Shortcomings in Medicare bonus payments for physicians in underserved areas.
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This study examines trends in Medicare spending for basic payments and bonus payments for physician services provided to beneficiaries residing in nonmetropolitan counties. For our analysis, we used Medicare Part B physician/supplier claims data for 1992, 1994, 1996, and 1998. Payments under the congressionally mandated bonus payment program acccounted for less than 1 percent of expenditures for physician services in nonmetropolitan, underserved counties. Physician payments increased from 1992 to 1998, while bonus payments increased through 1996 but then declined by 13 percent by 1998. The share of bonus payments to primary care physicians declined throughout the decade, but the share for primary care services increased. (+info)
Age distribution and turnover of physicians in nonmetropolitan counties of the United States.
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Using data for 1975 to 1985 from the Area Resource File (ARF), net number changes in different age groups of physicians practicing in nonmetropolitan counties are examined. Small net increases are seen in the higher age groups in most county size categories but the most striking change is large increases in the age groups up to age 44. Family practitioners show a net decline in all county size categories for ages 45-54, but these are offset by increases in medical specialists. In counties of less than 25,000 population, the rate of turnover of physicians over the 1983-1988 period was 25 percent; physicians exiting these counties had a mean age of 52.3 years. The data indicate that aging of physicians in rural counties should not affect maintenance of current supply in the short run, but that increasing the physician-to-population ratio in areas with less adequate supply will be difficult, particularly if the rate of increase of younger physicians in nonmetropolitan counties does not continue. (+info)
Services provided for preschool-aged children with suspected amblyopia.
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BACKGROUND: Little is known about the pattern and variation of care offered to preschool-aged children who have had an abnormal vision screening test. PURPOSE: To evaluate the variations in pediatric eye care services and availability of optometrists and ophthalmologists for preschool-aged patients, referral patterns, and barriers to providing care as perceived by eye care specialists. METHODS: A survey was mailed to 542 ophthalmologists and a random sample of 501 optometrists actively practicing in Michigan. RESULTS: The response rate was 65% (optometrists, 75%; ophthalmologists, 57%). More optometrists than ophthalmologists evaluated preschool-aged children (97% vs 79%; P < .001). Of these, most managed amblyopia (80% vs 77%; P = .372) and strabismus (89% vs 80%; P = .002) themselves. Fewer optometrists than ophthalmologists dilated eyes routinely during the first evaluation of a preschool-aged child (39% vs 93%; P < .001). The leading barrier to care for preschool-aged children reported by both optometrists and ophthalmologists was difficulty of the examination (25% vs 23%; P = .501). Optometrists reported that most of their patients were referred from community-based screening programs or by parent self-referral. Ophthalmologists reported that most of their preschool-aged patients were referred from primary care providers. CONCLUSIONS: There are different sources of referrals for optometrists and ophthalmologists. Although most eye care specialists treat amblyopia, the types of care offered by optometrists and ophthalmologists differ. Future studies should address the impact that these patterns have on outcomes and cost. The results of these studies should be shared with those responsible for screening. (+info)
Assessing the cultures of medical group practices.
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BACKGROUND: The culture of medical group practices is gaining increasing attention as one of the most important organizational factors influencing the costs and quality of health care. Based on organizational theory, we propose that the culture of the practice differs depending on size, ownership, location, and the number of medical specialties. METHODS: A survey was sent to 1223 physicians in 191 clinics in the upper Midwest. The clinic response rate was 77%. The survey instrument identifies 9 culture dimensions, each with 3 to 6 measurement statements. RESULTS: Smaller clinics had higher scores on 6 of the 9 dimensions. Physician-owned clinics had higher scores on 4 of the 9 dimensions, whereas system-owned clinics had a higher score on only 1 dimension. Only 1 dimension differed among the locations. Single-specialty clinics had higher scores on 4 dimensions and multispecialty clinics had higher scores on 2 dimensions. CONCLUSION: Our data confirm the contention that the culture of medical group practices varies considerably; to a degree, this variance is as predicted by organizational theory. The culture changes as group practices become larger and more complex through diversification into multispecialty practices or become part of larger health care systems. (+info)
Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington.
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PURPOSE: Little is known about whether different types of physician and nonphysician primary care clinicians vary in their propensity to care for underserved populations. The objective of this study was to compare the geographic distribution and patient populations of physician and nonphysician primary care clinicians. METHODS: This study was a cross-sectional analysis of 1998 administrative and survey data on primary care clinicians (family physicians, general internists, general pediatricians, nurse practitioners, physician assistants, and certified nurse-midwives) in California and Washington. For geographic analysis, main outcome measures were practice in a rural area, a vulnerable population area (communities with high proportions of minorities or low-income residents), or a health professions shortage area (HPSA). For patient population analysis, outcomes were the proportions of Medicaid, uninsured, and minority patients in the practice. RESULTS: Physician assistants ranked first or second in each state in the proportion of their members practicing in rural areas and HPSAs, and in California physician assistants also had the greatest proportion of their members working in vulnerable populations areas (P < .001). Compared with primary care physicians overall, nurse practitioners and certified nurse-midwives also tended to have a greater proportion of their members in rural areas and HPSAs (P < .001). Family physicians were much more likely than other primary care physicians to work in rural areas and HPSAs (P < .001). Compared with physicians, nonphysician clinicians in California had a substantially greater proportion of Medicaid, uninsured, and minority patients (P < .001). CONCLUSIONS: Nonphysician primary care clinicians and family physicians have a greater propensity to care for underserved populations than do primary care physicians in other specialties. Achieving a more equitable pattern of service to needy populations will require ongoing, active commitment by policy makers, educational institutions, and the professions to a mission of public service and to incentives that support and promote care to the underserved. (+info)
A comparison of primary care graduates from schools with increasing production of family physicians to those from schools with decreasing production.
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BACKGROUND AND OBJECTIVES: This study investigated factors related to declining interest in family medicine by US medical school graduates. METHODS: A questionnaire was sent to all physicians who graduated from 24 medical schools in 1997-1999, and who entered a family medicine residency, and a randomly selected equal number of graduates from the same years who entered other primary care specialties. Between 1997 and 1999, 12 of these schools had increases and 12 had decreases in the proportion of graduates choosing family medicine residencies. RESULTS: Between 1997 and 1999, at schools with increasing proportions of graduates choosing family medicine, there were significant increases in the proportion of graduates who (1). had entered medical school with a specialty preference of family medicine, (2). spent their required family medicine clerkship at two or more sites, (3). ranked the competence of family medicine faculty highly, (4). reported the faculty member they most wanted to be like was a family physician, and (5). experienced clinical rotations in both family medicine and primary care. At schools with declines in the proportion of graduates choosing family medicine, there were significant declines in the proportion of graduates who (1). ranked the competence of family medicine faculty highly, (2). stated that they were encouraged to go into family medicine, and (3). reported that the faculty member they most wanted to be like was a family physician. In schools with decreases in family medicine graduates, there was a significant increase in the proportion of graduates intending a large city or suburban practice. Using binary logistic regression, the variables that remained significantly correlated with attending a school with increases or decreases in students selecting family medicine were the number of required clinical rotations in family medicine and primary care, the perception of the clinical competence of the family medicine faculty, and an intent to practice, or subsequently having a practice, in a rural area. CONCLUSIONS: Schools that want to increase their production of family physicians should consider admissions policies that select students inclined toward family medicine and rural practice, should adopt a curriculum that maximizes clinical training with family physicians and other primary care physicians, and should ensure that their family medicine faculty are perceived as competent role models. (+info)
Medical students' perceptions of rural practice following a rural clerkship.
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BACKGROUND AND OBJECTIVES: Evidence suggests that rural experiences can positively influence students' preferences for rural practice. This study examined changes in students' perceptions toward rural primary care following a required rural clerkship. METHODS: Third-year students completed pre- and post-clerkship questionnaire items assessing their beliefs about primary care physicians who practice in rural communities in comparison with their urban/suburban counterparts. A factor analysis was performed, and pre- and post-clerkship scale means were calculated to determine differences. RESULTS: A total of 428 (88%) students completed these questionnaires. There was a significant increase in students' perceptions of rural primary care physicians' primary care service features and medical expertise. Students perceived the physicians' work demands more positively, and there was no change in students' perceptions of the physicians' income potential. CONCLUSIONS: Results suggest that the rural primary care clerkship positively influenced students' perceptions toward rural primary care. (+info)
Geographic location of commercial plasma donation clinics in the United States, 1980-1995.
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OBJECTIVE: We examined the location of commercial plasma donation centers in the United States over the period 1980 to 1995 relative to the geographic distribution of risk behaviors associated with transfusion-transmissible infections. METHODS: The census tract locations of commercial source plasma clinics were described by measures of neighborhood social disadvantage and the prevalence of illicit drug use and active local drug economies. RESULTS: Depending on the measure of social environment used, commercial plasma clinics were 5 to 8 times more likely to be located in census tracts designated high-risk than would be expected by chance. CONCLUSIONS: Commercial source plasma clinics were overrepresented in neighborhoods with very active local drug economies. These patterns persisted after the links between human immunodeficiency virus and hepatitis C virus infections and plasma products had been established and may present risks to blood system safety. (+info)