Kids' visits shifting farther away from family physicians
■ Changing demographics and financial concerns might explain the increase for pediatricians.
By Damon Adams — Posted Feb. 9, 2004
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The percentage of children seeing pediatricians for office visits has increased while the proportion going to family physicians has decreased, a new analysis shows.
From 1990 to 2000, the percentage of nonsurgical office visits to general pediatricians by children through age 17 rose from 56.2% to 64.2%, according to a study in the January Archives of Pediatrics & Adolescent Medicine. During the same period, office visits for children to family physicians dropped from 33.7% to 23.9%.
The amount of primary care office visits by children to pediatricians accelerated during the late-1990s, furthering the shift in who is providing health care for the nation's children.
"The distribution is changing. This is one of the [signs] of a trend that should concern us all," said Michael Fleming, MD, president of the American Academy of Family Physicians.
For their study, researchers wanted to determine if there had been changes in the proportion of office visits for children from birth to age 17 to pediatricians and family physicians from 1980 to 2000. Using the National Ambulatory Medical Care Survey, they analyzed visits by physician type and patient age.
They said the proportion of office visits by children was relatively stable during the 1980s, but there were marked changes in the 1990s.
From 1980 to 2000, pediatricians gained a bigger portion of office visits by children through age 10. In 1980, a larger percentage of children ages 11 to 17 saw family physicians (51%) than pediatricians (26.3%). But by 2000, 40.4% of visits in that age group were to family physicians while 37.4% were to pediatricians.
Researchers said the changes occurred despite a small increase in the number of pediatricians.
Meanwhile, during the 20 years studied, pediatric specialists gained a bigger chunk of child office visits (1.6% in 1980 to 4.5% in 2000).
Less obstetrical care might play a role
The study said possible reasons for the shift in care were demographics and finances.
It said family physicians have a financial incentive to care for older patients with private insurance and Medicare rather than caring for younger patients with Medicaid, which has low reimbursement rates.
The study also said an aging population, longer life expectancy and a relatively stable birth rate mean that children make up a smaller proportion of the patient base for doctors who see patients across the lifespan. Caring for the aging population could mean crowding out children at family physician practices.
"It could be that fewer family physicians are providing obstetric care, therefore, there are fewer infants entering family practice," said study lead author Gary L. Freed, MD, MPH, director of general pediatrics at the University of Michigan Medical School in Ann Arbor.
Dr. Fleming said some family physicians had dropped obstetrical care in recent years because of higher medical liability insurance rates.
Christopher B. Forrest, MD, PhD, agrees that demographics might help explain the shift.
"Family physicians are seeing more adults, so the pediatricians may be picking up more child visits," said Dr. Forrest, who wrote an editorial on the study in the same Archives issue and is associate professor in health policy and pediatrics at Johns Hopkins University in Baltimore.
The American Academy of Pediatrics said there would be enough pediatricians to meet the demand.
"The supply of pediatricians is growing much faster than the population of children," said David Goodman, MD, member of the AAP's Committee on Pediatric Workforce .
But Dr. Fleming said the AAFP was concerned about a possible shortage of family physicians and what that could mean to the treatment of child patients. "We really need to do some work in improving student interest in family medicine. There is a lower number of students choosing family medicine. That's very worrisome concerning the continued care of children."