Rural residence and migration for specialty physician care

This article describes why rural residents migrate or travel outside their local market area for specialty physician care. Data were collected through a random mail survey of persons residing in Iowa's rural counties. The results imply that migration for specialty care is not simply a function of a low perceived availability of local specialty physicians. Managers of rural and urban health care systems may need to rethink the extent to which specialty physician services should be distributed across rural markets.     

Why Rural Residents Migrate for Family Physician Care

Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy-makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.     

Effect of Primary Care Visits on the Demand for Specialty Care in Health Maintenance Organizations

Health maintenance organizations (HMOs) provide low cost access to primary care physicians (PCPs) in an effort to restrict expensive specialty use. Although managed care plans hope that low cost primary care will reduce specialist use, the theoretical effect of easing access to primary care on specialty use is unclear. Despite the importance of estimating the effect of PCP visits on specialty use, no previous studies have directly addressed this question at the enrollee level. This study examines the effect of visits to the PCP on the demand for episodes of specialty care in two health plans: a gatekeeper HMO and a point-of-service plan. Using person-level data, we estimate a generalized method of moments model of specialty episodes that accounts for the endogeneity of PCP visits within a count-data framework. We compare this model to three alternative models—an OLS model, a negative binomial model, and a two-stage least squares model. We find evidence that increases in primary care visits increase episodes of specialty care in both plans. We also find that the three alternative models yield biased but more efficient estimates compared to the generalized method of moments model.This revised version was published online in June 2005 with a corrected cover date.     

US physicians' perceptions of the effect of practice guidelines and ability to provide high-quality care

OBJECTIVES: In the USA, health care organizations frequently disseminate practice guidelines to physicians, but physicians often resist implementing guidelines when they perceive no improvements in quality of care will result. Greater involvement with a single health care organization may a inverted exclamation market physicians' perceptions of guidelines. We examined the relationship between the perceived effect of guidelines on practice and perceived quality of care for US primary care physicians (PCPs) and specialists with varying levels of financial involvement with a single managed care organization. METHODS: Data were from the 1996-1997 Community Tracking Study, a nationally representative, cross-sectional survey of 12,528 physicians. Data were adjusted for possible confounders using ordinal logistic regression. RESULTS: Almost half the physicians described a moderate to very large perceived effect of guidelines (46% of PCPs, 46% of specialists). Physicians' financial involvement with a single organization was modest: PCPs received on average 24% of their revenue from their largest contract, while specialists averaged 18%. For specialists, increasing perceived effect of guidelines was associated with increasingly negative perceptions of quality of care [beta= -0.16, 95% confidence interval (-0.22, -0.10)]. Similar results were obtained for PCPs with low levels of financial involvement with a single organization. However, this negative association disappeared for PCPs with higher levels of financial involvement. CONCLUSIONS: PCPs with substantial financial involvement with a single organization who perceive greater effects of guidelines on practice have less negative perceptions of their ability to provide high-quality care. Although our data cannot confirm a causal relationship, financial involvement with a single organization may be one factor linking practice guidelines to high-quality care.     

Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.     

Effects of Online Physician Reviews and Physician Gender on Perceptions of Physician Skills and Primary Care Physician (PCP) Selection

ABSTRACT

Physician review websites have become more relevant and important in people’s selection of physicians. The current study experimentally examined how online physician reviews endorsing a primary care physician’s (PCP’s) technical or interpersonal skills, along with a physician’s gender, may influence people’s perceptions of the physician’s skills and their willingness to choose the physician. Participants were randomly assigned to view a mockup physician review web page and to imagine that they needed to find a new PCP in a new city. They were then asked to report their perceptions of the physician and willingness to choose the physician as their PCP. The results suggested that people’s willingness to choose a PCP was affected by physician reviews through their influence on people’s perceptions of the PCP’s technical and interpersonal skills. More importantly, this study found that when physician reviews endorsed a PCP’s technical skills people perceived a female PCP to be more interpersonally competent than a male PCP and thus were more likely to choose the female PCP. The gendered perception, however, was not extended to a PCP’s technical skills. Practical implications for health providers and consumers are discussed.     

Back in the driver's seat: specialists regaining autonomy

Between 1997 and 2001, the proportion of specialists reporting more freedom to make clinical decisions that meet their patients' needs increased significantly, much more so than among primary care physicians (PCPs), according to a new study by the Center for Studying Health System Change (HSC). Specialists now are also more likely to believe they can make clinical decisions in the best interest of their patients without reducing their income and can maintain continuing relationships with their patients to promote high-quality care. In contrast, PCPs' views on these issues have changed little. These findings about physicians' perceptions are likely a reflection of recent changes in managed care. Responding to a strong consumer and physician backlash, health plans gave consumers a broader choice of physicians and eased restrictions on care in the late 1990s     

Primary care physician practice styles and patient care: Evidence from physician exits in Medicare

Primary care physicians (PCPs) provide frontline health care to patients in the U.S.; however, it is unclear how their practice styles affect patient care. In this paper, we estimate the long-lasting effects of PCP practice styles on patient health care utilization by focusing on Medicare patients affected by PCP relocations or retirements, which we refer to as “exits.” Observing where patients receive care after these exits, we estimate event studies to compare patients who switch to PCPs with different practice style intensities. We find that PCPs have large effects on a range of aggregate utilization measures, including physician and outpatient spending and the number of diagnosed conditions. Moreover, we find that PCPs have large effects on the quality of care that patients receive, and that all of these effects persist for several years. Our results suggest that switching to higher-quality PCPs could significantly affect patients’ longer-run health outcomes.     

Access to Patient-Centered Medical Homes in Children with Sickle Cell Disease

To determine the proportion of children with sickle cell disease (SCD) followed in a subspecialty clinic with access to a primary care provider (PCP) exhibiting practice-level qualities of a patient-centered medical home (PCMH). We surveyed 200 parents/guardians of children with SCD using a 44-item tool addressing PCP access, caregiver attitudes toward PCPs, barriers to healthcare utilization, perceived disease severity, and satisfaction with care received in the PCP versus SCD clinic settings. Individual PCMH criteria measured were a personal provider relationship and medical care characterized as accessible, comprehensive and coordinated. Although 94 % of respondents reported a PCP for their child, there was greater variation in the proportion of PCPs who met other individual PCMH criteria. A higher proportion of PCPs met criteria for coordinated care when compared to accessible or comprehensive care. In multivariate models, transportation availability, lower ER visit frequency and greater PCP visit frequency were associated favorably with having a PCP meeting criteria for accessible and coordinated care. Child and respondent demographics and disease severity had no impact on PCMH designation. Average respondent satisfaction scores for the SCD clinic was higher, when compared to satisfaction scores for the PCP. For children with SCD, access to a PCP is not synonymous with access to a medical home. While specific factors associated with PCMH access may be identified in children with SCD, their cause and effect relationships need further study.     

Organizational and Market Influences on Physician Performance on Patient Experience Measures

Objective. To examine the extent to which medical group and market factors are related to individual primary care physician (PCP) performance on patient experience measures. Data Sources. This study employs Clinician and Group CAHPS survey data (n=105,663) from 2,099 adult PCPs belonging to 34 diverse medical groups across California. Medical group directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the adoption of patient experience improvement strategies. Primary care services area (PCSA) data were used to characterize the market environment of physician practices. Study Design. We used multilevel models to estimate the relationship between medical group and market factors and physician performance on each Clinician and Group CAHPS measure. Models statistically controlled for respondent characteristics and accounted for the clustering of respondents within physicians, physicians within medical groups, and medical groups within PCSAs using random effects. Principal Findings. Compared with physicians belonging to independent practice associations, physicians belonging to integrated medical groups had better performance on the communication ( p=.007) and care coordination ( p=.03) measures. Physicians belonging to medical groups with greater numbers of PCPs had better performance on all measures. The use of patient experience improvement strategies was not associated with performance. Greater emphasis on productivity and efficiency criteria in individual physician financial incentive formulae was associated with worse access to care ( p=.04). Physicians located in PCSAs with higher area‐level deprivation had worse performance on the access to care ( p=.04) and care coordination ( p<.001) measures. Conclusions. Physicians from integrated medical groups and groups with greater numbers of PCPs performed better on several patient experience measures, suggesting that organized care processes adopted by these groups may enhance patients' experiences. Physicians practicing in markets with high concentrations of vulnerable populations may be disadvantaged by constraints that affect performance. Future studies should clarify the extent to which performance deficits associated with area‐level deprivation are modifiable.     

When do older patients change primary care physicians?

BACKGROUND: Concerns have been raised about changes in the health care system that may disrupt continuity of care and thereby reduce the quality of that care. The purpose of this study was to look at the reasons that older patients give for changing primary care physicians (PCPs) and to look at relationships between the duration of the PCP-patient relationship and the perceived quality of primary care received. METHODS: We analyzed data collected during the first 2 years of a longitudinal study of primary care patients 65 years of age and older. Variables included sociodemographic characteristics, duration of relationship with current PCP, reasons for leaving last PCP, estimated numbers of visits to PCP, other clinics, and emergency departments, and admissions to hospitals and nursing homes in the last year, self-rated health, 2 measures of health-related quality of life, and the Components of Primary Care Index (CPCI). RESULTS: 799 patients of 23 PCPs were enrolled in year 1 of the longitudinal study, and 579 were re-evaluated in year 2. The mean and median PCP-patient relationship durations were 10.27 and 8 years, respectively. Duration of the PCP-patient relationship was associated with greater patient age, income, level of education, and frequency of visits to the PCP. Longer relationship duration was also associated with higher scores on all 8 CPCI subscales. The distribution of reasons for changing PCP was associated with duration of relationship; those with a longer relationship were more likely to change involuntarily. Insurance-related reasons for changing PCP were more common in those who had changed more recently. One hundred and fourteen (14%) changed PCP during the first year of the study. Three CPCI subscale scores predicted PCP change, accumulated knowledge, communication, and family orientation. Eighty-seven percent changed involuntarily, 44% for insurance-related reasons and 40% because their doctors had moved, retired, or died. CONCLUSIONS: Older patients, particularly those who are older and have more education and income, tend to stay with their PCPs until they are forced to change. The longer they stay in the relationship, the better they feel about the quality of the primary services they receive. Changes in the health care system may have increased the number of patients forced to change PCP.     

Recommend,but also Discuss: Different Patterns of Physician-Perceived Barriers to Discussing HPV Vaccination and Their Association with Vaccine Administration in 11–12 Year-Old Girls

Objectives We examined variation in primary care physicians’ (PCPs’) perceptions of barriers to physician-initiated discussion of HPV vaccination, and how this is associated with the rates at which they discuss, initiate and continue to administer vaccination with 11–12 year-old girls. Methods We surveyed 301 PCPs using systematic random sampling. PCP variation in perceived barriers to discussing HPV vaccination was modeled using latent class analysis (LCA). The distinct PCP groups identified were compared with each other using three iterative logistic regression models to predict the likelihood of initiating vaccine discussion and the reported percentages of 11–12 year-old patients who initiated HPV vaccination and received follow-up shots. Results LCA revealed three groups of PCPs who perceived major, moderately significant and relatively minor barriers (17.9, 41.9 and 40.2 % of respondents, respectively). Pediatricians, PCPs who were female, had minority racial/ethnic status and who perceived only minor barriers had significantly higher odds of initiating discussion. PCPs were more likely to initiate HPV vaccination if they had initiated discussion and perceived minor or moderate communication barriers. Increased likelihood to administer follow-up HPV vaccine was associated with having initiated discussion, perceiving only minor barriers and working outside Deep South states, but not with having initiated vaccination. Conclusions for Practice PCPs who discuss HPV vaccination with girls aged 11–12 and their mothers are more likely to start and sustain vaccine administration. However, different PCPs perceive barriers to discussion in different ways. Interventions tailored to different groups of PCPs should assist them in overcoming barriers to discussing their recommendations when necessary.     

The Effects of Physician In-migration to Rural Colorado (1992 to 1995)

This paper reports the results of an analysis of the American Medical Association Masterfile. The purpose of this study was to examine changes in health care accessibility in rural Colorado from 1992 to 1995, and to describe the pattern of in-migration of physicians to nonmetropolitan statistical area counties of the state during that period. The number of direct patient care providers increased from 532 to 700 (31.6%) during the three-year period vs. a growth of 11.2 percent in the general population of nonmetropolitan statistical area counties. Of the 700 physicians serving residents of Colorado's 52 rural counties, 308 (44%) had been practicing in their community since 1992. The rate of departure from nonmetropolitan statistical area practice sites in 1992 was 26.4 percent (140 of 532). Physicians new to their rural practice locations were younger and proportionally more female, but they were similar in primary medical specialty to doctors who had remained in their 1992 sites. Population to physician and to primary care physician ratios were much more favorable for 1995 than for 1992. Accessibility to care was most improved in counties with fewer than 10,000 inhabitants.     

Effects of Second Office and Hospital Consulting Practices of Physicians on Rural Communities

This research examined the prevalence of second offices and hospital consulting practices of physicians in Missouri, the characteristics of physicians participating in such practices, the change in availability of services through these practices, the characteristics of counties and hospitals involved, and the practice organization of participating physicians. The assessment of the factors was conducted within the conceptual framework of community and physician characteristics, practice form and organization, and health system resources. In 1993, 64 of the 93 nonmetropolitan counties in Missouri gained, on average, 1.3 full-time equivalent physicians through second office and hospital consulting practices. Eighteen nonmetropolitan counties lost, on average, 0.4 full-time equivalent physicians through these practices; 11 nonmetropolitan counties were not affected. The majority of physicians engaged in these two types of practices are nonprimary care specialists. Consequently, in addition to the net contribution to total physician service availability, many nonmetropolitan counties gained access locally to a wider variety of specialty services. This change in availability of physician services, not generally incorporated in decisions, needs to be considered when policy efforts are undertaken to change the spatial and specialty distribution of physicians.     

Access to Spanish-speaking physicians in California: supply, insurance, or both

BACKGROUND: National studies report patients with limited English proficiency (LEP) have difficulty finding bilingual physicians; however, it is unclear whether this situation is primarily a result of an inadequate supply of bilingual physicians or a lack of the insurance coverage necessary to gain access to bilingual physicians. In California, 12% of urban residents are Spanish-speaking with some limited proficiency in English. The majority of these residents (67%) are uninsured or on Medicaid. METHODS: In 2001, we performed a mailed survey of a probability sample of primary care and specialist physicians practicing in California. We received 1364 completed questionnaires from 2240 eligible physicians (61%). Physicians were asked about their demographics, practice characteristics, whether they were fluent in Spanish, and whether they had Medicaid or uninsured patients in their practice. RESULTS: Twenty-six percent of primary care and 22% of specialist physicians in the 13 urban study counties reported that they were fluent in Spanish. This represented 146 primary care and 66 specialist physicians who spoke Spanish for every 100,000 Spanish-speaking LEP residents. In contrast to the general population, there were only 48 Spanish-speaking primary care and 29 specialist physician equivalents available for every 100,000 Spanish-speaking LEP patients on Medicaid and even fewer (34 primary care and 4 specialist) Spanish-speaking physician equivalents for every 100,000 Spanish-speaking physician equivalents for uninsured Spanish-speaking LEP patients. CONCLUSION: Although the supply of Spanish-speaking physicians in California is relatively high, the insurance status of LEP Spanish-speaking patients limits their access to the physicians. Addressing health insurance-related barriers to care for those on Medicaid and the uninsured is critical to improving health care for Spanish-speaking LEP patients.     

Rhetoric or Reality: Are Health Systems Redesigning How Health Care Is Delivered?

Policymakers continue to set aggressive targets for alternative payment model engagement, aiming to spur a transition from volume- to value-oriented payment to drive performance improvements. However, the extent to which payments to providers have transitioned to paying for value is unclear. Given their greater ability to enter into payment arrangements with financial risk, health systems may be particularly well-positioned to reflect value-orientation in their physician compensation and incentives. In this study, we sought to characterize frontline physician compensation and financial incentives for health system affiliated physician organizations (POs). Between 2017 and 2019, we fielded surveys and conducted semi-structured interviews with leaders of POs affiliated with health systems. The interviews elicited the structure and features of compensation arrangements for primary care physicians (PCPs) and specialists and the POs’ revenues and incentives from payers. The survey addressed the structure of financial incentives and the top three actions physicians could take to increase their compensation. We assessed the frequency of compensation and financial incentive components and the association between POs’ fee-for-service revenue and their physicians’ productivity-based compensation. A purposive sample of 28 POs in 24 not-for-profit health systems in California, Minnesota, Wisconsin, and Washington, of which all provided PCP compensation information and all but 2 provided specialist compensation information. Among included POs, financial performance incentives were used by 25 (89.3%) for PCPs, averaging 4.0% of total compensation (range 0.05% to 13.72%) and 16 (61.5%) for specialists, averaging 3.1% of compensation (range 0.5% to 13.0%). Productivity was the most common base compensation component for both PCPs (24 POs, 85.7%) and specialists (25 POs, 96.2%). Capitation and salary were also commonly used for both PCPs (8 POs, 28.6% and 6 POs, 21.4%, respectively) and specialists (3 POs, 11.5% and 6 POs, 23.1%, respectively). When included as a component of PCP compensation productivity averaged 62.4% of compensation, salary 62.5%, and capitation 46.1%. Increasing productivity was cited as the top action physicians could take to increase their compensation by 19 POs (67.9%) for PCPs and 19 POs (73.1%) for specialists. Improving clinical quality was next most commonly cited action to increase compensation for both PCPs and specialists. The correlation between PO’s percent fee-for-service revenue and their physicians’ percent productivity-based compensation was moderately positive (r = .52) for PCPs and weakly positively for specialists (r = .40). Among health system POs, productivity is the most prominent component of PCP and specialist compensation and the most commonly noted means for physicians to increase their income. Financial performance incentives were commonly used but comprised a very small portion of total compensation. POs’ fee-for-service revenue percentage was more strongly positively correlated with the percentage compensation for productivity for PCPs than for specialists. Despite emphasis on transitioning from volume- to value-based payment, productivity remains the principal component of physician compensation in health system affiliated POs that may have greater capacity and motivation to develop alternate compensation and incentive schemes. The ongoing primacy of productivity incentives for frontline physicians is likely to blunt the impact of value-oriented payment and delivery system reforms. Agency for Healthcare Research and Quality.     

Vulnerability and the patient-practitioner relationship: the roles of gatekeeping and primary care performance

OBJECTIVES: We examined whether patients' perceptions of their relationships with primary care practitioners (PCPs) vary by vulnerability status and assessed the extent to which gatekeeping arrangements and primary care performance moderate potential disparities. METHODS: We used the nationally representative 1996-1997 Community Tracking Study Household Survey as our data source. RESULTS: Whites reported better patient-practitioner relationships than minorities. Requirements that patients select a PCP and obtain referral authorization neither reduced nor exacerbated racial disparities in the patient-practitioner relationship. On the other hand, access to and continuity with a PCP substantively reduced disparities, especially for the most vulnerable group. CONCLUSIONS: Enhancing primary care performance may reduce some of the barriers to care experienced by vulnerable populations, thereby improving patients' relationships with their PCPs.     

The Effect of Capitation on Switching Primary Care Physicians

Objective.  To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs.
Data Sources/Study Setting.  Administrative enrollment and claims/encounter data for 1994–1995 from four physician organizations.
Study Design.  We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods.
Data Collection/Extraction Methods.  Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis.
Principal Findings.  Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model, this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs.
Conclusions.  A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives.