Andrew A. Sorensen

The tides of rural physicians: the ebb and flow, or why physicians move out of and into small communities.

To determine the characteristics of physicians who move into and out of rural areas, as well as their reasons for establishing or leaving such practices, we sent questionnaires to 67 physicians who began practice in selected rural counties in upstate New York and 88 physicians who left practices in roughly the same area. From the 52 physicians (77.6 per cent) who responded to the former survey we found that 1) good professional support is mandatory for maintaining a satisfying small community practice, 2) a predisposition to small community living is essential for physicians to be recruited for rural practice, and 3) there are substantial differences with respect to demographic characteristics among persons who share similar reasons for practicing medicine in this region. For the 68 physicians (72.0 per cent) who responded to the latter survey, the reasons for leaving could be grouped in the following categories; economic, social, and professional, logistic. Although all of these factors contribute to the decision to leave, physician geographical mobility seems to stem chiefly from an unsatisfactory professional situation. These findings suggest several strategies for improving the situations in which rural physicians practice, and thus altering the massive imbalance in physician: patient ratios in urban and rural areas.

Factors Influencing Disenrollment From an HMO

A survey was conducted of people who disenrolled from a prepaid group practice Health Maintenance Organization (HMO). Disenrollees were more dissatisfied with the organization of the HMO and the care they received than those who remained in the plan. Changes in eligibility for HMO coverage and dissatisfaction with medical service were the first and second most frequently reported reasons for disenrollment. Although the sample was drawn during a period when there was an increase in the cost of HMO premiums and a concomitant decrease in the cost of comparable Blue Cross/Blue Shield premiums the disparity of costs for health insurance was given by only a small proportion of respondents as the reason for disenrollment.

Demographic Characteristics and Prior Utilization Experience of HMO Disenrollees Compared With Total Membership

In the 2 months immediately after a premium rate increase, the Genesee Valley Croup Health Association (Group Health) lost over 600 subscriber contracts. A survey was conducted to determine the reasons for disenrollment and compare the demographic and utilization characteristics of disenrollees with those of all members during the previous calendar year. The disenrollees were members of smaller families and were concentrated in a younger adult age group (15 to 35 years). The disenrollee ambulatory utilization rate was 14.5 per cent lower than for all members and their inpatient utilization (days/1,000) rate was 35 per cent lower. While maternity/nursery days were higher for disenrollees, medical/surgical days were 56 per cent lower. Age-adjusted medical/ surgical days were 63.9 per cent lower. Although there was concern about possible adverse effects of a rate increase, the 1980 group Health inpatient utilization rates were virtually the same as for 1979, the year before the rate increase studied.

Appropriateness of Vitamin and Mineral Prescription Orders for Residents of Health Related Facilities

A study was made of the medical charts of 433 elderly patients admitted to four Health Related Facilities in upper New York State, to determine whether the respective prescription orders for vitamins and minerals were appropriate to the given diagnoses and, if not, to identify the variables correlated with inappropriateness. For 11.1 percent of the patients, vitamins or minerals were prescribed when there was no specific diagnostic indication, or they were not prescribed when the medical diagnosis indicated that they should have been. Women and Medicaid patients were more likely than men and self‐paying patients to be treated inappropriately with respect to vitamins and minerals, but the differences were not statistically significant.

Discrepancies between admission and discharge diagnoses in a university hospital.

Admission screening and certification systems for utilization review are based on acceptance of attending physicians’ admitting diagnoses. This study was conducted to: 1) determine the consistency of admission diagnosis as compared to discharge diagnosis: 2) identify the characteristics of patients and diagnoses subject to higher rates of diagnostic discrepancy; and 3) analyze the apparent reasons for such discrepancies. The following methods were used: direct comparison of admission and discharge diagnosis on a sample (n = 955) of university hospital patients using a rating scale to measure the degree of change in specificity and category of diagnosis; analysis of diagnostic change by hospital service, demographic characteristics of patients, length of stay, and source of payment; review of charts with the greatest diagnostic discrepancy. Diagnostic changes were found in 26.8 per cent of all admissions (n = 230) and were most frequent in neurological, medical and pediatric patients. The rate of change varied with patient age and length of stay and was lowest in Medicaid patients. Changes were usually from general to more specific diagnoses in related categories, with 4.3 per cent being discharged undiagnosed and 2.9 per cent with unrelated diagnoses. Major causes for discrepancies were related to clinical and laboratory findings. No evidence was found for deliberate diagnostic manipulation to gain admission or to improve financial coverage.

Selection of Medical School Deans in the US, 1954-1979

A review of biographical data of all persons who served as deans of United States medical schools from 1954 until 1979 indicated that: firstly, clinical faculty continue to dominate deanships; secondly, faculty from fields such as pathology and pharmacology that bridge the traditional dichotomy between pre-clinical and clinical faculty are increasingly being selected as deans; thirdly, clinical specialty fields in which the salaries are very high (with the notable exception of surgery) have consistently contributed few deans; lastly, being a graduate of a highly prestigious medical school is of diminishing value in affecting the likelihood that one will be appointed dean at any medical school, except at highly prestigious medical schools.

The effects of regional planning on a rural hospital: a case study.

Abstract The growth of regional health planning in the Rochester region is described, and it is pointed out that much of the impetus came from cost-conscious industrial leaders. Then the impact of the increasing regulatory powers of various health planning agencies on one local community attempting to build a new hospital is discussed. The successful effort to build the new hospital has resulted in the attraction of new physicians to the community, which had until then been in danger of losing the few physicians who still provided care to local residents. The new physicians were necessary in order to enlarge the hospital catchment area, attract more patients and pay for the new hospital. Other important consequences for the community were related to the infusion of jobs and money that the new and enlarged hospital provided. Moreover, along with the school system, availability of health care is important if suburbanizing communities are to attract new residents and become economically viable. Thus, the fact that this community was able to build a new hospital gives it a competitive edge over other subdominant communities within the regional economy.

Changing health care opinions in Regionville, 1946-1973.

This survey is a partial replication study of a community with the fictitious name of Regionville which was first studied by E. L. Koos in the period 1946-50. In the present paper, we are concerned principally with that part having to do with the changing health care beliefs in this community. The indications are that: 1) there has been considerable liberalization of opinion, particularly among upper class respondents, in terms of issues relating to national health insurance and the role of ancillary medical personnel such as social workers; and 2) social classes are much more similar in their perceptions of many medical care issues now than they were a generation ago. Finally, we suggest that the changing pattern of responses to the questions asked in the late 1940s and again in 1973 is reflective of profound changes in American life.

The relation of membership duration to prepaid group practice utilization rates: a reexamination.

length of time in an HMO increased might not be due to the selective disenrollment of members with higher rates of utilization. While our earlier disenrollment study published in Medical Care did not address this point,5 the evidence in an article that is in this issue of Medical Care (p. 1241) shows that the ambulatory utilization of Genesee Valley Group Health Association (Group Health) disenrollees during the calendar year immediately preceding disenrollment is 14.5 per cent lower than for all

Mutual Education of Drug Addicts and Townspeople: Establishing a Residential Facility in a Nonurban Area

The development of Alpha House, a therapeutic community in Ithaca, New York, is described. The success of this program is attributed to many factors, such as: the inclusion of a variety of persons in program planning, the response to a perceived drug crisis, the commitment of established community leaders, and the reliance upon the immediate community for financial support during the programs early stages.