Rural-urban differences in primary care physicians' practice patterns, characteristics, and incomes

CONTEXT: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. PURPOSE: To examine rural-urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians. METHODS: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics. FINDINGS: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: -$14,569, -$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts. CONCLUSIONS: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.     

Rural–Urban Differences in Primary Care Physicians' Practice Patterns, Characteristics, and Incomes

ABSTRACT:  Context: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. Purpose: To examine rural–urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians. Methods: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics. Findings: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: −$14,569, −$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts. Conclusions: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.     

Rural and Urban Physicians' Perceptions Regarding the Role and Practice of the Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife

ABSTRACT: Context: There is a dearth of literature citing the differences in rural and urban physicians' perceptions of the role and practice of nurse practitioners, physician assistants, and certified nurse midwives (nonphysician providers). Purpose: The purpose of this study was to investigate and compare differences, if any, between rural and urban primary care physicians' perceptions of the role and practice of nonphysician providers. Results: Despite a 15.55% response rate using a mail-out survey in South Carolina, data from 681 rural and urban primary care physicians indicated that they perceived that nonphysician providers possess the necessary skills and knowledge to provide primay care to patients, are an asset to a physician's practice, free the physician's time to handle more critically ill patients, and increase revenue for the practice, but increase the risk of patient care mistakes and a physician's time in administrative duties. Urban physicians' mean scores were higher for perceiving that nonphysician providers are able to see as many patients in a given day as a physician but experience impediments in the delivery of patient care. Conclusions: Results will be used to clarify physicians' perceptions regarding the role and practice of nonphysician providers to reduce impediments to patient care access.     

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients

CONTEXT: The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients. METHODS: This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors. FINDINGS: A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse. CONCLUSIONS: Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.     

Characteristics of physicians practicing in alternative primary care settings: a Quebec study of local community service center physicians

Since the early 1970s, there have been two primary care networks in Quebec: the traditional one characterized by private practice remunerated on a fee-for-service basis, and the public one comprising 15 percent of physicians and characterized by salaried practice within publicly funded local community health service centers (CLSCs). Using data collected on 616 Quebec generalists, 333 in private practice and 283 in CLSCs, we compared physicians' profiles in both networks. In contrast to their colleagues in private practice, CLSC physicians are younger, more often women, and more often graduates of innovative primary care training programs. They are more sensitive to the biopsychosocial nature of health problems and to giving patients an active role in their care. Significant differences were also observed in physicians' self-reported clinical practices, more so for women than for men. The study suggests that alternative primary care settings attract physicians that are more preventive and socially oriented. As a result, they may contribute to the emergence of a more comprehensive type of medical practice in health care delivery systems.     

The ethics of managed care. An initial look at physicians' perspectives

The need for medical care in the United States had exceeded the financial resources required to pay for that care. To address this problem, managed care health insurance programs have become commonplace. With managed care programs, however, physicians are facing increasing ethical pressures. This article reviews the ethical dilemmas physicians face under a managed care system and conducts a national random sample of general practitioners and surgeons regarding four major ethical dilemmas: under treatment of patients due to overt pressures or financial incentives, breaches of patient confidentiality by the physician that are required by the managed care plan, lack of disclosure to the patient of the financial incentives or overt pressures under which the physician functions, and overuse of practice guidelines. The results of this survey suggest that physicians are more likely to compromise patients' confidentiality and not discuss financial arrangements with patients than they are to compromise actual patient care. Those physicians with more than 30 percent of their patient load coming from managed care are more likely to have faced the scenarios presented by the survey. There is, however, no statistically significant difference in the physicians' responses to these scenarios based on the percentage of the physicians' patient load coming from managed care.     

Variations in physicians' hospitalization practices: a population-based study in Manitoba, Canada.

This paper uses claims data from a universal health care system to describe physicians' hospitalization styles after adjusting for case-mix characteristics of their primary patients. Patients were uniquely assigned to that physician (general or family practitioners, internist, general surgeon, or obstetrician/gynecologist) seen most frequently over each two two-year periods (1972-74 and 1974-76). Four indices were developed including: 1) percentage of primary patients hospitalized; 2) mean number of readmissions for such patients; 3) mean length of stay; and 4) total days of hospitalization per primary care patient (a summary measure combining the first three). Rates of admission, not length of stay, were shown to be strongly related to this summary measure. Marked variations in the hospitalization indices were observed across physicians; these variations cannot be explained by the health or sociodemographic characteristics of a physician's patients. Rural physicians practicing in areas with high bed-to-population ratios and low occupancy rates were particularly high users of hospitals. The economic implications of different practice styles are shown to be large; physicians who were high users of hospitals serve 27 per cent of the patients but their patients consume 42 per cent of the hospital days.     

Higher fees paid to US physicians drive higher spending for physician services compared to other countries

Higher health care prices in the United States are a key reason that the nation's health spending is so much higher than that of other countries. Our study compared physicians' fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians' incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries' national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians' counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.     

The effect of physician practice organization on efficient utilization of hospital resources.

OBJECTIVE. This study examines variations in the efficient use of hospital resources across individual physicians. DATA SOURCES AND SETTING. The study is conducted over a two-year period (1989-1990) in all short-term general hospitals with 50 or more beds in Arizona. We examine hospital discharge data for 43,625 women undergoing cesarean sections and vaginal deliveries without complications. These data include physician identifiers that permit us to link patient information with information on physicians provided by the state medical association. STUDY DESIGN. The study first measures the contribution of physician characteristics to the explanatory power of regression models that predict resource use. It then tests hypothesized effects on resource utilization exerted by two sets of physician level factors: physician background and physician practice organization. The latter includes effects of hospital practice volume, concentration of hospital practice, percent managed care patients in one's hospital practice, and diversity of patients treated. Efficiency (inefficiency) is measured as the degree of variation in patient charges and length of stay below (above) the average of treating all patients with the same condition in the same hospital in the same year with the same severity of illness, controlling for discharge status and the presence of complications. PRINCIPAL FINDINGS. After controlling for patient factors, physician characteristics explain a significant amount of the variability in hospital charges and length of stay in the two maternity conditions. Results also support hypotheses that efficiency is influenced by practice organization factors such as patient volume and managed care load. Physicians with larger practices and a higher share of managed care patients appear to be more efficient. CONCLUSIONS. The results suggest that health care reform efforts to develop physician-hospital networks and managed competition may promote greater parsimony in physicians' practice behavior.     

Physicians' responses to their changing environment

The loss of physician autonomy, the changing shape of physicians' practices, and efforts to control the cost of health care have left American physicians increasingly dissatisfied with the U.S. health care system. A survey of 300 office and hospital-based physicians shows 59 percent favor reform of the U.S. system; only 31 percent favor retaining the current system. Doctors face increased competition for patients (the supply of physicians has increased three times faster than the population), reduced autonomy because of intervention by government and other third party payers, pressure from patients to provide unnecessary care including expensive new technology, and increased cost containment. Yet a majority of physicians believe the causes of rising health care costs are patient demand for services and the current medical malpractice system. A minority (23 percent) blame hospitals and physicians for rising costs.     

Patient race and physicians' decisions to prescribe opioids for chronic low back pain

Nonwhite patients are less likely than white patients to have their pain adequately treated. This study examined the influence of patient race and patient verbal and nonverbal behavior on primary care physicians' treatment decisions for chronic low back pain in men. We randomly assigned physicians to receive a paper-based, clinical vignette of a chronic pain patient that differed in terms of patient race (white vs. black), verbal behavior ("challenging" vs. "non-challenging"), and nonverbal behavior (confident vs. dejected vs. angry). We employed a between-subjects factorial design and surveyed primary care physicians (N=382), randomly selected from the American Medical Association Physician Masterfile. The primary dependent measure was the physician's decision as to whether (s)he would switch the patient to a higher dose or stronger type of opioid. Logistic regression was used to determine the effects of patient characteristics on physicians' prescribing decisions. There was a significant interaction between patient verbal behavior and patient race on physicians' decisions to prescribe opioids. Among black patients, physicians were significantly more likely to state that they would switch to a higher dose or stronger opioid for patients exhibiting "challenging" behaviors (e.g., demanding a specific narcotic, exhibiting anger) compared to those exhibiting "non-challenging" behaviors (55.1%). For white patients there was an opposite pattern of results in which physicians were slightly more likely to escalate treatment for patients exhibiting "non-challenging" (64.3%) vs. "challenging" (54.5%) verbal behaviors. Results point to the need for better understanding of the way a complex interplay of non-clinical characteristics affects physician behavior in order to improve quality of pain management and other clinical decision-making.     

Hospitalization style of physicians in Manitoba: the disturbing lack of logic in medical practice.

Variations in hospital admission rates across small areas are ubiquitous, and it is increasingly assumed that high rates result from physicians' discretionary decisions. Data for elderly patients from the health insurance system of Manitoba were used to construct an index that divided physicians into four groups based on their propensity to admit patients to the hospital. I then determined whether physicians who are more prone to admit patients use hospitals for more discretionary purposes and admit patients who are less ill. Although the differences between physicians with different practice styles were in the expected direction, the most compelling finding was the similarity in characteristics of patients admitted by physicians with markedly different practice styles. Such findings suggest a very wide latitude in physicians' decisions to admit patients; this latitude is not well captured by a model that posits a logical relationship between physician treatment patterns and patient need.     

Obese women's perceptions of their physicians' weight management attitudes and practices

BACKGROUND: Obesity has reached epidemic proportions in the United States. Primary care physicians will see increasing numbers of patients with long-term weight management problems. OBJECTIVE: To examine obese women's perceptions of their physicians' weight management attitudes and practices. DESIGN AND SETTING: Women who participated in obesity trials at a university clinic completed a questionnaire that assessed their views of weight control provided by their primary care physician. PARTICIPANTS: The patients were 259 women whose age was 44.0 +/- 10.0 years; weight, 96.7 +/- 13.2 kg; and body mass index (calculated as weight in kilograms divided by the square of height in meters), 35.2 +/- 4.5 (all data given as mean +/- SD). MAIN OUTCOME MEASURES: Using 7-point scales (1 indicates low; and 7, high), patients rated their satisfaction with care provided for their general health and that for their obesity. They also identified methods their physician recommended for weight management and the frequency of negative interactions with their physician concerning weight control. RESULTS: Participants were generally satisfied with the care they received for their general health and with their physicians' medical expertise (mean scores, 6. 1 and 6.2, respectively). They were significantly (P<.001) less satisfied with care for their obesity and with their physicians' expertise in this area (mean scores, 4.1 and 4.3, respectively). Almost 50% reported that their physician had not recommended any of 10 common weight loss methods, and 75% indicated they looked to their physician a "slight amount" or "not at all" for help with weight control. Only a small minority of patients (0.4%-8.0%) reported frequent, negative interactions with physicians concerning their weight. CONCLUSIONS: The last finding helps allay concerns that obese patients are routinely treated disrespectfully by physicians when discussing weight. The challenge, however, for primary care physicians appears to be providing patients better assistance with weight management.     

The impact of perceived barriers on primary care physicians' screening practices for female partner abuse

OBJECTIVES: Our purpose was to examine primary care physicians' screening practices for female partner abuse in different clinical situations and to investigate the relationship between perceived barriers and screening practices. METHODS: A cross-sectional survey was mailed to Alaska physicians practicing in the following specialties: family practice, internal medicine, obstetrics/gynecology and general practice. RESULTS: The survey response rate was 80 percent (305/383). The majority (85.7%) of primary care physicians screened often or always when a female patient presents with an injury, but they rarely screened at initial visits (6.2%) or annual exams (7.5%). More than one-third of respondents estimated that 10% or more of their female patients had experienced some type of intimate partner abuse. Several barriers to screening described in the literature were not predictive of physicians' screening practice patterns. Physicians' perceptions that abuse is prevalent among their patients and physicians' beliefs that they have a responsibility to deal with abuse were the only variables independently associated with screening at initial visits and annual exams. The only variable predictive of screening when a patient presents with an injury was physicians' perceived prevalence of abuse. CONCLUSION: Primary care physicians have not integrated screening for partner abuse into routine care. Strategies to increase awareness of the high prevalence of abuse in the primary care setting and to educate providers on the negative health effects of victimization can help physicians to acknowledge their responsibility in addressing abuse and the importance of screening at routine visits. Further rigorous studies are needed to identify and evaluate predictors of screening for abuse.     

Mode of payment, practice characteristics, and physician support for patient self care

PURPOSE: The purpose of this study was to assess the influence of payment mode and practice characteristics on physicians' attitudes toward and support of self-care among their patients. It is a common practice for health plans and health insurance companies to distribute and make available various self-care services and products to members. These self-care products are generally part of a larger demand-management strategy. The adoption and dissemination of self-care products by both fee-for-service and capitated systems of care suggest an implicit assumption that there is no connection between physician payment mode and the support of self-care products by physicians for their patients. This study empirically examines this assumption. METHODS: Physicians from three Northwest communities were sampled and face-to-face interviews were conducted (N=448). RESULTS: The findings show that younger, primary care, and female physicians are more supportive of self care for their patients. Physicians with more income from capitation or salary are also more supportive of self care for their patients. After controlling for other factors, physician mode of payment is the only statistically significant predictor of support for self care. Research and policy implications are discussed. CONCLUSION: The findings suggest that physicians who are paid on a capitation basis have more motivation to have patients be less reliant on the formal care structure. It is unclear whether the payment mode generates this support, or if physicians supportive of patient self care self-select themselves into capitated systems of care.     

Direct observation of physician counseling on dietary habits and exercise: patient, physician, and office correlates

BACKGROUND: This study documented the frequency and correlates of directly observed physicians' counseling on dietary habits and exercise in private medical practices. METHODS: Trained medical students observed physician, office, and patient characteristics in 4344 patient visits in 38 nonmetropolitan primary care physician offices. RESULTS: Counseling rates ranged from 0% in some offices to 55% in others. Physicians counseled patients on dietary habits in 25% of visits and exercise in 20% of visits. Physicians counseled new patients 30% more often than established ones (P < 0.05). Dietary counseling was associated with having dietary and exercise brochures in the office (P < 0.05). When counseling occurred, physicians (rather than patients) initiated both dietary and exercise counseling 61% of the time. Counseling for dietary habits was associated with counseling for exercise (P < 0.05); some physicians may be more likely to give preventive counseling. Counseling was not associated with physicians' age, years in practice, or number of patients per week. CONCLUSION: Physician counseled patients in 20-25% of visits, and this was not affected by physician characteristics. Results suggest that physician counseling protocols and other office prompts should be developed and promoted. Strategies targeting both physician and the health care system may improve the consistency of physician preventive counseling practices.     

Patient reciprocity and physician burnout: what do patients bring to the patient-physician relationship?

Despite its criticality to the provision of health care, little is known about how the patient-physician relationship influences burnout. This article seeks to understand how patient performance (e.g. being informative about needs) during office visits is associated with perceived reciprocity in the patient-physician relationship, which is in turn associated with physician burnout. To that end, we report the results of a cross-sectional survey of 252 matched pairs of patients and their primary care physicians about a recent office visit. The findings support a social exchange model of burnout that suggests that patient stressors and patient performance predict perceived reciprocity and subsequent burnout. Interestingly, patients' perceptions of their performance differed from physicians' perceptions; physicians' perceptions of performance fit the social exchange model better than patients' perceptions of performance.The present work suggests that while they are a source of demands, patients also provide resources that are critical to the patient-physician relationship. To the extent that we can encourage these resources, we can improve perceived reciprocity and reduce burnout in physicians.     

Specialist physicians providing primary care services in Colorado

BACKGROUND: There is general consensus that the size of the US physician workforce now exceeds the health care needs of the American public. There is a greater proportion of specialists than primary care physicians, a specialty mix different from that of most other developed countries. METHODS: The Colorado Board of Medical Examiners sent a one-page questionnaire to all physicians licensed to practice in the state. It contained the question: "How many hours in the last week did you provide primary care services, defined as either preventive care, routine physical exams, or treatment of common ailments?" The responses of physicians who reported non-primary-care medical specialties were analyzed with respect to their personal and practice characteristics. RESULTS: Just under half (46.5%) of the 2745 specialist respondents reported having provided primary care services. As a group, however, 27.9% of specialist physicians' direct patient care time was devoted to primary care activities. The amount of primary care services being provided was greater among those not board-certified in their specialties, osteopathic physicians, and specialists spending less time in direct patient care. CONCLUSION: Additional evaluation is needed with a more comprehensive definition of primary care than used in this article, which includes important but difficult-to-measure elements, such as the integration of services, a sustained partnership with patients, and practice in the context of family and community. To the extent possible, this definition should not rely on physician self-definition of which examinations are routine and which ailments are common. However, the contribution of specialists should be considered in future primary care needs assessments, and specialists who experience low demand for their particular specialties may be especially inclined to provide primary care services.     

Emergency Department Coverage by Primary Care Physicians in a Rural Practice-Based Research Network: Incentives, Confidence, and Training

ABSTRACT:  Context: In rural areas of the United States, emergency departments (EDs) are often staffed by primary care physicians, as contrasted to urban and suburban hospitals where ED coverage is usually provided by physicians who are residency-trained in emergency medicine. Purpose: This study examines the reasons and incentives for rural Oregon primary care physicians to cover the ED and their reported measures of confidence and priorities for additional training. Methods: We conducted a cross-sectional survey of primary care physicians in rural Oregon who are members of the Oregon Rural Practice-Based Research Network (ORPRN). The survey was sent to 70 primary care physicians in 27 rural Oregon practices. Findings: Fifty-two of 70 (74%) ORPRN physicians representing 24 practices returned the questionnaire. Nineteen of the 52 responding physicians reported covering the ED. The majority (75%) of physicians covering the ED did so as a requirement for practice employment and/or hospital privileges. Physicians covering the ED reported low confidence in pediatric emergencies and expressed the need for additional training in pediatric emergencies as their top priority. Conclusions: Almost two fifths of surveyed primary care physicians in a rural practice-based research network provide ED coverage. Based on these physicians' low levels of confidence and desire for additional training in pediatric emergencies, effective education models are needed for physicians covering the ED at their rural hospitals.     

Rural Physician Satisfaction: Its Sources and Relationship to Retention

This study uses survey data to identify areas of satisfaction and dissatisfaction for primary care physicians working in rural areas across the country. It also identifies the specific areas of satisfaction associated with longer retention within a given rural practice, as well as the characteristics of individuals, practices, jobs, and communities associated with the areas of satisfaction that predict retention. Study subjects comprised a sample of 1,600 primary care physicians who moved to nonmetropolitan counties nationwide during the years 1987 through 1990, with oversampling of those who moved to federally designated health professional shortage areas (HPSAs). Physicians serving in the National Health Service Corps (NHSC) were excluded. Sixty-nine percent of the eligible subjects returned completed mail questionnaires in 1991. Analyses for this study were limited to the 620 primary care physicians who worked more than 20 hours per week in towns of fewer than 35,000 population; who were neither in the military nor the NHSC; and who were not in urgent care, emergency room, or full-time teaching positions. Analyses revealed that the areas of rural physicians' greatest satisfaction were their relationships with patients, clinical autonomy, the care they provided to medically needy patients, and life in small communities. Physicians were least satisfied with their access to urban amenities and the amount of time they spent away from their practices. Retention was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals. Retention was also marginally related to physicians' satisfaction with their earnings. Among the areas of satisfaction not related to retention were satisfaction with autonomy, access to medical information and consultants, and the quality of doctor-patient relationships. In a subsequent series of analyses of the factors that predict the three areas of satisfaction that were associated with retention (satisfaction with the community, professional goal attainment, and earnings), a variety of physician, work, and community factors were identified. These findings reveal that specific features of rural physicians, their work, and their communities predict each of the various aspects of satisfaction and that only certain aspects of satisfaction predict rural physicians' retention. There are no magic bullets to make rural physicians satisfied in all ways. Nevertheless, there are identified approaches to elevate the specific aspects of rural physicians' satisfaction important to their retention. Programs to improve the satisfaction of rural physicians should focus on those areas of satisfaction that predict longer retention and other important outcomes.