Linkage between the Israeli Defense Forces Primary Care Physician Demographics and Usage of Secondary Medical Services and Laboratory Tests

MILITARY MEDICINE, 170, 10:836, 2005 Linkage between the Israeli Defense Forces Primary Care Physician Demographics and Usage of Secondary Medical Services and Laboratory Tests Guarantor: LTC Ilan Levy, IDF Contributors: LTC Ilan Levy, IDF; COL Avishay Goldberg, IDF (Ret.); LTC Shlomo Vinker, IDF; Shifra Shvarts, PhD Background: The primary care physicians in the Israeli Defense Forces, as in the Israeli civilian health system, have two major subpopulations. Graduates of Israeli schools of medicine, and graduates of foreign medical schools, most of them in Eastern Europe. Objective: To evaluate differences in the referral patterns of primary care physicians according to their graduation institution and demographic characteristics. Methods: The study took place in one primary care practice in central Israel. The referrals to consultations and laboratory tests over a period of 1 year were evaluated. Physicians that had less than 37 encounters were excluded from the study. Data were extracted from the central computerized databases of the Medical Corps and Israeli Defense Forces. Results: Sixty-eight physicians had a total of 18,402 encounters that resulted in 23,845 outcomes. There were no associations between demographic and training backgrounds of the physicians and their actual referral rates to consultations and laboratory tests. Conclusion: The background data of the primary care physicians does not predict their referral patterns and their role as gate keepers. Introduction he Medical Corps (MC) of the Israeli Defense Forces (IDF) is T responsible for the medical care of IDF regular service soldiers and on-duty reserve forces. 1 Medical treatment is given in conjunction with the civilian health system. In recent years, cost containment became an important issue in the military health system throughout the entire Western world. The Israeli national health insurance law of 1994 2 had reinforced the previous perception of the IDF s obligation for the health of its soldiers. This obligation is required because the military prohibits regular service soldiers from obtaining private medical treatment. The regular service milieu is different from the civilian milieu due to the relatively young (ages 18 21 years) and healthy population, as well as the intense and often dangerous activities that the soldiers participate in. Regular service is obligatory in Israel but there are almost no chronically ill recruits. The regular service officers and the reserve forces are older (ages 22 50 years) and usually have health problems that are similar to those of civilians. The Israeli soldiers, especially the conscripted, *Healthcare Management, Ben-Gurion University of the Negev, Bear Sheva, Israel. Faculty of Health Sciences & School of Management, Ben-Gurion University of the Negev, Bear Sheva, Israel. Surgeon General of the Israel Navy, IDF Medical Corps, Tel Aviv, Israel. Faculty of Health Sciences & School of Management, Ben-Gurion University of the Negev, Bear Sheva, Israel. This manuscript was received for review in November 2003. The revised manuscript was accepted for publication in August 2004. Reprint & Copyright by Association of Military Surgeons of U.S., 2005. regular servicemen have a very high rate of health care resources utilization, much higher then their civilian counterparts. 3 6 The MC is responsible for the health services in three levels: primary care, secondary care given by subspecialists, and tertiary (in hospital) care. The primary care is given by in-unit practices; for smaller units there are regional primary care practices. Soldiers on vacation can get first aid in special primary care practices close to their residence. This primary care network facilitates high availability of health care services. 7,8 The secondary care is given in multidisciplinary military medical centers, both frontal and home front and by hospital ambulatory services. The tertiary care is given in civilian hospitals, the military recovery center, and military sick rooms both in-unit and regional ones. Primary Care Service Primary care in the IDF is given exclusively by the MC. The MC is comprised of physician officers, nurses, and other paramedical staff, using military facilities and working under IDF and MC regulations. Medical officers have a diverse demographic and professional background. Most Israeli physicians (71%) graduated from foreign medical schools. 6 Graduates from western countries as well as Eastern Europe, Latin America, and other countries comprise a wide range of qualifications and attitudes. In general, the MC personnel of physicians can be categorized to six main groups: 9 1. Regular service medical officers: They are graduates of Israeli medical schools and are drafted for 4 to 5 years after graduation. This group is highly motivated and qualified but lack medical experience. They usually serve in front units and have both medical as well as administrative and command tasks. After 1 to 2 years, they become higher level medical officers, but they still lack medical experience and they are not supervisors or consultants of the younger medical officers. The medical officers have dual loyalty, to their commanders and to their patients. In recent years, another subgroup of regular service physicians has been formed. These are new immigrants to Israel, some of whom are more experienced. 2. Career service medical officers: These are more experienced physicians, qualified in a wide range of specialties and subspecialties. They are the medical officer commanders of large primary care clinics and other medical facilities. 3. Reservist physicians: They serve as primary care physicians or as consultants for a period of approximately 20 to 836

Physician Demographics and Medical Services Use 30 days each year. These physicians have more clinical experience; most of them serve for many years and are familiar with the military milieu, although somewhat exhausted. 4. Civilian physicians under special contract with the army: These are mostly primary care physicians (65%) serving in frontal units and home front units. Others serve as consultants in the military specialists centers. 5. Nurses and medical assistants: These individuals are in regular service and in the reserve force. 6. Other medical staff: The individuals are administrators, clerks, and others. According to the MC regulations, there is only minimal direct access to specialists and one of the tasks of the primary care physician is to serve as a gatekeeper. 10 The primary care physician is expected to check the necessity of the referral or the requested tests and to restrict those found unnecessary. There are some scenarios in which referrals are obligatory, but this is not the rule. New regulations established priorities in the referral policy and the physicians are asked to make the military consultation centers their preference. The referrals to in-hospital civilian consultations had been limited to emergency room attendance to follow-up hospitalizations and subspecialties that are either not available or limited in the MC centers. There is a special contract between the Defense Ministry and these hospitals that is called the contract of combining. 11 13 The regular service soldiers have a full insurance policy as does the civilian population in Israel. The MC is an equivalent of a Health Maintenance Organization (HMO). The HMO participates in the health services with its own personnel and facilities and by buying other services on fee for service or fee per case formats. The primary care physician may play a roll in health care cost containment, especially when regulation of referrals and physician empowerment are used. 9,14 17 In other western armies the primary care physicians are expected to be gatekeepers. In the U.S. army, the physicians are instructed to refer patients to in-military health care facilities as a part of cost containment. 18 20 In the Negev district of the Clalit Health Services, we found that physicians trained in Eastern Europe tended to use referrals and laboratory tests more than their counterparts with Israeli training. 21 We hypothesize that the country of training, professional status, and other demographic data affect the referral rates and the role of the physician as a gatekeeper. The aim of this study was to evaluate the association among background data, professional status, and referral rates. Methods Data Sources Data were retrieved from the computerized database of the MC 22 and through telephone interviews with the physicians. Data that were retrieved are as follows: physicians workload (number of encounters per month); encounter outcomes (referral rate: referrals to consultants, emergency room, hospitalization in military sick rooms, and laboratory and imaging tests [per 100 encounters]); encounter outcomes (return to service, sick leaves, and exemption of reservist soldiers from active service); personal data (age, gender, country of birth, origin [father s country of birth], socioeconomic data, country where graduation occurred, country where specialization professional status is current, military service status, place of residence, etc.). Countries that train have been divided into the western countries as compared with third world and eastern European countries Study Population This study was undertaken in one large home-front primary care clinic. In this clinic, there were 18,763 encounters made by 102 physicians in the study year. Physicians that had less than 37 encounters were excluded from the study. Sixty-eight physicians (each of them had at least 37 encounters) had a total of 18,402 enconters. A referral from any kind at the end of each encounter has been defined as an endpoint with referral. These referrals included consultation with a specialist, consultation in an emergency room, referral to a military health status committee, and laboratory analysis. Other endpoints were: allowing a sick leave, discharging reserve force soldiers from active duty, and a referral to a military hospitalization room. Statistical Analysis We used descriptive statistics for the dependent and independent variables. We analyzed the association between personal data and encounter outcomes. Results 837 The study included 18,402 encounters made by 68 military physicians. This resulted in 23,845 encounter outcomes. The encounters resulted in 4,589 referrals to a specialist, 1,033 referrals to the emergency room, and 195 transfers to a military hospitalization room. Laboratory analysis was recommended in 822 cases. Sick leave was allowed in 2,952 encounters, and in another 299 encounters reservist soldiers were discharged from active duty. The association between the physician s gender and referral rates are listed in Table I. Results show that male physicians made 1.4% more specialist referrals; male physicians sent back to duty, without a referral or a sick leave, 4.85% more soldiers; and female physicians admitted 1.4% more individuals to the military hospitalization room. These differences did not reach statistical significance. The association between the physician s residence and referral rates are shown in Table II. The results revealed that urban habitant physicians sent 1.26% more laboratory tests; urban habitant physicians sent back to duty, without a referral or a sick leave, 4.76% more soldiers; rural habitant physicians approved 2.39% more sick leaves; and rural habitant physicians sent 1.84% more patients to the emergency room. These differences Table III illustrates the association between the physician s socioeconomic level and referral rates. There was no significant association between the socioeconomic level and the referral rates. Table IV provides the results of the association between the

838 Physician Demographics and Medical Services Use TABLE I RESULTS ACCORDING TO THE PHYSICIAN S GENDER Physician s Gender Male Female Specialist committee 63 0.17 0.42 5 0.22 0.23 68 0.17 0.40 Specialist physician 63 22.34 12.17 5 20.90 14.13 68 22.23 12.21 Laboratory 63 3.16 2.52 5 4.02 2.84 68 3.23 2.53 Canceled Reserve Duty 63 1.69 1.55 5 1.66 0.84 68 1.69 1.50 Hospitalization room 63 0.87 1.42 5 2.26 2.89 68 0.97 1.58 Emergency room 63 5.08 4.96 5 8.46 3.67 68 5.33 4.93 Sick leave 63 17.58 8.95 5 17.68 8.58 68 17.59 8.86 Back to duty 63 74.79 13.16 5 69.94 8.91 68 74.43 12.90 TABLE II RESULTS ACCORDING TO THE PHYSICIAN S RESIDENCE Physician s Residence Countryside City Specialist committee 14 0.17 0.39 54 0.17 0.41 68 0.17 0.40 Specialist physician 14 21.87 13.03 54 22.32 12.12 68 22.23 12.21 Laboratory 14 2.23 1.74 54 3.49 2.65 68 3.23 2.53 Canceled Reserve Duty 14 1.76 1.65 54 1.66 1.48 68 1.69 1.50 Hospitalization room 14 1.30 2.40 54 0.89 1.31 68 0.97 1.58 Emergency room 14 6.79 8.67 54 4.95 3.41 68 5.33 4.93 Sick leave 14 19.49 10.51 54 17.10 8.42 68 17.59 8.86 Back to duty 14 70.65 19.33 54 75.41 10.68 68 74.43 12.90 TABLE III RESULTS ACCORDING TO THE PHYSICIAN S RESIDENCY SOCIOECONOMIC LEVEL Physician Residency Socioeconomic Level Western Eastern Specialist committee 37 0.1 0.2 31 0.2 0.5 68 0.17 0.40 Specialist physician 37 22.4 9.4 31 22.0 15.0 68 22.23 12.21 Laboratory 37 3.5 2.3 31 2.9 2.8 68 3.23 2.53 Canceled Reserve Duty 37 1.7 1.5 31 1.6 1.5 68 1.69 1.50 Hospitalization room 37 1.1 1.8 31 0.8 1.3 68 0.97 1.58 Emergency room 37 5.1 4.6 31 5.6 5.3 68 5.33 4.93 Sick leave 37 17.3 8.1 31 17.9 9.8 68 17.59 8.86 Back to duty 37 74.8 12.2 31 74.0 13.8 68 74.43 12.90 physician s country of birth and referral rates. It was determined that immigrant physicians made 5.81% more specialist referrals and that physicians born in Israel sent back to duty, without a referral or a sick leave, 1.6% more soldiers. The differences The association between the physician s country of origin and referral rates is listed in Table V. We found that physicians originating from Eastern (low-income) countries made 2.69% more specialist referrals, and physicians originating from Eastern (low-income) countries ordered 1.17% more laboratory tests. Physicians originating from Eastern (low-income) countries sent back to duty, without a referral or a sick leave, 4.81% more soldiers, and those originating from Western (high-income) countries gave 2.69% fewer sick leaves. These differences The association between the physician s country of training and referral rates is depicted in Table VI. Physicians graduating from Eastern (low-income) countries made 4.84% more specialist referrals, and those graduating from Eastern (low-income) countries made 1.13% more emergency room referrals. Physicians graduating from Eastern (low-income) countries allowed 1.42% more sick leaves, and those graduating from Western (high-income) countries sent back to duty, without a referral or a sick leave, 1.94% more soldiers. These differences did not reach statistical significance. Table VII depicts the association between the physician s

Physician Demographics and Medical Services Use 839 TABLE IV RESULTS ACCORDING TO THE PHYSICIAN S COUNTRY OF BIRTH Physician s Country of Birth Western Country Eastern Country Specialist committee 35 0.11 0.22 33 0.24 0.53 68 0.17 0.40 Specialist physician 35 19.41 11.01 33 25.22 12.87 68 22.23 12.21 Laboratory 35 3.22 2.36 33 3.23 2.74 68 3.23 2.53 Canceled Reserve Duty 35 1.47 1.55 33 1.92 1.43 68 1.69 1.50 Hospitalization room 35 1.19 2.02 33 0.75 0.91 68 0.97 1.58 Emergency room 35 4.92 4.94 33 5.75 4.96 68 5.33 4.93 Sick leave 35 17.23 8.49 33 17.97 9.35 68 17.59 8.86 Back to duty 35 75.21 13.07 33 73.61 12.88 68 74.43 12.90 TABLE V RESULTS ACCORDING TO THE PHYSICIAN S ORIGIN Physician s Origin Unknown Western Country Eastern Country N Mean SD Specialist committee 5 0.22 0.49 9 0.21 0.33 54 0.16 0.41 68 0.17 0.40 Specialist physician 5 19.34 17.10 9 25.06 10.82 54 22.03 12.11 68 22.23 12.21 Laboratory 5 2.12 1.95 9 3.44 2.11 54 3.29 2.65 68 3.23 2.53 Canceled Reserve Duty 5 1.72 1.12 9 2.39 1.92 54 1.56 1.45 68 1.69 1.50 Hospitalization room 5 0.90 1.32 9 1.74 2.22 54 0.85 1.47 68 0.97 1.58 Emergency room 5 6.00 3.58 9 5.07 2.11 54 5.31 5.39 68 5.33 4.93 Sick leave 5 21.16 5.82 9 17.7 7.54 54 17.24 9.31 68 17.59 8.86 Back to duty 5 70.22 4.89 9 73.14 8.99 54 75.03 13.93 68 74.43 12.90 TABLE VI RESULTS ACCORDING TO THE PHYSICIAN S COUNTRY OF TRAINING Country of Training (Medicine) Western Country Eastern Country Specialist committee 48 0.11 0.21 20 0.33 0.66 68 0.17 0.40 Specialist physician 48 20.81 11.24 20 25.65 14.00 68 22.23 12.21 Laboratory 48 3.49 2.39 20 2.60 2.81 68 3.23 2.53 Canceled Reserve Duty 48 1.72 1.50 20 1.61 1.53 68 1.69 1.50 Hospitalization room 48 1.12 1.79 20 0.62 0.85 68 0.97 1.58 Emergency room 48 4.99 4.52 20 6.12 5.85 68 5.33 4.93 Sick leave 48 17.17 7.90 20 18.59 10.99 68 17.59 8.86 Back to duty 48 75.00 11.63 20 73.06 15.81 68 74.43 12.90 country of specialization and referral rates. There were only two physicians that graduated from specialization programs in foreign countries and we could not analyze the effect of this parameter. There was no significant association between the country of specialization and the referral rates. The association between the military service status and referral rates is shown in Table VIII. Reserve forces physicians made 5.59% more specialist referrals in comparison to regular service physicians. Regular service physicians sent back to duty, without a referral or a sick leave, 4.75% more soldiers in comparison to the reserve force physicians, and reserve force physicians allowed 4.92% more sick leaves in comparison to regular service physicians. Civilian physicians under special contract with the army made 2.58% more specialist referrals in comparison to regular service physicians, and civilian physicians under special contract with the army gave permission for 10.07% more sick leaves in comparison to regular service physicians. Regular service physicians sent back to duty, without a referral or a sick leave, 12.04% more soldiers in comparison to civilian physicians under special contract with the army. Discussion A previous study demonstrated differences in referral rates that were associated with the sociodemographic data of physicians. 18 This study was done in a civilian population in southern Israel. In a military setting this difference was not confirmed. 22 In the present study, we did not demonstrate that there is any

840 Physician Demographics and Medical Services Use TABLE VII RESULTS ACCORDING TO THE PHYSICIAN S COUNTRY OF SPECIALIZATION Physician s Country of Main Specialization Unknown Western Country Eastern Country N Mean SD Specialist committee 28 0.13 0.23 38 0.14 0.31 2 1.30 1.84 68 0.17 0.40 Specialist physician 28 21.09 12.46 38 23.24 12.42 2 19.10 0.99 68 22.23 12.21 Laboratory 28 3.43 2.55 38 3.00 2.57 2 4.75 1.20 68 3.23 2.53 Canceled Reserve Duty 28 1.81 1.68 38 1.54 1.37 2 2.75 1.63 68 1.69 1.50 Hospitalization room 28 1.59 2.19 38 0.57 0.74 2 0.00 0.00 68 0.97 1.58 Emergency room 28 6.64 6.29 38 4.33 3.58 2 5.80 0.71 68 5.33 4.93 Sick leave 28 19.22 9.42 38 15.98 8.32 2 25.35 2.33 68 17.59 8.86 Back to duty 28 70.74 14.90 38 77.58 10.74 2 66.10 1.41 68 74.43 12.90 TABLE VIII RESULTS ACCORDING TO THE PHYSICIAN S MILITARY SERVICE STATUS association between the background data of country of training and specialization. Referral rates were not associated with the military service status of the physician as well. The different findings in the military setting could be explained in light of the regulations in the MC. There are clinical guidelines and the Surgeon General regulations that result in a limited flexibility of the clinical decision-making process. On the other hand, there are large and comprehensive health services that gives the Israeli soldiers balanced and high-level health care. 23 mcin conclusion, a prejudice existing among the MC policy makers maintains that the sociodemographic and professional status of the primary care physician has an impact on the referral rates. In this study, we have constructed a model that integrated eight outcomes of the encounter and none of them was found to be associated with the physician s background. 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