The Resilience of the Health Care Safety Net, 1996–2001

Objective .  To determine how the capacity and viability of local health care safety nets changed over the last six years and to draw lessons from these changes.
Data Source .  The first three rounds (May 1996 to March 2001) of Community Tracking Study site visits to 12 communities.
Study Design .  Researchers visited the study communities every two years to interview leaders of local health care systems about changes in the organization, delivery, and financing of health care and the impact of these changes on people. For this analysis, we collected data on safety net capacity and viability through interviews with public and not-for-profit hospitals, community health centers, health departments, government officials, consumer advocates, academics, and others. We asked about the effects of market and policy changes on the safety net and how the safety net responded, as well as the impact of these changes on care for the low-income uninsured.
Principal Findings .  The safety net in three-quarters of the communities was stable or improved by the end of the study period, leading to improved access to primary and preventive care for the low-income uninsured. Policy responses to pressures such as the Balanced Budget Act and Medicaid managed care, along with effective safety net strategies and supportive conditions, helped reinforce the safety net. However, the safety net in three sites deteriorated and access to specialty services remained inadequate across the 12 sites.
Conclusions.  Despite pessimistic predictions and some notable exceptions, the health care safety net grew stronger over the past six years. Given considerable community variation, however, this analysis indicates that policymakers can apply a number of lessons from strong and improving safety nets to strengthen those that are weaker, particularly as the current economy poses new challenges.     

Long-term Care in Rural West Virginia: Managed Care and Future Roles for the Aging Network

The managed care movement emphasizes the rationalization of health care delivery through fixed price or capitation of service and the utilization of a preferred physician or health gatekeeper. These features are advanced as measures of cost control in health care delivery. This approach presents the aging network, established under the Older Americans Act, with a number of daunting challenges which are particularly acute to service providers in rural areas. How this network responds will determine its future efficacy in the delivery of health and long-term care services. This article examines these concerns among eight rurally based senior centers and two Area Agencies on Aging in Southern West Virginia. Issues of management capacity, present and future positioning, and receptivity to managed care are emphasized. These providers stand on the strengths of a long tradition of serving clients, knowledge of their needs and face-to-face interactions with them--capabilities managed care organizations do not have. However, little outreach to managed care in these areas has occurred.     

Multimethod evaluation of health policy change: an application to Medicaid managed care in a rural state

Objective. To answer questions about the impacts of Medicaid managed care (MMC) at the individual, organizational/community, and population levels of analysis.
Data Sources/Study Setting. Multimethod approach to study MMC in New Mexico, a rural state with challenging access barriers.
Study Design. Individual level: surveys to assess barriers to care, access, utilization, and satisfaction. Organizational/community level: ethnography to determine changes experienced by safety net institutions and local communities. Population level: analysis of secondary databases to examine trends in preventable adverse sentinel events.
Data Collection/Extraction Methods. Survey: multivariate statistical methods, including factor analysis and logistic regression. Ethnography: iterative coding and triangulation to assess documents, field observations, and in-depth interviews. Secondary databases: plots of sentinel events over time.
Principal Findings. The survey component revealed no consistent changes after MMC, relatively favorable experiences for Medicaid patients, and persisting access barriers for the uninsured. In the ethnographic component, safety net institutions experienced increased workload and financial stress; mental health services declined sharply. Immunization rate, as an important sentinel event, deteriorated.
Conclusions. MMC exerted greater effects on safety net providers than on individuals and did not address problems of the uninsured. A multimethod approach can facilitate evaluation of change in health policy.     

Identifying Affordable Sources of Medical Care among Uninsured Persons

Objective. To examine the effects of policy, health system, and sociodemographic characteristics on the likelihood that uninsured persons pay a lower price at their regular source of care, or that they are aware of lower priced providers in their community.
Data Sources. The 2003 Community Tracking Study household survey, a nationally representative sample of the U.S. population and 60 randomly selected communities.
Study Design. The survey asked uninsured persons if they paid full or reduced cost at their usual source of medical care, or if they were aware of providers in their community that charge less for uninsured people. We use binomial and multinomial logistic regression analysis to examine the effects of various policy, health system, and sociodemographic characteristics on use and awareness of lower priced providers. We focus especially on the effects of safety-net capacity, measured by safety-net hospitals, community health centers, physicians' charity care, and Community Access Program (CAP) grants.
Principal findings. Less than half of the uninsured (47.5 percent) reported that they used or were aware of a lower priced provider in their community. Multivariate regression analysis shows that greater safety-net capacity is associated with a higher likelihood of having a lower priced provider as the regular source of care and greater awareness of lower priced providers. Lower incomes and racial/ethnic minorities also had a higher likelihood of having a lower priced provider, although health status did not have statistically significant effects.
Conclusion. Although increased safety-net capacity may lead to more uninsured having a lower priced provider, many uninsured who live near safety-net providers are not aware of their presence. Greater outreach designed to increase awareness may be needed in order to increase the effectiveness of safety-net providers in improving access to care for the uninsured.     

Delayed Care and Unmet Needs among Health Care System Users: When Does Fiduciary Trust in a Physician Matter?

Objectives. To examine whether fiduciary trust in a physician is related to unmet health care needs and delayed care among patients who have a regular physician, and to investigate whether the relationships between trust and unmet health care needs and delays in care are attenuated for disadvantaged patients who face structural obstacles to obtaining health care.
Data Sources/Study Setting. The 1998–1999 Community Tracking Study (CTS) Household Survey, a cross-sectional sample representative of the U.S. noninstitutionalized population. This study analyzes adults who usually see the same physician for their health care ( n =29,994).
Study Design. We estimated logistic regression models of the association of trust with unmet health care needs and delayed care. We tested interactions between trust and barriers to obtaining care, including minority race/ethnicity, poverty, and the absence of health insurance. Control variables included patients' sociodemographic characteristics, health status, satisfaction with the available choice of primary physicians, and the number of physician visits during the last year.
Principal Findings. Patients' fiduciary trust in a physician is negatively associated with the likelihood of reporting delayed care and unmet health care needs among most patients. Among African Americans, Hispanics, the poor, and the uninsured, however, fiduciary trust is not significantly associated with the likelihood of delayed care. For unmet needs, only the uninsured have no significant association with trust.
Conclusions. Results show that trust is associated with improved chances of getting needed care across most subgroups of the population, although this relationship varies by subpopulation.     

Managed Care, Access to Specialists, and Outcomes among Primary Care Patients with Pain

Objective. To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain.
Data Sources/Study Setting. Patient, physician, and office manager questionnaires collected in the Seattle area in 1996–1997, plus data abstracted from patient records and health plans.
Study Design. A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle.
Data Collection. Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines.
Principal Findings. A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians.
Conclusions. Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.     

HMOs and Managed Care: Implications for Rural Physician Manpower Planning*

American health care is changing dramatically. Health maintenance organizations (HMOs) and other managed care plans are central to this change. Today, the majority of Americans living in metropolitan areas receive their care from these types of plans. The goal of this article is two-fold. First, it will discuss the potential implications of HMOs and managed care for physician needs and supply in rural regions. Second, it will derive insight into alternative approaches for meeting rural health manpower needs by analyzing HMO staffing patterns. As HMOs and other managed care plans expand, rural physicians, their practices, and their patients will almost certainly be affected. As described in this paper, most of these effects are likely to be positive. The staffing patterns used by HMOs provide an interesting point of comparison for those responsible for rural health manpower planning and resource development. HMOs appear to meet the needs of their enrollees with significantly fewer providers than are available nationally or suggested by the federal standards. Moreover, HMOs make greater use of nonphysician providers such as nurse practitioners and physician assistants.     

Does the Universal Health Insurance Program Affect Urban‐Rural Differences in Health Service Utilization Among the Elderly? Evidence From a Longitudinal Study in Taiwan

Purpose: To assess the impact of the introduction of Taiwan's National Health Insurance (NHI) on urban‐rural inequality in health service utilization among the elderly. Methods: A longitudinal data set of 1,504 individuals aged 65 and older was constructed from the Survey of Health and Living Status of the Elderly. A difference‐in‐differences model was employed and estimated by the random‐effect probit method. Finding: The introduction of universal NHI in Taiwan heterogeneously affected outpatient and inpatient health service utilization among the elderly in urban and rural areas. The introduction of NHI reduced the disparity of outpatient (inpatient) utilization between the previously uninsured and insured older urban residents by 12.9 (22.0) percentage points. However, there was no significant reduction in the utilization disparity between the previously uninsured and insured elderly among rural residents. Conclusions: Our study on Taiwan's experience should provide a valuable lesson to countries that are in an initial stage of proposing a universal health insurance system. Although NHI is designed to ensure the equitable right to access health care, it may result in differential impacts on health service utilization among the elderly across areas. The rural elderly tend to confront more challenges in accessing health care associated with spatial distance, transportation, social isolation, poverty, and a lack of health care providers, especially medical specialists.     

HMOs and Managed Care: Implications for Rural Physician Manpower Planning*

ABSTRACT: American health care is changing dramatically. Health maintenance organizations (HMOs) and other managed care plans are central to this change. Today, the majority of Americans living in metropolitan areas receive their care from these types of plans. The goal of this article is two-fold. First, it will discuss the potential implications of HMOs and managed care for physician needs and supply in rural regions. Second, it will derive insight into alternative approaches for meeting rural health manpower needs by analyzing HMO staffing patterns. As HMOs and other managed care plans expand, rural physicians, their practices, and their patients will almost certainly be affected. As described in this paper, most of these effects are likely to be positive. The staffing patterns used by HMOs provide an interesting point of comparison for those responsible for rural health manpower planning and resource development. HMOs appear to meet the needs of their enrollees with significantly fewer providers than are available nationally or suggested by the federal standards. Moreover, HMOs make greater use of nonphysician providers such as nurse practitioners and physician assistants.     

Managed Care and Gender Disparities in Problematic Health Care Experiences

Objective. To determine whether gender differences in reports of problematic health care experiences are associated with characteristics of managed care.
Data Sources. The 2002 Yale Consumer Experiences Survey ( N =5,000), a nationally representative sample of persons over 18 years of age with private health insurance, Interstudy Competitive Edge HMO Industry Report 2001, Area Resource File 2002, and the American Hospital Association Annual Survey of Hospitals 2002.
Study Design. Independent and interactive effects of gender and managed care on reports of problematic health care experiences were modeled using weighted multivariate logistic regression.
Principal Findings. Women were significantly more likely to report problems with their health care compared with men, even after controlling for gendered differences in expectations about medical care. Gender disparities in problem reporting were larger in plans that used certain managed care techniques, but smaller in plans using other methods. Some health plan managed care practices, including closed networks of providers and gatekeepers to specialty care, were associated with greater problem reporting among women, while others, such as requirements for primary care providers, were associated with greater problem reporting among men. Markets with higher HMO competition and penetration were associated with greater problem reporting among women, but reduced problem reporting among men. Women reported more problems in states that had enacted regulations governing access to OB/GYNs, while men reported more problems in states with regulations allowing specialists to act as primary care providers in health plans.
Conclusions. There are nontrivial gender disparities in reports of problematic health care experiences. The differential consequences of managed care at both the plan and market levels explain a portion of these gender disparities in problem reporting.     

Rural Health Care Providers in the United States

One of the most recalcitrant problems of the rural health landscape is the uneven distribution and relative shortage of medical care providers. Despite considerable efforts by federal and state governments over the past three decades to address these problems, rural provider distribution and shortage issues have persisted. The purpose of this article is to identify the challenges for rural health research and policy regarding health provider supply in the first decade of the 21st century. While the emphasis in this article is on physicians, workforce concerns pertaining to nurses, nurse practitioners, and physician assistants are briefly described. Physician supply, geographic and specialty distribution, age, gender, quality of care, recruitment and retention, training, productivity and income, reimbursement aid managed care, federal and state ameliorative programs, safety net, and telehealth are discussed. Also highlighted are issues concerning rural health care workforce research, methods, and data as well as a series of policy-relevant questions. Solutions to rural health personnel problems can only be successfully addressed through multifaceted approaches. No vision of the future of rural health can come to fruition if it does not promote stable, rewarding, and fulfilling professional and personal lives for rural health care providers.     

Community Demographics and Access to Health Care among U.S. Hispanics

Objective. To explore the influence of the communities in which Hispanics live on their access to health care.
Data. 1996–2002 Medical Expenditure Panel Survey data, linked to secondary data sources and including 14,504 observations from 8,371 Mexican American respondents living in metropolitan areas.
Study Design. We use multivariate probit regression models, stratified by individuals' insurance status, for analyses of four dependent variables measuring access to health care. We measure community characteristics at the zip code tabulation area level, and key independent variables of interest are the percentage of the population that speaks Spanish and percentage of the population that is immigrant Hispanic. Each of these measures is interacted with individual-level measures of nativity and length of U.S. residency.
Principal Findings. For Mexican American immigrants, living in an area populated by relatively more Spanish speakers or more Hispanic immigrants is associated with better access to care. The associations are generally stronger for more recent immigrants compared with those who are better established. Among U.S.-born Mexican Americans who are uninsured, living in areas more heavily populated with Spanish-speaking immigrants is negatively associated with access to care.
Conclusions. The results suggest that characteristics of the local population, including language and nativity, play an important role in access to health care among U.S. Hispanics, and point to the need for further study, including analyses of other racial and ethnic groups, using different geographic constructs for describing the local population, and, to the extent possible, more specific exploration of the mechanisms through which these characteristics may influence access to care.     

Urban and Rural Differences in Health Insurance and Access to Care

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies.
Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P<0.01). These differences were confirmed by multivariate analysis.
Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.     

Health Care Expenditures for Urban and Rural Veterans in Veterans Health Administration Care

Objective. To compare Veterans Health Administration (VA) patients, non-VA-using veterans, and nonveterans, separated by urban/rural residence and age group, on their use of major categories of medical care and payment sources.
Data Source. Expenditures for health care–using men in Medical Expenditure Panel Surveys from 1996 through 2004.
Study Design. Retrospective, cross-sectional analysis.
Data Collection/Extraction Methods. Controlling for demographics, health status, and insurance, we compared groups on population-weighted expenditures for inpatient, hospital-based outpatient, office-based, pharmacy, and other care, by major payers (self/family, private insurance, Medicare, other sources, and VA).
Results. VA users received most of their health care outside of the VA system, paid through private insurance or Medicare; self-payments were substantial. VA users under 65 reported worse health if they were rural residents but also lower expenditures overall and less care through private insurance.
Conclusions. VA health care users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.     

Access to and Use of Eye Care Services in Rural Arkansas

Context: Rural residents are more likely to be uninsured and have low income.
Purpose: To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents.
Methods: Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations.
Findings: Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit.
Conclusions: In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.     

Access to Health Care: Urban-Rural Comparisons from a Midwestern Agricultural State

Lack of access to quality health care for a large number of Americans, particularly those living in rural areas, is a major health care problem. Differences in access between rural and urban areas are caused by obstacles to providing adequate care, such as hospital closures and physician shortages, and low income and/or employment that does not provide health insurance as an employee benefit. This study, based on a random sample of 6,000 households in Nebraska, finds that access to health care is better for residents of rural than urban areas. The relationship holds with controls for health status and health insurance. The pattern in Nebraska reflects an absence of differences in income, health insurance, and health status that produce differences in access between rural and urban areas nationwide. The findings suggest that any serious proposal to reform health care delivery should involve the states and use established patterns of seeking care among state residents.     

A “Medical Mission” at Home: The Needs of Rural America in Terms of Otolaryngology Care

Objectives: Describe the population, Medicaid, uninsured, and otolaryngology practice demographics for 7 representative rural Southeastern states, and propose academic‐affiliated outreach clinics as a service to help meet the specialty care needs of an underserved rural population, based on the “medical mission” model employed in international outreach clinics. Methods: A needs assessment was conducted via review of medical licensing and practice location data from state medical licensing authorities, together with population, Medicaid, and uninsured data from state health/human services departments and the US Census Bureau. Results: In all states examined, there are significantly more practicing otolaryngologists per capita in urban areas compared to rural areas (P < .05), with the exception of West Virginia, where the difference was not statistically significant (P= .33). In the majority of the states examined, there were higher rates (expressed as a percentage of total county population) of both Medicaid recipients and uninsured patients in rural counties compared to urban counties. Notable exceptions include Louisiana and West Virginia, where there are higher percentages of Medicaid patients in urban areas, and Kentucky and Tennessee, where there are higher percentages of uninsured patients in the urban areas (P < .05 for each comparison). Conclusions: Borrowing design elements from the international outreach clinics, which involve many US otolaryngologists, a similar medical mission model could be of benefit domestically. There are rural areas of the Southeast where visiting outreach clinics could improve access to otolaryngology care and facilitate effective use of existing “safety net” health care resources.     

Service Use of Rural and Urban Medicaid Beneficiaries Suffering From Depression: The Role of Supply

Despite the prevalence and consequence of depression in rural areas, the literature on treating depression in rural areas is relatively scarce and inconclusive. The use of mental health services by rural people suffering from depression and the role that supply may play in explaining these differences are not well understood. Understanding these issues for rural Medicaid beneficiaries is important as Medicaid managed carefor physical and behavioral health care is expanded to rural areas. This study compares the mental health service use of rural and urban Medicaid beneficiaries, ages 18 to 64, in Maine suffering from depression and examines what influence mental health and primary care supply have in explaining observed differences. Two models are used to estimate the use of ambulatory mental health services: (1) a logit likelihood estimate of whether a beneficiary uses any outpatient mental health services for depression; (2) an ordinary least squares regression estimating the number of annualized ambulatory mental health care visits among users. Rural beneficiaries suffering from depression have lower utilization than urban beneficiaries. Rural and urban Aid for Families with Dependent Children (AFDC)--and Supplemental Security Income (SSI)--beneficiaries suffering from depression rely more on mental health than on general health care providers to receive ambulatory mental health care. Rural beneficiaries (AFDC and SSI) rely relatively more on general health care providers than urban beneficiaries. Multivariate analysis suggests that mental health supply and patient-level factors, but not primary care supply, account for utilization differences. This article describes the need to better understand factors limiting participation of primary care providers and to study the role of supply across multiple states.     

Geographic Access to Health Care for Rural Medicare Beneficiaries

CONTEXT: Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. PURPOSE: To compare the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington. METHODS: Retrospective design, using 1998 Medicare billing data. Travel time was determined by computing the road distance between 2 population centroids: the patient's and the provider's zone improvement plan codes. FINDINGS: There were 2,220,841 patients and 39,780 providers in the cohort, including 6,405 (16.1%) generalists, 24,772 (62.3%) specialists, and 8,603 (21.6%) nonphysician providers. There were 20,693,828 patient visits during the study. The median overall 1-way travel distance and time was 7.7 miles (interquartile range 1.9-18.7 miles) and 11.7 minutes (interquartile range 3.0-25.7 minutes). The patients in rural areas needed to travel 2 to 3 times farther to see medical and surgical specialists than those living in urban areas. Rural residents with heart disease, cancer, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was also related to decreased visits to specialists and an increasing reliance on generalists. CONCLUSIONS: Residents of rural areas have increased travel distance and time compared to their urban counterparts. This is particularly true for rural residents with specific diagnoses or those undergoing specific procedures. Our results suggest that most rural residents do not rely on urban areas for much of their care.