Stephen S. Mick

Primary care service areas: a new tool for the evaluation of primary care services.

OBJECTIVEnTo develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians.nnnDATA SOURCE/STUDY SETTINGnThe 1996-1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996).nnnSTUDY DESIGNnA patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims.nnnDATA COLLECTION/EXTRACTION METHODSnPart B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes.nnnPRINCIPAL FINDINGSnThe study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005-1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical.nnnCONCLUSIONSnPrimary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.

Variations in geographical distribution of foreign and domestically trained physicians in the United States: ‘safety nets’ or ‘surplus exacerbation’?

In the United States, a debate has existed for decades about whether foreign-trained physicians (known in the US as international medical graduates or IMGs) and US medical graduates (USMGs) have been differentially distributed such that IMGs were more likely to be found in locales characterized as high in need or medical underservice. This safety net hypothesis has been countered by the IMG surplus exacerbation argument that IMGs have simply swelled an already abundant supply of physicians without any disproportionate service to areas in need. Through an analysis of the American Medical Association Physician Masterfile and the Area Resource File, we classified post-resident IMGs and USMGs into low and high need counties in each of the US states, compared the percentage distributions, and determined whether IMGs were found disproportionately in high need or underserved counties. Using four measures (infant mortality rate, socio-economic status, proportion non-white population, and rural county designation), we show that there were consistently more states having IMG disproportions than USMG disproportions. The magnitude of the differences was greater for IMGs than for USMGs, and there was a correlation between IMG disproportions and low doctor/100,000 population ratios. These findings are shown to exist simultaneously with two empirical facts: first, not all IMGs were located in high new or underserved counties; second, IMGs were more likely than USMGs to be located in states with a large number of physicians. The juxtaposition of an IMG presence in safety net locales and of IMGs contribution to a physician abundance is discussed within the context of the current debate about a US physician surplus and initiatives to reduce the number of IMGs in residency training.

Why Do Some Primary Care Practices Engage in Practice Improvement Efforts Whereas Others Do Not

OBJECTIVEnTo understand what motivates primary care practices to engage in practice improvement, identify external and internal facilitators and barriers, and refine a conceptual framework.nnnDATA SOURCESnIn-depth interviews and structured telephone surveys with clinicians and practice staff (n = 51), observations, and document reviews.nnnSTUDY DESIGNnComparative case study of primary care practices (n = 8) to examine aspects of the practice and environment that influence engagement in improvement activities.nnnDATA COLLECTION METHODSnThree on-site visits, telephone interviews, and two surveys.nnnPRINCIPAL FINDINGSnPressures from multiple sources create conflicting forces on primary care practices improvement efforts. Pressures include incentives and requirements, organizational relationships, and access to resources. Culture, leadership priorities, values set by the physician(s), and other factors influence whether primary care practices engage in improvement efforts.nnnCONCLUSIONSnMost primary care practices are caught in a cross fire between two groups of pressures: a set of forces that push practices to remain with the status quo, the 15-minute per patient approach, and another set of forces that press for major transformations. Our study illuminates the elements involved in the decision to stay with the status quo or to engage in practice improvement efforts needed for transformation.

The influence of institutional pressures on hospital electronic health record presence

Electronic health records (EHR) are a promising form of health information technology that could help US hospitals improve on their quality of care and costs. During the study period explored (2005-2009), high expectations for EHR diffused across institutional stakeholders in the healthcare environment, which may have pressured hospitals to have EHR capabilities even in the presence of weak technical rationale for the technology. Using an extensive set of organizational theory-specific predictors, this study explored whether five factors - cause, constituents, content, context, and control - that reflect the nature of institutional pressures for EHR capabilities motivated hospitals to comply with these pressures. Using information from several national data bases, an ordered probit regression model was estimated. The resulting predicted probabilities of EHR capabilities from the empirical models estimates were used to test the studys five hypotheses, of which three were supported. When the underlying cause, dependence on constituents, or influence of control were high and potential countervailing forces were low, hospitals were more likely to employ strategic responses that were compliant with the institutional pressures for EHR capabilities. In light of these pressures, hospitals may have acquiesced, by having comprehensive EHR capabilities, or compromised, by having intermediate EHR capabilities, in order to maintain legitimacy in their environment. The study underscores the importance of our assessment for theory and policy development, and provides suggestions for future research.

GEOCODING PUBLIC HEALTH DATA

Krieger et al. correctly alert readers to potential sources of error when linking health data to census-derived socioeconomic data.1 The authors’ criticisms of zip code–based data speak to neither the advantages of postal zip codes (ZCs) nor the limitations of other geographies. We would like to correct some minor factual errors in Krieger et al. and to point out that researchers must pay careful attention to spatiotemporal discontinuities in all geography-based analyses. n nSpatiotemporal discontinuities in calculating rates for specific geographies occur because populations change over time and space. ZCs reflect population change more quickly than census tracts (CTs), and commercial products are available with current estimates of ZC populations. CTs appear more stable only because they are updated less frequently. Using 1999 estimates of cancer incidence in a numerator with 1990 estimates of population in the denominator creates problems regardless of the geographic unit. n nChanges in CT boundaries occur as well. Between 1980 and 1990, 23% of CTs had deliberate changes to boundaries (K. Miller, Geographic Areas Branch, US Census Bureau, oral communication, July 12, 2002). Using the CT Relationship Files,2 we calculate that at least 21% of CTs in 2000 had changes resulting in at least 2.5% of the population’s being spatially located in a new tract. Both ZCs and CTs require careful attention to potential spatiotemporal discontinuities. n nThe authors also state that large areas of ZCs can straddle state lines. In our own research we have found only 6 cases out of more than 30 000 1999 ZCs in which state boundaries were crossed.3,4 n nData from the 2000 census are being released in zip code tabulation areas. Zip code tabulation areas will be stable until the next decennial census, and they provide highly accurate sociodemographic data. n nAlthough we applaud the authors’ contributions to the growing interest in geocoding public health data and recognize the limitations of a research brief, we believe a more balanced presentation of problems with all geographic units is called for.

Foreign medical graduates in the 1980s: trends in specialization.

Secondary analysis of data collected by the American Medical Association and the Graduate Medical Education National Advisory Committee (GMENAC) suggests that measures to diminish the flow of alien Foreign Medical Graduates (FMGs) into the United States have been less effective than planned. Declining trends in the proportion of FMG house officers in the mid- to late-1970s have recently stabilized around 19 per cent. There has also been a dramatic increase in the number of US citizen Foreign Medical Graduates ( USFMGs ) in house officer positions. A pattern of alien FMG and USFMG house officer specialization correlates with specialties designated by the GMENAC as shortage areas by 1990 (r = -.49, p less than .05). Despite the GMENAC prediction of a surplus of physicians by 1990, differential selection of alien FMGs and USFMGs into shortage specialties may assure their substantial future presence in the US health care system.

The Physician "Surplus" and the Decline of Professional Dominance

��� Two immediate circumstances cast a shadow over [physicians, voluntary hospitals, and medical schools’] future: the rapidly increasing supply of physicians and the continued search by government and employers for control over the growth of medical expenditures. —Paul Starr, The Social Transformation of American Medicine (emphasis added) This essay examines the relationship that Paul Starr hypothesized in The Social Tranformation of American Medicine (1982) between the supply of physicians (both allopaths and osteopaths) and their professional dominance, a relationship, he argued, that began to turn negative about the time of the passage of Medicaid and Medicare in 1965. In particular, Starr posited that an increasing number of physicians, dubbed a “surplus,” would become an essential condition in reducing their dominance over the health care system, while abetting the larger process of corporatization that the medical profession was experiencing (421‐427). In the pages that follow, I first outline the main points of Starr’s argument, one that was also accepted by many others (Mick 1980). Second, I discuss how and why growth in physician supply has not contributed as much as was predicted to a putative decline in medicine’s privileged professional status. Finally, I propose that whether physician supply is in surplus (or shortage) is a

Public Attitudes toward Health Planning under the Health Systems Agencies

The demise of the National Health Planning and Resources Development Act of 1974 (PL 93-641) raises questions about the degree of public support it had for planning goals. The results of a 1978 nationwide public opinion poll reveal (1) low confidence in and recognition of the Acts institutional arms, the Health Systems Agencies; (2) little support for hospital cost containment strategies and their consequences; and (3) less than average support for these goals and consequences among those groups traditionally under-represented in health planning activities. The results suggest that the Act did not reconcile centralized federal goal formation with democratic local health planning.