Addressing the unique challenges of inner-city practice: a direct observation study of inner-city, rural, and suburban family practices

Previous research on geographic variations in health care contains limited information regarding inner-city medical practice compared with suburban and rural settings. Our main objective was to compare patient characteristics and the process of providing medical care among family practices in inner-city, suburban, and rural locations. A cross-sectional multimethod study was conducted emphasizing direct observation of out patient visits by trained research nurses involving 4, 454 consecutive patients presenting for outpatient care to 138 family physicians during 2 days of observation at 84 community family practices in northeast Ohio. Time use during office visits was assessed with the Davis Observation Code; satisfaction was measured with the Medical Outcomes Study nine-item Visit Rating Scale; delivery of preventive services was as recommended by the US Preventive Services Task Force; and patient-reported domains of primary care were assessed with the Components of Primary Care Instrument. Results show that inner-city patients had more chronic medical problems, more emotional problems, more problems evaluated per visit, higher rates of health habit counseling, and longer and more frequent office visits. Rural patients were older, more likely to be established with the same physician, and had higher rates of satisfaction and patient-reported physician knowledge of the patient. Suburban patients were younger, had fewer chronic medical problems, and took fewer medications chronically. Inner-city family physicians in northeast Ohio appear to see a more challenging patient population than their rural and suburban counterparts and have more complex outpatient office visits. These findings have implications for health system organization along with the reimbursement and recruitment of physicians in medically underserved inner-city areas.     

The Rural Physician Workforce in Florida: A Survey of US- and Foreign-Born Primary Care Physicians

CONTEXT: To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed. PURPOSE: This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida. METHODS: Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians. FINDINGS: Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians. CONCLUSIONS: Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.     

Competition in health care and the rural poor: an assessment from Arizona's competitive Medicaid experiment.

Market competition has been advocated as a possible solution to the rapidly increasing costs of Medicaid programs. However, there have been no major assessments of the impact of this approach on the rural poor. Past efforts have been located in urban areas; where existing HMOs were used to enroll the Medicaid population that elected to join the plans. In 1981 the Arizona Health Care Costs Containment System (AHCCCS, pronounced "access"), a statewide Medicaid experiment involving prepayment and enrollment in health plans, was created. Data from two state-wide, cross-sectional telephone surveys indicate that competitive Medicaid programs may be a feasible strategy in rural areas, but without innovative solutions for those ineligible for Medicaid, many of the rural poor will continue to have in adequate access to medical care.     

Title VII Funding and Physician Practice in Rural or Low-Income Areas

CONTEXT: Whether Title VII funding enhances physician supply in underserved areas has not clearly been established. PURPOSE: To determine the relation between Title VII funding in medical school, residency, or both, and the number of family physicians practicing in rural or low-income communities. METHODS: A retrospective cross sectional analysis was carried out using the 2000 American Academy of Family Physicians physician database, Title VII funding records, and 1990 U.S. Census data. Included were 9,107 family physicians practicing in 9 nationally representative states in the year 2000. FINDINGS: Physicians exposed to Title VII funding through medical school and residency were more likely to have their current practice in low-income communities (11.9% vs 9.9%, P< or =.02) and rural areas (24.5% vs 21.8%, P< or =.02). Physicians were more likely to practice in rural communities if they attended medical schools (24.2% vs 21.4%; P =.009) and residencies (24.0% vs 20.3%; P =.011) after the school or program had at least 5 years of Title VII funding vs before. Similar increases were not observed for practice in low-income communities. In a multivariate analysis, exposure to funding and attending an institution with more years of funding independently increased the odds of practicing in rural or low-income communities. CONCLUSIONS: Title VII funding is associated with an increase in the family physician workforce in rural and low-income communities. This effect is temporally related to initiation of funding and independently associated with effect in a multivariate analysis, suggesting a potential causal relationship. Whereas the absolute 2% increase in family physicians in these underserved communities may seem modest, it can represent a substantial increase in access to health care for community members.     

The missing voice: Impacts of health system change on low-income communities

Unique problems in obtaining adequate health care face poor urban communities. These include the rising number of uninsured, abuses in the managed-care system, the unwillingness of private providers to deliver health care for either Medicaid recipients or the uninsured, and an insufficient supply of primary care physicians in minority neighborhoods. If the managed-care system is to bring decent health care to poor urban communities, it must avoid the mistakes of the past. The health care system must be community based, oriented toward primary care, sufficiently funded, and universally accessible. There needs to be better coordination between medical schools and community health requirements and better support for public health facilities. Without adequate health care for the poor, urban living will eventually become more onerous for all.     

The National Area Health Education Center Program and Primary Care Residency Training

The Area Health Education Center (AHEC) program was established in 1972 to improve the supply, distribution, retention and quality of primary care and other health practitioners in medically underserved areas. Through academic/community partnerships, regional AHECs offer a broad array of educational programs for students, residents and practicing health professionals. With primary care medical education a core part of AHEC programs, AHECs have been involved in decentralized residency training from the outset, with particular attention to family medicine. This paper provides an overview of the national AHEC program, its core components and its support for primary care residency training. Although AHECs have achieved considerable success in training primary care physicians for their respective states, continued refinements of programs are needed to address the needs of the most rural and underserved communities.     

National Health Service Corps Staffing and the Growth of the Local Rural Non-NHSC Primary Care Physician Workforce

CONTEXT: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. PURPOSE: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.     

Rural healthcare needs and solutions

Many rural communities are finding it necessary to create innovative ways to make healthcare more accessible to their residents. Successful rural healthcare delivery systems require the resources of an institution willing to serve the rural healthcare market, a community wanting to improve its healthcare, and dedicated practitioners. Physicians must be willing to see Medicaid and charity care patients. If physicians in the community are too busy or unwilling to accept indigent patients, the community may need more physicians. When the community recruits additional physicians, leaders must clarify that all physicians have a responsibility to serve indigent patients. As a result, a community-wide healthcare planning process is essential. Because residents might not always be aware that they should receive certain routine healthcare services or how to access those services, the community must establish strategies to reduce this knowledge gap. Urban healthcare centers can help by bringing health screening services to the rural community and by providing health education programs. Providers can close another part of the knowledge gap by helping patients fill out the insurance forms required to receive payment and by helping them find and apply for indigent patient coverage. To help solve the physician shortage problem in rural areas, communities can work with urban healthcare providers to purchase or start new practices in rural areas and then supplement the practices with additional primary care physicians or other healthcare practitioners.     

Location patterns of recent physician settlers in rural America

The location patterns of young physicians who settled in the most rural communities of America between 1973 and 1976 are analyzed. The majority of these recent rural settlers were primary care practitioners. They tended to be the alumni of state university medical schools in states with large rural populations. Foreign medical graduates were heavily represented. The principal finding—a tendency toward further concentration of rural physicians within existing medical communities—suggests that those rural communities with the greatest needs may remain underserved without the assistance of organized external programs.     

HMO Financial Arrangements With Rural Physicians

The growth of managed care in general suggests that a substantially larger number of rural primary care physicians will be asked to enter into risk-bearing contracts with Health Maintenance Organizations (HMOs) in the near future. This article describes the different types of payment and risk-sharing arrangements that exist between HMOs and primary care physicians and presents survey data relating to their prevalence in rural areas. Also, it describes in detail the payment arrangements used by four HMOs that contract with rural primary care physicians. The concluding discussion highlights policy issues regarding risk-sharing arrangements that are especially pertinent in rural settings.     

Education of Physician Assistants, Nurse Midwives, and Nurse Practitioners for Rural Practice

Physician assistants, nurse midwives, and nurse practitioners have been described as a vital and unique solution to the problem of providing adequate access to high quality health care for many Americans. Each of these classifications of health care providers has been accepted as separate professions with their own standards and identities. Their curricula and educational pathways have developed into clearly distinguishable educational tracks that complement the larger disciplines of nursing and medicine. Physician assistants, nurse midwives, and nurse practitioners have been singled out in federal legislation for their potential contribution to underserved rural communities (e.g., the Rural Health Clinics Services Act of 1977 and its subsequent amendments). This designation is partly due to the fact that certified nurse midwives, nurse practitioners, and physician assistants traditionally chose to practice in rural, underserved areas, and because their skills and practice structures were well matched to the needs and resources of rural areas. That pattern of practice, however, appears to have changed and the distribution of these practitioners has begun to resemble the distribution of physicians and other clinicians with heavy concentrations in urban areas and a growing shortage in rural and underserved areas.     

Regional and individual differences in physician practices for joint-ventured versus non-joint-ventured physicians.

OBJECTIVE. This article compares characteristics of physicians who have invested in health care business (joint ventures) to characteristics of physicians who have not, based on a survey of Florida physicians. DATA SOURCES/STUDY SETTING. In early 1990, a survey was mailed to a stratified random sample of 1,000 Florida physicians. Half were randomly selected from lists of joint-ventured physicians who had been identified as owners in a previous study by the Florida Health Care Cost Containment Board. The remaining half were assumed to be non-joint-ventured (although incomplete results from the previous study meant that some of these physicians would be joint ventured as well). We tagged survey variables with additional variables from the same year representing exogenous influences. STUDY DESIGN. The survey was mailed to a stratified random sample of physicians across specialty and geographic area, with half to identified joint-ventured physicians and half to a control group, some of whom were expected to be joint-ventured. Thus, results regarding differences would be understated. Key variables include referring versus nonreferring physician, to shed light on motivation for joint-venturing; clientele served, to see if systematic differences had implications related to access for poor or underserved persons; geographic area, to see if joint-ventures were undertaken to increase access in rural areas; and other practice variables such as size and type of practice. DATA COLLECTION/EXTRACTION METHODS. Data from all received surveys were encoded and analyzed using SPSS. Incomplete surveys were also encoded so that all information would be available for possible use. PRINCIPAL FINDINGS. Results indicate that joint-ventured physicians are more likely than non-joint-ventured physicians to be referring physicians. Also, joint-ventured physicians report serving lower proportions of Medicaid and self-pay (uninsured) patients and higher proportions of Medicare patients. Joint-ventured physicians are also more likely to practice in urban areas, to practice full time, to be members of larger practices, and to practice in group practices. Further, joint-ventured physicians are more likely to practice in areas with high proportions of Medicare patients. CONCLUSIONS. Policymakers should continue to regard physician joint ventures as problematic, since results of this study indicate that physicians who engage in a joint venture almost always have the ability to refer patients to that joint venture due to the nature of their practices. Results also show that joint ventures are associated with decreased access: that is, they provide care to lower proportions of poor and underserved patients and rural patients than their non-joint ventured counterparts.     

Commentary on Gurewich et Al, "comparative performance of community health centers and other usual sources of primary care": community health centers: valuable partners for state medicaid programs

Community health centers are well positioned to bring needed primary care to populations experiencing the most acute health disparities. Health centers already care for 1 in 7 Medicaid beneficiaries and 1 in 5 low-income, uninsured individuals. And they generate $24 billion in annual savings to the entire health care system, including $6 billion for Medicaid programs. Health center patients are distinctly different from patients of other providers, and successfully meet the challenges associated with serving those who have special needs that require more time and resources to address. For this reason, health centers provide a much more comprehensive array of services, both health care and services that facilitate access to care, compared to private practice physicians. With more beneficiaries joining the Medicaid rolls under health reform, and the limited number of providers available to serve the most complex, hard-to-reach, and underserved patients, health centers will play an increasingly important partnership role with state Medicaid programs. Continued investments are necessary to effectively serve at-risk patients.     

Alternative models for the delivery of rural health care: a case study of a western frontier state.

This is a case study illustrating the wide variety of models for rural health care delivery found in a western "frontier" state. In response to a legislative mandate, the University of Nevada School of Medicine created the Office of Rural Health in 1977. Utilizing a cooperative, community development approach, this office served as a resource, as well as a catalyst, in the development and expansion of a variety of alternative practice models for health care delivery to small, underserved rural communities. These models included small, single, and multispecialty group practices; self-supporting and subsidized solo practices; contract physicians; midlevel practitioners; and National Health Service Corps personnel. The rural health care system that was created featured regional and consortial arrangements, urban and medical school outreach programs, and a "flying doctor" service.     

International medical graduate physicians in the United States: changes since 1981

Nearly a quarter of all active U.S. physicians are international medical graduates (IMGs)--physicians trained outside the United States and Canada. We describe changes in characteristics of IMGs from 1981 to 2001 and compare them with their U.S. medical graduate (USMG) counterparts. Since 1981, the leading source countries for IMGs have included India, the Philippines, and Mexico. IMGs were more likely to be generalists and to practice in designated underserved areas than USMGs but slightly less likely to practice in isolated small rural areas and persistent-poverty counties. IMGs are an important source of primary care physicians in rural and underserved areas.     

Use of cooperative health statistics system physician data in small area manpower needs assessment: the case of rural Colorado.

Maldistribution with respect of medical practice location and specialty continues to present barriers to quality care for many Americans. Residents of rural communities in Colorado often lack access to health care services appropriate in number and nature to their needs. A valid determination of the severity of inaccessibility of medical care is a prerequisite to effective programming for alleviating the problem. Any such needs assessment must be predicated on the use of a reliable, detailed physician manpower data base. Physician data used in evaluating the adequacy of health care delivery systems serving small or sparsely populated rural areas have traditionally proved inadequate, causing loss of credibility in the findings derived from those efforts. A concerted attempt was made in rural Colorado to establish a physician inventory for identifying health manpower shortage areas and assessing the degree of medical underservice. This undertaking was organized and directed by staff members of the Statewide Educational Activities for Rural Colorado''s Health (SEARCH) program, the area health education center program of the University of Colorado Health Sciences Center. Cooperative Health Statistics Systems (CHSS) physician data, collected in an annual survey conducted by the Colorado Department of Health, were determined to be exceptionally accurate in describing the physician manpower practicing in the State''s federally designated medically underserved counties. CHSS proved to be an outstanding source of physician data upon which small area manpower needs assessment can be based for the purpose of designating medically underserved or health manpower shortage areas.     

Selected Comparisons and Implications of a National Rural and Urban Survey on Health Care Access, Demographics, and Policy Issues

As the national health debate evolved over the past two years, a need to better understand the differential constraints of rural health delivery and popular attitudes toward policy initiatives became apparent. Selected 1994 and 1995 results of two national surveys designed to compare rural and urban household responses are reported. The average distance those living in rural households must travel to access medical providers and emergency care is nearly double that of urban household residents. Rural household resident responses show a higher level of acceptance of nonphysician health care providers such as physicians assistants and registered nurses. Means testing of Medicare programs and use of special indicators for providing more Medicaid funds to states with medically underserved and sparsely populated areas are examples of two policy initiatives that receive favorable responses from both urban and rural household residents, but would disproportionately benefit rural areas.     

Health manpower trends in a market-driven environment

In the context of the American health system shifting to a more market-driven environment of networks and HMOs, this article focuses on the possible effects of these competitive strategies on the future demand for various categories of health manpower. The consolidation in healthcare resources by forming alliances and aligned HMOs, and the reduction in Medicare and Medicaid reimbursements have the impact of paying specialists less and generalists more. Some medical schools modified their curricula and encouraged more of their graduates to pursue family practice, general internal medicine, and pediatrics. Until recently, none of these efforts made a dent. Medical school graduates continue to find the specialties to be intellectually more rigorous, technologically more exciting, and know that they were still financially more rewarding than engaging in a primary care practice. And, the academic health centers continue to offer a large number of fellowships to supply the highly skilled, relatively inexpensive labor for delivering tertiary services. When completing their training programs, almost all subspecialists (anesthesiologists being among the exceptions) were still being recruited for positions that allowed them to make a comfortable living.     

The Physician Pipeline to Rural and Underserved Areas in Pennsylvania

ABSTRACT: Context: An implicit objective of a state's investments in medical education is to promote in‐state practice of state educated physicians. Purpose: To present a tool for evaluating this objective by analyzing the “pipeline” from medical education to patient care, primary care, rural areas, and underserved areas in Pennsylvania. Methods: AMA Masterfile data (2004) including all physicians with a Pennsylvania address or who received medical education in Pennsylvania were analyzed. These data were combined with local physician supply data. Results: About 36% of Pennsylvania medical school graduates provide patient care in the Commonwealth, 16% primary care, 7% rural care, 4% rural primary care, and 0.5% primary care in a rural underserved area. Fifty‐four percent of physicians who received both undergraduate and graduate medical education in‐state are retained. Conclusions: These retention rates have developed within the context of a middle‐of‐the‐road educational pipeline policy. If Pennsylvania policy makers consider that further pipeline development is advisable, there is room to amend current policy to that end. Conditions are favorable for other states to consider similar policy amendments.     

Residents' preferences and preparation for caring for underserved populations

Access to care by low-income persons and residents of rural and poor innercity areas is a persistent problem, yet physicians tend to be maldistributed relative to need. The objectives were to describe prefernces of resident physicians to locate in underserved areas and to assess their preparedness to provide service to low-income populations. A national survey was made of residents completing their training in eight specialties at 162 USacademic health center hospitals in 1998, with 2,626 residents responding. (Of 4,832 sampled, 813 had invalid addresses or were no longer in the residency program. Among the valid sample of 4,019, the response rate was 65%). The percentage of residents ranking public hospitals, rural areas, and poor inner-city areas as desirable employment locations and the percentage feeling prepared to provide specified services associated with indigent populations were ascertained. Logistic regressions were used to calculate adjusted percentages, controlling for sex, race/ethnicity, international medical graduate (IMG) status, plans to subspecialize, ownership of hospital, specialty, and exposure to underserved patients during residency. Only one third of residents rated public hospitals as desirable settings, although there were large variations by specialty. Desirability was not associated with having trained in a public hospital or having greater exposure to underserved populations. Only about one quarter of respondents ranked rural (26%) or poor inner-city (25%) areas as desirable. Men (29%. P<.01) and noncitizen IMGs (43%, P<.01) were more likely than others to prefer rural settings. Residents who were more likely to rate poor innercity settings as desirable included women (28%, P=.03), noncitizen IMGs (35%, P=.01), and especially underrepresented minorities (52%, P<.01). Whereas about 90% or more of residents felt prepared to treat common clinical conditions, only 67% of residents in four primary care specialties felt prepared to counsel patients about domestic violence or to care for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or substance abuse patients (all 67%). Women were more likely than men to feel prepared to counsel patients about domestic violence (70% vs. 63%, P=.002) and depression (83% vs. 75%, P<.01). Underrepresented minority residents were more likely than other residents to feel prepared to counsel patients about domestic violence (P<.01) and compliance with care (P=.04). Residents with greater exposure to underserved groups were more prepared to counsel patients about domestic violence (P=.01), substance abuse (P=.01), and to treat patients with HIV/AIDS (P=.01) or with substance abuse problems (P<.01). This study demonstrates the need to expose graduate trainees to underserved populations and suggests a contininuing role of minorities, women, and noncitizen physicians in caring for low-income populations.