Accessibility of primary care services in safety net clinics in New York City.

OBJECTIVES: This study analyzed data from a survey of New York City ambulatory care facilities to determine primary care accessibility for low-income patients, as evidenced by the availability of enabling services, after-hours coverage, and policies for serving the uninsured. METHODS: Ambulatory care facilities were surveyed in 1997, and analysis was performed on a set of measures related to access to care. Only sites that provided comprehensive primary care services were included in the analysis. For comparison, site were classified by sponsorship (public, nonprofit voluntary hospital, federally qualified health center, non-hospital-sponsored community health center). RESULTS: Publicly sponsored sites and federally qualified health center sites showed the strongest performance across nearly all the measures of accessibility that were examined. CONCLUSIONS: As safety net clinics confront the financial strain of implementing mandatory Medicaid managed care while also dealing with declining Medicaid caseloads and increasing numbers of uninsured, their ability to sustain the policies and services that support primary care accessibility may be threatened.

Medicaid managed care in New York City: recent performance and coming challenges.

OBJECTIVES: This study evaluated New York City's voluntary Medicaid managed care program in terms of health care use and access. METHODS: A survey of adults in Medicaid managed care and fee-for-service programs during 1996-1997 was analyzed. RESULTS: Responses showed significant favorable risk selection into managed care but little difference in use of health care services. Although some measures of access favored managed care, many others showed no difference between the study groups. CONCLUSIONS: The early impact of mandatory enrollment will probably include an increase in the average risk of managed care enrollees with little change in beneficiary use and access to care.

Primary care productivity and the health care safety net in New York City.

Urban safety net providers are under pressure to improve primary care productivity. In a survey of ambulatory care facilities in New York City, productivity (measured as the number of primary care visits per provider hour) increases with exam rooms per physician but has no association with computerized information systems or tightly controlled reimbursement. Also, sample facilities rely heavily on residents, which makes these facilities sensitive to medical education policies and raises questions about quality of care for the poor. We conclude that urban safety net providers will have difficulty making the productivity improvements demanded by a more competitive health system.

HMO market penetration and costs of employer-sponsored health plans.

Using two employer surveys, we evaluate the role of increased health maintenance organization (HMO) market share in containing costs of employer-sponsored coverage. Total costs for employer health plans are about 10 percent lower in markets in which HMOs' market share is above 45 percent than they are in markets with HMO enrollments of below 25 percent. This is the result of lower premiums for HMOs than for non-HMO plans, as well as the competitive effect of HMOs that leads to lower non-HMO premiums for employers that continue to offer these benefits. Slower growth in premiums in areas with high HMO enrollments suggests that expanded HMO market share may also lower the long-run growth in costs.

Health plan responses to Medicaid managed care policy in New York City.

Nearly all states in the United States have instituted managed care programs to serve Medicaid recipients and are developing policies to increase program participation. State practices regarding managed care contracting, premiums, and enrollment have implications for whether managed care plans will respond in a manner consistent with overall state policy objectives for the Medicaid managed care program. The experience of expanding the Medicaid managed care program in New York City, where the number of Medicaid beneficiaries exceeds the number in all but three states, has provided an interesting opportunity to look at the relationship between Medicaid managed care policy and plan enrollment. This paper analyzes trends in Medicaid managed care enrollment in New York City from January 1991 to September 1998, a period of critical changes in Medicaid managed care policy in New York.

Effect of an intensive educational program for minority college students and recent graduates on the probability of acceptance to medical school.

CONTEXT: Increasing the number of minority physicians is a long-standing goal of professional associations and government. OBJECTIVE: To determine the effectiveness of an intensive summer educational program for minority college students and recent graduates on the probability of acceptance to medical school. DESIGN: Nonconcurrent prospective cohort study based on data from medical school applications, Medical College Admission Tests, and the Association of American Medical Colleges Student and Applicant Information Management System. SETTING: Eight US medical schools or consortia of medical schools. PARTICIPANTS: Underrepresented minority (black, Mexican American, mainland Puerto Rican, and American Indian) applicants to US allopathic medical schools in 1997 (N =3830), 1996 (N = 4654), and 1992 (N =3447). INTERVENTION: The Minority Medical Education Program (MMEP), a 6-week, residential summer educational program focused on training in the sciences and improvement of writing, verbal reasoning, studying, test taking, and presentation skills. MAIN OUTCOME MEASURE: Probability of acceptance to at least 1 medical school. RESULTS: In the 1997 medical school application cohort, 223 (49.3%) of 452 MMEP participants were accepted compared with 1406 (41.6%) of 3378 minority nonparticipants (P= .002). Positive and significant program effects were also found in the 1996 (P=.01) and 1992 (P=.005) cohorts and in multivariate analysis after adjusting for nonprogrammatic factors likely to influence acceptance (P<.001). Program effects were also observed in students who participated in the MMEP early in college as well as those who participated later and among those with relatively high as well as low grades and test scores. CONCLUSIONS: The MMEP enhanced the probability of medical school acceptance among its participants. Intensive summer education is a strategy that may help improve diversity in the physician workforce.

Challenges of state health reform: variations in ten states.

This DataWatch reports on the key findings from the 1993 Robert Wood Johnson Foundation Family Health Insurance Survey, which interviewed more than 27,000 families in ten states. There is considerable variation among the states in insurance coverage, health status, and access to care of both adults and children. Moreover, states with higher percentages of uninsured residents also have populations with lower health status and more access problems. This clustering of problems in certain states may make health care reform even more challenging for their elected officials to accomplish.

Physician service to the underserved: implications for affirmative action in medical education.

Affirmative action is under increasing scrutiny. In medicine, the observation that minority physicians disproportionately serve minority patients has been one rationale for affirmative action. Using two large physician surveys, we find that minority and women physicians are much more likely to serve minority, poor, and Medicaid populations. Weaker, but significant association exists between physician and patient socioeconomic background. Service patterns are sustained over time and are generally consistent with physician career preferences. Ending affirmative action in medicine may imperil access to care. Results do not support affirmative action based on economic disadvantage instead of race, ethnicity, and sex.

Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey.

This DataWatch presents findings on Americans' ability to obtain health care. Data from the 1994 National Access to Care Survey sponsored by The Robert Wood Johnson Foundation suggest that earlier studies have underestimated the access problems facing Americans by not asking about supplementary services such as prescription drugs, eyeglasses, dental care, and mental health care or counseling. Using this more inclusive definition of health care needs, we estimate that 16.1 percent of Americans were unable to obtain at least one service they believed they needed. While income is highly correlated with unmet need, most persons reporting access problems are not poor.

Private employment-based health insurance in ten states.

This Data Watch reports key findings from the 1993 Robert Wood Johnson Foundation Employer Health Insurance Survey, through which more than 20,000 employers in ten states were interviewed. Our report contrasts the behavior of four size classes of small businesses (fewer than fifty workers) with that of all other businesses. We examine offer rates by business size; characteristics of employers and workers in business offering and not offering insurance; premiums, benefits, and medical underwriting; the extent of choice among plans; and self-insurance. We discuss the implications of our findings for health policy.

What makes young HMO physicians satisfied?

While much attention has been paid to the effect of managed care on patient outcomes and health care costs, little attention has been focused on the ways in which managed care affects the satisfaction of physicians. Examination of the practice and career satisfaction of 189 young physicians practicing in group and staff model HMOs finds high levels of satisfaction. More than 82% are satisfied with their current practice. The most important factor influencing physician satisfaction appears to be the extent of perceived autonomy. Neither the number of hours worked per week nor yearly income were strongly associated with decreases in satisfaction. The fact that minority and female physicians report less satisfaction with some dimensions of practice raises important issues for HMO physicians and managers.

Attending physician coverage in a teaching hospital's emergency department: effect on malpractice.

It seems self-evident that the establishment of 24-hour per day attending physician coverage in a teaching hospital's emergency department would enhance risk management. However, prior to this study, little investigation had been done to corroborate the effects of full-time emergency department attending physician coverage. In a retrospective study from a large teaching hospital's emergency department, malpractice claims filed for 1985-1987 (part-time attending physician coverage) were analyzed and compared to those for 1987-1989 (full-time attending physician coverage). A total of 98 claims were filed; these data were derived from 466,862 patient visits. Attending physician presence increased from 6000 hours per year in 1985-1987 to 26,280 hours per year in 1987-1989. There was an 18.5% decrease in claims filed, and a 70.1% decrease in disbursements for the first 2 years after the introduction of full-time attending physician coverage as compared with the preceding 2 years. These findings suggest that full-time attending physician coverage in the emergency department is associated with improved risk management.

Preparedness for practice. Young physicians' views of their professional education.

OBJECTIVE: To describe the views of young physicians (younger than age 45 years) regarding the appropriateness of specific aspects of medical training that have often been criticized as inadequate. DESIGN: Proportional analysis of survey data, stratified by medical school type and graduate medical education specialty and adjusted for demographics. SETTING: National sample of 4756 allopathic and osteopathic physicians trained in allopathic residencies representing a variety of practice settings. DEPENDENT VARIABLES: Overall satisfaction with medical training, including medical school through residency and fellowship; satisfaction with preparedness for five aspects of practice and six types of patients; and satisfaction with the amount of time spent in each of six training settings. RESULTS: Eighty percent of young physicians reported that their formal medical training did an excellent or good job of preparing them for medical practice. Much smaller proportions (21% to 78%) reported excellent or good preparation to treat specific conditions or types of patients, and few (3%) reported being well prepared to manage business aspects of practice. Large proportions (35% to 63%) would prefer to have received more training in settings outside of hospitals, including managed care settings (67%). Significant differences in preparedness were observed by type of training; those trained in general and family practice reported better preparedness along many dimensions than did those trained in general internal medicine. CONCLUSIONS: Young physicians generally confirm critiques of medical training noted by scholars and commissions. Health care reform is likely to increase the urgency for remedial action.

Physicians' perspectives on caring for patients in the United States, Canada, and West Germany.

BACKGROUND: The United States is considering enacting a national health plan and global health care budget similar to those in other countries. There are few data on the effects of such policies on physicians and patients. METHODS: We conducted a telephone survey of 602 physicians in the United States, 507 physicians in Canada, and 519 physicians in the former West Germany from February through May 1991; the response rates were 44 percent, 49 percent, and 41 percent, respectively. Among other topics, the questionnaire included measures of satisfaction with the health care system and with medical practice. RESULTS: In the United States, 23 percent of the physicians surveyed thought the health care system worked well, as compared with 33 percent in Canada and 48 percent in West Germany. Seventy-three percent of U.S. physicians reported that patients' inability to afford necessary treatment was a serious problem, as compared with 25 percent in Canada and 15 percent in West Germany. Seventy-seven percent of West Germany physicians, 56 percent of Canadian physicians, and 54 percent of U.S. physicians said the shortage of competent nurses was a serious problem. In Canada, 50 percent of the respondents cited the lack of well-equipped medical facilities as a problem, as compared with 14 percent in the United States and 20 percent in West Germany. CONCLUSIONS: Programs of universal coverage and cost containment necessitate important trade-offs. In Canada and West Germany, physicians do not report serious problems of access to care for the poor and uninsured. In the United States, doctors do not face the limited access to sophisticated forms of medical technology that was reported in Canada or the diminished quality of some services reported in West Germany.

Health reform lessons learned from physicians in three nations.

To explore the concerns of practicing physicians as a way to inform the health reform debate, the authors conducted a survey of physicians in the United States, Canada, and Germany. Survey results indicate that U.S. physicians are most likely to view affordability as the greatest barrier to access to care for their patients. However, unavailability of services and long waiting times were cited most often by Canadian physicians. German physicians did not cite access problems as frequently as Canadian physicians did; other measures of satisfaction were closer to U.S. levels, suggesting fewer trade-offs if the United States were to adopt aspects of the German health care system.

Physician satisfaction under managed care.

Data from a survey of young physicians have been analyzed to study the relationship between practicing medicine under managed care and the levels of perceived professional autonomy, practice satisfaction, and career satisfaction. Although practicing under managed care is associated with lower levels of perceived autonomy in patient selection and time allocation, it is associated with higher levels of perceived autonomy in use of hospital care, tests, and procedures. Specialists associated with managed care perceive more autonomy than generalists. Analyses of physicians' satisfaction with their practices and careers show that practicing under managed care is not uniformly associated with lower levels of satisfaction. Overall, managed care does not seem to have had the deleterious impact on medical practice that was forecast for it.

Young physicians most and least likely to have second thoughts about a career in medicine.

To identify factors associated with apparent disaffection with medicine as a career, the authors analyzed data for 4,931 young physicians surveyed in 1987. Using survey responses, the authors classified 932 of the physicians (18.9%) as most likely to have second thoughts about their career choices and 1,094 (22.2%) as least likely to have second thoughts. The group with the greatest reservations included significantly higher proportions of white women, blacks, and Hispanics. This group reported significantly lower incomes, higher educational debt, and more hours and patients' visits per week. Among employee physicians, those most disaffected were significantly more likely to report inappropriate use of tests and procedures and lack of autonomy in their practices. The authors conclude that it is important to reexamine the heavy reliance on debt financing of medical education, especially for minority students, and to explore the equality of career opportunities for women and minorities in medicine.