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PURPOSE Care continuity is foundational to the clinician/patient relationship; however, little has been done to operationalize continuity of care (CoC) as a clinical quality measure. The American Board of Family Medicine developed the Primary Care CoC clinical quality measure as part of the Measures That Matter to Primary Care initiative. METHODS Using 12-month Optum Clinformatics Data Mart claims data, we calculated the Bice-Boxerman Continuity of Care Index for each patient, which we rolled up to create an aggregate, physician-level CoC score. The physician quality score is the percent of patients with a Bice-Boxerman Index [greater than or equal to] 0.7 (70%). We tested validity in 2 ways. First, we explored the validity of using 0.7 as a threshold for patient CoC within the Optum claims database to validate its use for reflecting patient-level continuity. Second, we explored the validity of the physician CoC measure by examining its association with patient outcomes. We assessed reliability using signal-to-noise methodology. RESULTS Mean performance on the measure was 27.6%; performance ranged from 0% to 100% (n = 555,213 primary care physicians). Higher levels of CoC were associated with lower levels of care utilization. The measure indicated acceptable levels of validity and reliability. CONCLUSIONS Continuity is associated with desirable health and cost outcomes as well as patient preference. The CoC clinical quality measure meets validity and reliability requirements for implementation in primary care payment and accountability. Care continuity is important and complementary to access to care, and prioritizing this measure could help shift physician and health system behavior to support continuity. https://doi.org/10.1370/afm.2880, INTRODUCTION Continuity of care (CoC) is a central tenet of primary care and is associated with fewer hospitalizations and emergency department (ED) visits, better patterns of care utilization, lower costs [...]

PURPOSE Physicians' use of self-assessment to guide quality improvement or board certification activities often does not correlate with more objective measures, and they may spend valuable time on activities that support their strengths instead of addressing gaps. Our objective was to study whether viewing quality measures, with peer comparisons, would affect the selection of certification activities. METHODS We conducted a cluster-randomized controlled trial--the Trial of Data Exchange for Maintenance of certification and Raising Quality (TRADEMaRQ)--with 4 partner organizations during 2015-2017. Physicians were presented their quality data within their online certification portfolios before (intervention) vs after (control) they chose board certification activities. The primary outcome was whether the selected activity addressed a quality gap (a quality area in which the physician scored below the mean for the study population). RESULTS Of 2,570 invited physicians, 254 physicians completed the study: 130 in the intervention group and 124 in the control group. Nearly one-fifth of participating physicians did not complete any certification activities during the study. A sizable minority of those in the intervention group, 18.4%, never reviewed their quality dashboard. Overall, just 27.2% of completed certification activities addressed a quality gap, and there was no significant difference in this outcome in the intervention group vs the control group in either bivariate or adjusted analyses (odds ratio = 1.28; 95% CI, 0.90-1.82). CONCLUSIONS Physicians did not use quality performance data in choosing certification activities. Certification boards are being pressed to make their programs relevant to practice, less burdensome, and supportive of quality improvement in alignment with value-based payment models. Using practice data to drive certification choices would meet these goals. Ann Fam Med 2022;20:110-114. https://doi.org/10.1370/afm.2770, INTRODUCTION The Crossing the Quality Chasm landmark report of the Institute of Medicine (now National Academy of Medicine) detailed the uneven quality of the US health care system nearly 20 [...]

PURPOSE The Trial of Aggregate Data Exchange for Maintenance of Certification and Raising Quality was a randomized controlled trial which first had to test whether quality reporting could be a by-product of clinical care. We report on the initial descriptive study of the capacity for and quality of exchange of whole-panel, standardized quality measures from health systems. METHODS Family physicians were recruited from 4 health systems with mature quality measurement programs and agreed to submit standardized, physician-level quality measures for consenting physicians. Identified measure or transfer errors were captured and evaluated for root-cause problems. RESULTS The health systems varied considerably by patient demographics and payer mix. From the 4 systems, 256 family physicians elected to participate. Of 19 measures negotiated for use, 5 were used by all systems. There were more than 15 types of identified errors including breaks in data delivery, changes in measures, and nonsensical measure results. Only 1 system had no identified errors. CONCLUSIONS The secure transfer of standardized, physician-level quality measures from 4 health systems with mature measure processes proved difficult. There were many errors that required human intervention and manual repair, precluding full automation. This study reconfirms an important problem, namely, that despite widespread health information technology adoption and federal meaningful use policies, we remain far from goals to make clinical quality reporting a reliable by-product of care. Key words: health information technology; quality measures; family physicians; quality indicators; health care; certification, INTRODUCTION Family physicians provide nearly 20% of all clinical outpatient visits, nearly 200 million visits in the United States annually. (1) Frontline clinicians continue to report failures of certified electronic [...]

Earlier this year, the National Academies of Sciences, Engineering, and Medicine (NASEM) published the first formal consensus study of primary care in 25 years. The consensus committee's report, 'Implementing High-Quality [...]

Still early in a long game of delivery system transformation, the United States is already experiencing some of the negative consequences of pursuing quality and value measurement on professionalism in [...]

Key words: practice transformation; organizational change; innovation; quality improvement; professional practice; health extension; outreach; practice facilitation; primary care; burnout; health information technology; practice-based research, This supplement to the Annals of Family Medicine brings together early learning from multiple examples of health extension and practice transformation support, with the goal of informing future efforts to [...]

COVID-19 altered the way the American public lived their lives,- the way they worked, ate, socialized, traveled, and ultimately received their health care. Family Medicine largely closed its doors to [...]

In May 2021, the National Academies of Sciences, Engineering, and Medicine (NASEM) released Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. (1) Linking coordination of primary care to [...]

Five papers in this issue could be read with hope and despair about change in clinical care, but I believe they all call for coaches--the need for facilitation in practice [...]

The redesign of primary care through the patient-centered medical home offers an opportunity to assess the role of primary care in treating mental health relative to the rest of the [...]

Purpose: Care continuity is foundational to the clinician/patient relationship; however, little has been done to operationalize continuity of care (CoC) as a clinical quality measure. The American Board of Family Medicine developed the Primary Care CoC clinical quality measure as part of the Measures That Matter to Primary Care initiative.Methods: Using 12-month Optum Clinformatics Data Mart claims data, we calculated the Bice-Boxerman Continuity of Care Index for each patient, which we rolled up to create an aggregate, physician-level CoC score. The physician quality score is the percent of patients with a Bice-Boxerman Index ≥0.7 (70%). We tested validity in 2 ways. First, we explored the validity of using 0.7 as a threshold for patient CoC within the Optum claims database to validate its use for reflecting patient-level continuity. Second, we explored the validity of the physician CoC measure by examining its association with patient outcomes. We assessed reliability using signal-to-noise methodology.Results: Mean performance on the measure was 27.6%; performance ranged from 0% to 100% (n = 555,213 primary care physicians). Higher levels of CoC were associated with lower levels of care utilization. The measure indicated acceptable levels of validity and reliability.Conclusions: Continuity is associated with desirable health and cost outcomes as well as patient preference. The CoC clinical quality measure meets validity and reliability requirements for implementation in primary care payment and accountability. Care continuity is important and complementary to access to care, and prioritizing this measure could help shift physician and health system behavior to support continuity. [ABSTRACT FROM AUTHOR]

Objectives. We estimated how many deaths would be averted if the entire population of Virginia experienced the mortality rates of the 5 most affluent counties or cities. Methods. Using census data and vital statistics for the years 1990 through 2006, we applied the mortality rates of the 5 counties/cities with the highest median household income to the populations of all counties and cities in the state. Results. If the mortality rates of the reference population had applied to the entire state, 24.3% of deaths in Virginia from 1990 through 2006 (range=21.8%-28.1%) would not have occurred. An annual mean of 12954 deaths would have been averted (range=10548-14569), totaling 220211 deaths from 1990 through 2006. In some of the most disadvantaged areas of the state, nearly half of deaths would have been averted. Conclusions. Favorable conditions that exist in areas with high household incomes exert a major influence on mortality rates. The corollary--that health suffers when society is exposed to economic stresses--is especially timely amid the current recession. Further research must clarify the extent to which individual-level factors (e.g., earnings, education, race, health insurance) and community characteristics can improve health outcomes. (Am J Public Health. 2010;100:750-755. doi:10.2105/AJPH.2009.165142)

Objectives: Social determinants of health, such as inadequate education, contribute greatly to mortality rates. We examined whether correcting the social conditions that account for excess deaths among individuals with inadequate education might save more lives than medical advances (e.g., new drugss and devices). Methods. Using US vital statistics data fro 1996 through 2002, we applied indirect standardization techniques to estimate the maximum number of averted deaths attributable to medical advances and the number of deaths that would have been averted if mortality rates among adults with lesser education had been the same as those among college-educated adults. Results. Medical advances averted a maximum of 178 193 deaths during the study period. Correcting disparities in education-associated mortality rates would have saved 1 369 335 lives during the same period, a ratio of 8:1. Conclusions. Higher mortality rates among individuals with inadequate education reflect a complex causal pathway and the influence of confounding disparities, but the changes would save more lives than would society's current heavy investment in medical advances. Spending large sums of money on such advances at the expense of social change may be jeopardizing public health. (doi:10.2105/AJPH.2005.084848)

Pediatric workforce studies suggest that there may be a sufficient number of pediatricians for the current and projected US child population. These analyses do not fully consider the role of family medicine in the care of children. Family physicians provide 16% to 26% of visits for children, providing a medical home for one third of the child population, but face shrinking panels of children. Family medicine's role in children's health care is more stable in rural communities, for adolescents, and for underserved populations. For these populations, in particular, family medicine's role remains important. The erosion of the proportion of visits to family medicine is likely caused by the rapid rise in the number of pediatricians relative to a declining birth rate. Between 1981 and 2004, the general pediatrician population grew at 7 times the rate of the US population, and the family physician workforce grew at nearly 5 times the rate. The number of clinicians caring for children meets or exceeds most estimates of sufficiency; however, the workforce distribution is skewed, leaving certain populations and settings underserved. More than 5 million children and adolescents live in counties with no pediatrician. Unmet need, addressing health in the context of families and communities, and tackling "millennial morbidities" represent common ground for both specialties that could lead to specific, collaborative training, research, intervention, and advocacy. Key Words child health workforce, diversity, family medicine, geographic distribution, health manpower, nonphysician clinicians, physician workforce, pediatrics, pediatric medical subspecialists Abbreviations AAP--American Academy of Pediatrics FP--family physician NAMCS--National Ambulatory Medical Care Survey MEPS--Medical Expenditure Panel Survey GP--general practitioner FTE--full-time equivalent NP--nurse practitioner PA--physician assistant CHC--Community Health Center, INTEREST IN ENSURING a medical home for every child in the United States sparked recent assessments of the workforce that cares for children. This includes a series of thoughtful articles [...]

The U.S. lags behind other developed countries in the use of indices and novel reimbursement models to adjust for social determinants of health (SDH) in medicine. This may be due in part to the inadequate body of research regarding outcomes after implementation of healthcare payments designed to address SDH. This perspective article focuses on four models employed both internationally and domestically to outline the implementation, successes, limitations, and research needed to support national application of SDH models. A brief history of prior models is introduced as a primer to the current U.S. system. Internationally, the United Kingdom and New Zealand employ small area indices to adjust healthcare dollar allocation based on increased social need in an area. Despite published evidence of disparate health outcomes based on SDH, research is limited on the association of SDH indices, subsequent increased reimbursement, and improved healthcare equity. In the U.S., the Massachusetts Managed Care Organization assesses and addresses social needs within communities served by Medicaid. Unsurprisingly, there is evidence of overlap between those with worse health outcomes and those with high social need. However, implementation in Massachusetts is too recent to demonstrate reduced healthcare disparities. Within Minnesota, Hennepin Healthcare System initiated a novel Medicaid waiver that provides extended services to high-need patients under a partial capitation reimbursement program. These services, including increased access to primary care, have promising results in financial improvement of the system, but have not yet demonstrated patient-oriented outcomes. The association between high social risk and poor medical outcomes has been established globally; however, healthcare payment policies designed to respond to this relationship generally lack evidence of affecting outcomes. U.S. policymakers are demonstrating increasing interest in requiring capture of SDH in health care, creating accountability for addressing SDH, paying differentially for patients with increased social risk, or all three. In countries with a legacy of adjusting healthcare payments for social risk, more robust evaluation of associated effects could be helpful. Payers, states, or health systems making similar resource commitments should build in robust longitudinal evaluations of outcomes to inform evolution of their payment policies. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation. [ABSTRACT FROM AUTHOR]

Purpose: Continuity of care is a defining characteristic of primary care associated with lower costs and improved health equity and care quality. However, we lack provider-level measures of primary care continuity amenable to value-based payment, including the Medicare Quality Payment Program (QPP). We created 4 physician-level, claims-based continuity measures and tested their associations with health care expenditures and hospitalizations.Methods: We used Medicare claims data for 1,448,952 beneficiaries obtaining care from a nationally representative sample of 6,551 primary care physicians to calculate continuity scores by 4 established methods. Patient-level continuity scores attributed to a single physician were averaged to create physician-level scores. We used beneficiary multilevel models, including beneficiary controls, physician characteristics, and practice rurality to estimate associations with total Medicare Part A & B expenditures (allowed charges, logged), and any hospitalization.Results: Our continuity measures were highly correlated (correlation coefficients ranged from 0.86 to 0.99), with greater continuity associated with similar outcomes for each. Adjusted expenditures for beneficiaries cared for by physicians in the highest Bice-Boxerman continuity score quintile were 14.1% lower than for those in the lowest quintile ($8,092 vs $6,958; β = -0.151; 95% CI, -0.186 to -0.116), and the odds of hospitalization were 16.1% lower between the highest and lowest continuity quintiles (OR = 0.839; 95% CI, 0.787 to 0.893).Conclusions: All 4 continuity scores tested were significantly associated with lower total expenditures and hospitalization rates. Such indices are potentially useful as QPP measures, and may also serve as proxy resource-use measures, given the strength of association with lower costs and utilization. [ABSTRACT FROM AUTHOR]

Background: Determining a community's health care access needs and testing interventions to improve access are difficult. This challenge is compounded by the task of translating the relevant data into a format that is clear and persuasive to policymakers and funding agencies. Geographic information systems can analyze and transform complex data from various sources into maps that illustrate problems effortlessly for experts and nonexperts. Objective: To combine the patient data of a community health center (CHC) with health care survey data to display the CHC service area, the community's health care access needs, and relationships among access, poverty, and political boundaries. Design: Georeferencing, analyzing, and mapping information from 2 databases. Setting: Boone County, Missouri. Participants: Community health center patients and survey respondents. Main Outcome Measures: Maps that define the CHC service area and patient demographics and show poor health care access in relation to the CHC service area, CHC utilization in relation to poverty, and rates of health care access by geopolitical region. Results: The CHC serves a distinctly different area than originally targeted. Subpopulations with unmet health care access needs and poverty were identified by census tract. These underserved populations fell within geopolitical boundaries that were easily linked to their elected officials. Conclusions: Geographic information systems are powerful tools for combining disparate data in a visual format to illustrate complex relationships that affect health care access. These systems can help evaluate interventions, inform health services research, and guide health care policy. Arch Fam Med. 2000;9:971-978

The American Board of Family Medicine routinely surveys its Diplomates in each national graduating cohort 3 years out of training. These data were used to characterize early career family physicians whose services include management of pregnancy and prescribing buprenorphine. A total of 261 (5.1%) respondents both provide maternity care and prescribe buprenorphine. Family physicians who care for pregnant women and also prescribe buprenorphine represented 50.4% of all buprenorphine prescribers. The family physicians in this group were trained in a small number of residency programs, with only 15 programs producing at least 25% of graduates who do this work. [ABSTRACT FROM AUTHOR]

From the 2011 Medicare data, we identified 1,107,709 beneficiaries cared for by 2682 general internists and 3396 family physicians. Despite differences in training and practice, general internists share with family physicians associations between increasing comprehensiveness and lower Medicare beneficiary costs highlighting the importance of comprehensiveness in primary care regardless of the type of primary care physician providing the care. [Extracted from the article]

Purpose: Family physicians report some of the highest levels of burnout, but no published work has considered whether burnout is correlated with the broad scope of care that family physicians may provide. We examined the associations between family physician scope of practice and self-reported burnout.Methods: Secondary analysis of the 2016 National Family Medicine Graduate Survey respondents who provided outpatient continuity care (N = 1,617). We used bivariate analyses and logistic regression to compare self-report of burnout and measures of scope of practice including: inpatient medicine, obstetrics, pediatric ambulatory care, number of procedures and/or clinical content areas, and providing care outside the principal practice site.Results: Forty-two percent of respondents reported feeling burned out from their work once a week or more. In bivariate analysis, elements of scope of practice associated with lower burnout rates included providing more procedures/clinical content areas (mean procedures/clinical areas: 7.49 vs 7.02; P = .02) and working in more settings than the principal practice site (1+ additional settings: 57.6% vs 48.4%: P = .001); specifically in the hospital (31.4% vs 24.2%; P = .002) and patient homes (3.3% vs 1.5%; P = .02). In adjusted analysis, practice characteristics significantly associated with lower odds of burnout were practicing inpatient medicine (OR = 0.70; 95% CI, 0.56-0.87; P = .0017) and obstetrics (OR = 0.64; 95% CI, 0.47-0.88; P = .0058).Conclusions: Early career family physicians who provide a broader scope of practice, specifically, inpatient medicine, obstetrics, or home visits, reported significantly lower rates of burnout. Our findings suggest that comprehensiveness is associated with less burnout, which is critical in the context of improving access to good quality, affordable care while maintaining physician wellness. [ABSTRACT FROM AUTHOR]

Purpose: Medicare beneficiary spending patterns reflect those of the 306 Hospital Referral Regions where physicians train, but whether this holds true for smaller areas or for quality is uncertain. This study assesses whether cost and quality imprinting can be detected within the 3,436 Hospital Service Areas (HSAs), 82.4 percent of which have only 1 teaching hospital, and whether sponsoring institution characteristics are associated.Methods: We conducted a secondary, multi-level, multivariable analysis of 2011 Medicare claims and American Medical Association Masterfile data for a random, nationally representative sample of family physicians and general internists who completed residency between 1992 and 2010 and had more than 40 Medicare patients (3,075 physicians providing care to 503,109 beneficiaries). Practice and training locations were matched with Dartmouth Atlas HSAs and categorized into low-, average-, and high-cost spending groups. Practice and training HSAs were assessed for differences in 4 diabetes quality measures. Institutional characteristics included training volume and percentage of graduates in rural practice and primary care.Results: The unadjusted, annual, per-beneficiary spending difference between physicians trained in high- and low-cost HSAs was $1,644 (95% CI, $1,253-$2,034), and the difference remained significant after controlling for patient and physician characteristics. No significant relationship was found for diabetes quality measures. General internists were significantly more likely than family physicians to train in high-cost HSAs. Institutions with more graduates in rural practice and primary care produced lower-spending physicians.Conclusions: The "imprint" of training spending patterns on physicians is strong and enduring, without discernible quality effects, and, along with identified institutional features, supports measures and policy options for improved graduate medical education outcomes. [ABSTRACT FROM AUTHOR]

Importance: Narrowing of the scope of practice of US family physicians has been well documented. Proposed reasons include changing practice patterns as physicians age, employer restrictions, or generational choices. Determining components of care that remain integral to the practice of family medicine may be informed by assessing gaps between the intended scope of practice of residents and actual scope of practice of family physicians.Objective: To compare intended scope of practice for American Board of Family Medicine (ABFM) initial certifiers at residency completion with self-reported actual scope of practice of recertifying family physicians.Design and Participants: Cross-sectional data were collected from a practice demographic questionnaire completed by all individuals applying to take the ABFM Maintenance of Certification for Family Physicians examination. Initial certifiers reported intentions and recertifiers reported actual provision of specific clinical activities. All physicians who registered for the 2014 ABFM Maintenance of Certification for Family Physicians examination were included: 3038 initial certifiers and 10,846 recertifiers.Exposures: Initially certifying physicians vs recertifying physicians.Main Outcomes and Measures: The Scope of Practice for Primary Care score (scope score), a psychometric scale, was calculated for each physician and ranged from 0 to 30, with higher numbers equating to broader scope of practice. Recertifiers were categorized by decades in practice.Results: The final sample included 13,884 family physicians and, because the questionnaire was a required component of the examination application, there was a 100% response rate. Mean scope score was significantly higher for initial certifier intended practice compared with recertifying physicians' reported actual practices (17.7 vs 15.5; difference, 2.2 [95% CI, 2.1-2.3]; P < .001). Compared with recertifiers, initial certifiers were more likely to report intending to provide all clinical services asked except pain management; this included obstetric care (23.7% vs 7.7%; difference, 16.0% [95% CI, 14.4%-17.6%]; P < .001), inpatient care (54.9% vs 33.5%; difference, 21.4% [95% CI, 19.4%-23.4%]; P < .001), and prenatal care (50.2% vs 9.9%; difference, 40.3 [95% CI, 38.5%-42.2%]; P < .001). Similar differences from initial certifiers were present when comparisons were limited to recertifiers in practice for only 1 to 10 years.Conclusions and Relevance: In this study of family physicians taking ABFM examinations, graduating family medicine residents reported an intention to provide a broader scope of practice than that reported by current practitioners. This pattern suggests that these differences are not generational, but whether they are due to limited practice support, employer constraints, or other causes remains to be determined. [ABSTRACT FROM AUTHOR]

Background and Objectives: Health information technology (health IT) and health technology, more broadly, offer tremendous promise for connecting, synthesizing, and sharing information critical to improving health care delivery, reducing health system costs, and achieving personal and community health. While efforts to spur adoption of electronic health records (EHRs) among US practices and hospitals have been highly successful, aspirations for effective data exchanges and translation of data into measureable improvements in health outcomes remain largely unrealized. There are shining examples of health enhancement through new technologies, and the discipline of family medicine is well poised to take advantage of these innovations to improve patient and population health. The Future of Family Medicine led to important family medicine health IT initiatives over the past decade. For example, the American Academy of Family Physicians (AAFP) Center for Health Information Technology and the Robert Graham Center provided important leadership for informing health IT policy and standard-setting, such as the Centers for Medicare and Medicaid Services EHR incentives programs (often referred to as "meaningful use."). As we move forward, there is a need for a new and more comprehensive family medicine strategy for technology. To inform the Family Medicine for America's Health (FMAHealth) initiative, this paper explores strategies and tactics that family medicine could pursue to improve the utility of technology for primary care and to help primary care become a leader in rapid development, testing, and implementation of new technologies. These strategies were also designed with a broader stakeholder audience in mind, intending to reach beyond the work being done by FMAHealth. Specific suggestions include: a shared primary care health IT center, meaningful primary care quality measures and capacity to assess/report them, increased primary care technology research, a national family medicine registry, enhancement of family physicians' technology leadership, and championing patient-centered technology functionality. [ABSTRACT FROM AUTHOR]

Background and Objectives: Between August 2013 and April 2014, eight family medicine organizations convened to develop a strategic plan and communication strategy for how our discipline might partner with patients and communities to build a new foundation for American health care. An outline of this initiative, Family Medicine for America's Health (FMAHealth), was formally announced to the public in October 2014. The purpose of this paper and the five papers to follow is to describe the guiding principles of FMAHealth in greater detail. FMAHealth is taking place at a pivotal point in the history of American health care, when the deficiencies of our overly expensive, underperforming health care delivery system are becoming more apparent than ever. By forming strategic partnerships to implement this initiative, family medicine seeks to define a new approach to health system leadership, care delivery, education, and research. This will require substantial reorientation of existing priorities and reimbursement systems, which are focused on delivering services, instead of on improving health. Family medicine is committed to engaging and empowering patients, their families and communities, and other health care professionals to establish a more equitable, effective, and efficient delivery system--a system in which health is the primary design element and the "Triple Aim" is the guiding principle. [ABSTRACT FROM AUTHOR]

This Viewpoint discusses a 2021 National Academies of Sciences, Engineering, and Medicine consensus report proposing patient-centered principles and recommendations to strengthen primary care services and systems, including payment and information technology reform and dedicated funding for primary care research. [ABSTRACT FROM AUTHOR]

As the U.S. health care delivery system undergoes rapid transformation, there is an urgent need to define a comprehensive, evidence-based role for the family physician. A Role Definition Group made up of members of seven family medicine organizations developed a statement defining the family physician's role in meeting the needs of individuals, the health care system, and the country. The Role Definition Group surveyed more than 50 years of foundational manuscripts including published works from the Future of Family Medicine project and Keystone III conference, external reviews, and a recent Accreditation Council on Graduate Medical Education Family Medicine Milestones definition. They developed candidate definitions and a "foil" definition of what family medicine could become without change. The following definition was selected: "Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health." This definition will guide the second Future of Family Medicine project and provide direction as family physicians, academicians, clinical networks, and policy-makers negotiate roles in the evolving health system. [ABSTRACT FROM AUTHOR]

Health care reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians. Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training. Title VII, Section 747 of the Public Health Service Act previously supported the growth of the health care workforce but has been severely cut over the past 2 decades. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and ultimately to improve the responsiveness of teaching hospitals to community needs. To accomplish these goals, Congress should act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section 747 with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk. [ABSTRACT FROM AUTHOR]

Objective: To use the ecology model of health care to contrast participation of black, non-Hispanics (blacks); white, non-Hispanics (whites); and Hispanics of any race (Hispanics) in 5 health care settings and determine whether disparities between those individuals exist among places where they receive care.Design: 1996 Medical Expenditure Panel Survey data were used to estimate the number of black, white, and Hispanic people per 1,000 receiving health care in each setting.Setting: Physicians' offices, outpatient clinics, hospital emergency departments, hospitals, and people's homes.Main Measurement: Number of people per 1,000 per month who had at least one contact in a health care setting.Results: Fewer blacks and Hispanics than whites received care in physicians' offices (154 vs 155 vs 244 per 1,000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1,000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than blacks or whites received home health care services (7 vs 14 vs 14 per 1,000 per month, respectively). After controlling for 7 variables, blacks and Hispanics were less likely than whites to receive care in physicians' offices (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.60 to 0.69 for blacks and OR, 0.79, 95% CI, 0.73 to 0.85 for Hispanics), outpatient clinics (OR, 0.73, 95% CI, 0.60 to 0.90 for blacks and OR, 0.71, 95% CI, 0.58 to 0.88 for Hispanics), and hospital emergency departments (OR, 0.80, 95% CI, 0.69 to 0.94 for blacks and OR, 0.80, 95% CI, 0.68 to 0.93 for Hispanics) in a typical month. The groups did not differ in the likelihood of receiving care in the hospital or at home.Conclusions: Fewer blacks and Hispanics than whites received health care in physicians' offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health. [ABSTRACT FROM AUTHOR]