribing methadone to treat opioid use disorder.11
- Collaboration within multidisciplinary teams: Integration of behavioral health into primary care practices is increasing the number of primary care providers who are part of multidisciplinary teams that include professional behavioral health providers.12
One goal of this analysis was to estimate the proportion of primary care physicians’ time spent providing treatment for patients’ behavioral health disorders. Insufficient information was available to estimate the proportion of time spent providing behavioral health services by nurse practitioners and physician assistants in primary care. Another goal was to better understand if this proportion of time differed by patient characteristics—e.g., residing in nonmetropolitan county or patient’s gender. This investigation is based on analysis of patient visits to primary care physician offices in the 2014, 2015 and 2016 NAMCS. As discussed earlier, the 2016 NAMCS is the most recent public use file that provides detailed specialty information.
NAMCS is based on a representative sample of physician office visits. The NAMCS sampling frame includes three specialties categorized as primary care: family medicine, general internal medicine, and general pediatrics. In addition to these three specialties, we created a fourth proxy category for geriatric medicine visits. We created this category by using all patients aged 75 and older in the family medicine or general internal medicine specialties across all three years of data.
Our analysis found that 14.1% of visits to a primary care physician includes a behavioral health diagnosis code (Exhibit IX‑1)13 . For patients with multiple diagnoses for the visit, insufficient information exists to know what proportion of physician time is spent addressing behavioral health diagnoses. Consequently, we pro-rated the visit time by dividing total behavioral health diagnoses by total diagnoses. If a 20-minute visit had two diagnoses and one was behavioral health, we counted half (10 minutes) of the visit as time spent providing behavioral health services. Physician screening or counseling for behavioral health services is not counted as time providing behavioral health services in the absence of a behavioral health diagnosis.
Using this approach, over 5.8% of physicians’ direct patient care time is spent providing behavioral health services. The time ranges from a high of 6.4% for family medicine to a low of 4.0% for geriatric medicine. Applying the pro-rated time to FTE primary physicians as calculated from the 2020 American Medical Association Masterfile, we estimate 15,000 of the 256,760 primary care physician FTEs in 2020 were to provide behavioral health services.
- 1ICD-10 codes identified as those for women’s health services are C50-C58 (malignant neoplasms of breast and female genital organs), D24-D28 (benign neoplasms of breast, ovary, female genital organs), E28 (ovarian dysfunction), K62 (diseases of anus and rectum), N39 (urinary system), N60-N64 (diseases of the breast), N70-N98 (non-inflammatory diseases of female genital tract / inflammatory diseases of female and pelvic organs), O00-O99 (pregnancy, termination of pregnancy, pregnancy observation, childbirth), R30-R39 (urinary system), Z124 (cervical exam), Z123 (breast screen), and Z30-Z39 (health service related to reproduction). ICD-9 codes are 180-183 (neoplasms of cervix, placenta, uterus, ovary), 217-221 (benign neoplasms of breast, uterus, ovary, other female organs), 630-679 (pregnancy and childbirth), and 760-779 (maternal causes of perinatal morbidity and mortality). Exams/screenings listed as women’s health services are breast exam, pelvic exam, Pap smear, pregnancy test, mammogram, fetal monitoring, and family planning.
- 2Eden AR, Peterson LE. Challenges Faced by Family Physicians Providing Advanced Maternity Care. Maternal and Child Health Journal. 2018;22(6):932-940.
- 3Rural Health Information Hub. Barriers to Improving Rural Maternal Health. RHIhub. Published May 17, 2021. Accessed August 22, 2022.
- 4Beck AJ, Page C, Buche J, Schoebel V, Wayment C. Behavioral Health Service Provision by Primary Care Physicians (PDF - 1 MB). University of Michigan; 2019. Accessed August 22, 2022.
- 5Livingston JD, Adams E, Jordan M, MacMillan Z, Hering R. Primary Care Physicians’ Views about Prescribing Methadone to Treat Opioid Use Disorder. Substance Use & Misuse. 2017;53(2):344-353.
- 6American Academy of Family Physicians. Mental Health Care Services by Family Physicians (Position Paper). Published 2018. Accessed August 22, 2022.
- 7U.S. Preventive Services Task Force. Final Recommendation Statement: Depression in Children and Adolescents: Screening. 2016.
- 8O’Connor E, Thomas R, Senger CA, Perdue L, Robalino S, Patnode C. Interventions to Prevent Illicit and Nonmedical Drug Use in Children, Adolescents, and Young Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2020;323(20):2067-2079.
- 9U.S. Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(18):1899.
- 10Siu AL, U.S. Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. Screening for Depression in Adults: U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4):380.
- 11Livingston JD, Adams E, Jordan M, MacMillan Z, Hering R. Primary Care Physicians’ Views about Prescribing Methadone to Treat Opioid Use Disorder. Substance Use & Misuse. 2017;53(2):344-353.
- 12Cantone RE, Fleishman J, Garvey B, Gideonse N. Interdisciplinary Management of Opioid Use Disorder in Primary Care. The Annals of Family Medicine. 2018;16(1):83-83.
- 13ICD-10 diagnosis codes that begin with “F” (including F00 – F99) were included as a behavioral health diagnosis. Insomnia and sleep disorders (ICD-10 code G470) were also considered a behavioral health diagnosis. ICD-9 diagnosis codes that describe mental health disorders (beginning with 290 – 319) were also included as a behavioral health diagnosis code.
The proportion of primary care physician time providing behavioral health services is almost twice as high in nonmetropolitan areas (9.9%) compared to metropolitan areas (5.5%). This is consistent with estimates of under-supply of behavioral health providers in nonmetropolitan areas and other possible barriers to seeing a behavioral health specialist (e.g., stigma).14 The time PCPs spent providing behavioral health services in metropolitan areas is equivalent to approximately 12,210 FTE primary care physicians. The time PCPs spent providing behavioral health services in nonmetropolitan areas is equivalent to approximately 2,790 FTE primary care physicians.
Comparing the PCP time spent providing behavioral health services to the estimated FTE supply of psychiatrists in 2020 shows that primary care physicians are providing approximately 21% of all physician-supplied behavioral health services in metropolitan areas. Primary care physicians are providing 53% of all physician-supplied behavioral health services in nonmetropolitan areas. That is, in nonmetropolitan counties primary care physicians represent more FTE time providing behavioral health services than do psychiatrists. This is a significant finding that suggests the gap in behavioral health services and lack of specialists and infrastructure in nonmetropolitan areas are being filled by primary care physicians to a large extent.
The main implication of this analysis for HWSM modeling is that estimates of supply adequacy for primary care providers should be considered in the context of estimated supply adequacy for behavioral health providers. The greater the shortfall of behavioral health providers in less densely populated areas, the more primary care providers will be called on to address this shortfall.