Medically underserved areas: are primary care teams efficient at attracting and retaining general practitioners?

Highlights

• The geographical imbalances of General Practitioners (GPs) may affect their access.

• Evaluate the impact of policies aiming at reducing these imbalances is required.

• We estimates the impact of Primary Care Teams (PCTs) settlements on GPs density.

• Results show that PCT settlements are attractive especially for young GPs.

• The magnitude of the effects are larger in medically underserved areas.

Abstract

The geographical imbalances of General Practitioners (GPs) may affect their accessibility for populations, especially in medically underserved areas. We investigate the effect of the dramatic and recent diffusion of Primary Care Teams (PCTs), especially in medically underserved areas, in order to attract and retain GPs through an improvement of their working conditions. We analyze the evolution of GPs and young GPs density between 2004 and 2017 according to a spatial taxonomy of French living areas in 6 clusters. Based on a quasi-experimental design comparing living areas, depending on the clusters, with PCTs (treated) and without PCTs (control), we used difference-in-differences models to estimate the impact of PCT new settlements on the evolution of both attraction and retention of GPs. Our results show that PCT settlements are efficient to attract young GPs and that the magnitude of the effects depends on the living area clusters. Results call for specific policies to address geographical inequalities of GPs that consider the type of place and also, in France, for new measures to attract and retain GPs in rural fringes.

Introduction

Access to healthcare is a major issue for both territorial cohesion and public health issues for two main reasons. First, according to the World Health Organization, health care service accessibility and utilization are two factors of population health status, including the physical, social and economic environment and a person's individual characteristics (income, social status, education, genetics, sex) and behaviors (Ono, 2014). Primary health care (PHC), which is delivered by different categories of health care professionals and organizations, supposedly provides accessibility, continuity, comprehensiveness, coordination and orientation and, as a consequence, is considered to be a pillar for improving accessibility and reducing health inequalities (Guagliardo, 2004; Barsanti et al., 2017). Second, the health care supply is a key dimension for territorial economic development and the sustainability of local communities (McGrail et al., 2011, 2017; Farmer et al., 2012). There are close interrelationships between spatial attractiveness and health professional and/or population locations. For instance, environmental amenities and/or quality of life (e.g., climate, equipment, distance to cities) influence the decision of the population and health professionals to settle in certain areas (McGrail et al., 2011, 2017, 2017; Chevillard and Mousquès, 2018). On the other hand, demographic dynamics can influence health professionals' locations (Chevillard et al., 2016).

That being said, health care access depends on several dimensions, as defined by Penchansky and Thomas (1981): availability of health human resources (HHR), geographical accessibility, accommodation, affordability and acceptability. All things considered, the unequal geographical distribution of HHR (Ryvicker, 2017), especially in primary care, is a major issue because it directly affects the following components of access: availability and spatial accessibility. Indeed, all countries, regardless of their type of health care system or welfare state (Reibling et al., 2019), face geographical imbalances of HHRs in terms of specialized and/or primary health care of varying intensities (Ono et al., 2014; Mbemba et al., 2016; Asghari et al., 2020). This leads to a local shortage of HHRs, defining so-called medically underserved areas (MUAs) that are often associated with rural areas; however, deprived urban areas may also be underserved. This situation will probably continue to increase considering the future increase in the needs of doctors following recent OECD projections (Scheffler and Arnold, 2019). It is also well documented that health care professionals, notably general practitioners (GPs) practicing in MUAs, have heavy workloads (Weeks and Wallace, 2008; McGrail et al., 2012; Morken et al., 2019), which can be detrimental to job satisfaction (Marchand and Peckham, 2017) and the quality of care delivered (Whalley et al., 2008; Basu et al., 2017; Silhol et al., 2019).

It is now well known that the reduction of geographical imbalances cannot be solved only by increasing the number of newly graduated doctors (Sousa et al., 2013; Ono et al., 2014; Asghari et al., 2020). It disregards the specific and independent relationship between supply and demand in health care, as well as other key factors influencing new entries into the physician labor market, their installation and retention in specific places, as well as the relative productive efficiency depending on their type of practice. Several types of measures have been implemented to attract and retain doctors in MUAs (Ono et al., 2014; Sousa et al., 2013). Among them, we focus here on a specific health care services delivery reorientation policy aiming to support the development of primary care teams (PCTs) in France, notably in MUAs, in contrast to solo and monodisciplinary practices.

PCTs are multiprofessional group practices with at least two GPs and one paramedic, delivering primary care and services based on cooperation and coordination. It is expected that PCTs simultaneously lead to improvements in health care professionals’ working conditions, quality, and efficiency gains in the delivery of care and services (i.e., do more and better with fewer doctors). Some research shows that medical students or young GPs prefer practicing in group practice in France, Canada, Germany and Switzerland (Buddeberg-Fischer et al., 2008; Hartmannbund, 2012; Saarma et al., 2012; Chaput et al., 2020). Thus, group practice could be more attractive for young doctors and result in better retention for practicing GPs. Thus, it is expected that PCT locations in MUAs could increase the number of doctors practicing in those areas. By comparing MUAs with and without PCTs, we examine here whether the French policy that supports PCT development in specific locations is effective in attracting and retaining GPs and young GPs in French MUAs.

The remainder of this paper is organized as follows. Section 2 presents the health policy background, empirical evidence and French context. Section 3 describes our data and our design to characterize places, identifies control groups and estimates the impacts. Section 4 presents the main results and robustness checks. Finally, Section 5 discusses the main results, policy relevance and conclusions.