Published 2023
In this module:
- Primary care 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 primary care physicians as a source of women’s health services
- The role of primary care physicians as a source of behavioral 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.
Primary care 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. Prior analyses focused on the role of family medicine physicians in delivering women’s health services. However, starting in 2018 the National Ambulatory Medical Care Survey (NAMCS) no longer identifies specific physician specialties but groups all primary care specialties into a primary care category—which includes obstetrics and gynecology (OB-GYN). 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 primary care physicians in delivering women’s health services is explored further within the context of this module.
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 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 from the 2018 and 2019 NAMCS from office visits with 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 primary care physicians and identified visits where women’s health services were provided. Because the 2018 and 2019 NAMCS include OB-GYNs in the primary care category, we subset the analysis on a variable indicating if the visit was with the patient’s primary care provider. Primary care physicians provide testing for sexually transmitted infections. For purposes of this analysis, we excluded sexually transmitted diseases as a women's health service because these services are not unique to women.
NAMCS reports the number of minutes the physician spent visiting with the patient. For patients with multiple diagnoses or exams/screening per 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 4.7% of primary care physician time in direct patient care is spent providing women’s health services. For visits where the patient is a woman or adolescent girl aged 13 or older, 9.2% of the visit time is spent providing women’s health services, on average. This includes 4.6% of time spent providing services to women and adolescent girls in metropolitan areas and 2.5% of time during visits in nonmetropolitan areas. Prior analysis with the 2015 and 2016 NAMCS found a much higher proportion of family physician time spent providing women’s health services. However, the updated analysis cannot distinguish between a visit to a family physician, general internist, or other type of primary care provider. The prior analysis focused on family physicians (who are disproportionally located in nonmetropolitan areas). The new analysis includes general internists (who are disproportionately in metropolitan areas).
Applying the above percentages to the physician workforce in 2021, approximately 4,850 full time equivalent (FTE) family physicians provided women’s health services—where FTE is defined as 40 hours per week of professional services. Approximately 3,890 FTE general internists provided women’s health services. These figures are calculated by multiplying the 4.7% in metropolitan areas and 2.6% in nonmetropolitan statistics by estimates from the 2021 American Medical Association Masterfile of the number of FTE physicians in metropolitan and nonmetropolitan 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.
Primary care physicians as a source of behavioral health services
Primary care providers are increasingly 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 U.S. 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 behavioral health conditions, and prescribing medications for 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 NPs and PAs in primary care. Another goal was to better understand if this proportion of time differed by patient characteristics (e.g., residing in a nonmetropolitan county or patient’s gender). This investigation is based on an analysis of patient visits to primary care physician offices in the 2018 and 2019 NAMCS. As discussed earlier, the 2018 NAMCS detailed specialty is no longer available and primary care physicians are grouped into one broad category.
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 per 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, then 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, 6.7% of physicians’ direct patient care time is spent providing behavioral health services, up from the 5.8% estimate from a similar analysis of the 2014-2016 NAMCS files. In the 2014-2016 NAMCS analysis, the percentage of physician time spent providing behavioral health services was substantially higher for family medicine and general internal medicine. Applying the pro-rated time to FTE family medicine physicians and general internal medicine physicians as calculated from the 2021 American Medical Association Masterfile, we estimate 17,600 of the 193,900 primary care physician FTEs in 2021 provided behavioral health services.
The proportion of primary care physician time providing behavioral health services is higher in nonmetropolitan areas (7.8%) compared to metropolitan areas (6.6%). 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 primary care physicians spent providing behavioral health services in metropolitan areas is equivalent to approximately 15,600 FTE primary care physicians. The time primary care physicians spent providing behavioral health services in nonmetropolitan areas is equivalent to approximately 2,000 FTE primary care physicians.
Comparing the primary care physician time spent providing behavioral health services to the estimated FTE supply of psychiatrists in 2021 shows that primary care physicians are providing approximately 25% of all physician-supplied behavioral health services in metropolitan areas. Primary care physicians are providing 46% of all physician-supplied behavioral health services in nonmetropolitan areas. That is, in nonmetropolitan counties primary care physicians represent almost as much FTE time providing behavioral health services as do psychiatrists. This is a substantial finding that suggests the gap in behavioral health services from the lack of specialists and infrastructure in nonmetropolitan areas is largely being filled by primary care physicians.
Not only is the estimated proportion of primary care physician time spent providing behavioral health services substantial, but the proportion appears to have grown in recent years. There is already concern that primary care physicians have insufficient time during the patient visit to provide all recommended preventive services, and the provision of behavioral health services adds to the workload for primary care physicians. 15 Therefore, for modeling purposes we add 17,600 FTEs to the estimated demand for primary care physicians. This added demand equates to additional 9,900 FTE demand for family medicine physicians and 7,700 FTE demand for general internal medicine physicians.