Community-oriented primary care. Implementation of a national rural demonstration.

A major objective of community-oriented primary care (COPC) is to focus the clinical practice on the health care problems of the community that the practice serves. The COPC process defines the community of interest, identifies and prioritizes community health problems, and implements and evaluates interventions. Under sponsorship from the W. K. Kellogg Foundation, the COPC National Rural Demonstration Program was established to explore the feasibility of implementing COPC in 13 rural practices. An evaluation of the program found that local communities played critical roles in defining and implementing COPC interventions. These interventions were most often focused on health promotion/illness prevention activities. At most sites, clinical practices were limited in their ability to incorporate COPC activities by staff and physician turnover and the extensive patient demands on the time of rural primary care physicians. While the COPC process proceeded at different rates across the sites, after 2 1/2 years of grant funding, most sites continued to devote the majority of their resources to designing and implementing interventions. Thus, it appears that coordination by dedicated nonphysician staff and more than 2 years of effort are required to implement COPC concepts in rural practices in underserved areas.

Organizational and administrative factors influencing the adoption of consortia programs by rural hospitals.

This study was designed to assess the effects of various hospital and environmental characteristics on the involvement of rural hospitals in forming and governing consortia and adopting consortia programs. The study focused on the 127 hospitals that are members of the nine rural consortia developed by grants from the Robert Wood Johnson Foundation during 1989 under its Hospital-Based Rural Hospital Consortia Program. Hospital involvement in the formation and governance of the consortia was found to be far less than expected for these grass-roots organizations. Only 38 percent of the administrators said that their hospitals were involved in developing the consortia, and 44 percent said that they played a role in determining the program menu. Governing board and medical staff involvement was even more limited. Program adoption rates were found to be related to both the types of programs offered by the consortia and the characteristics of the hospitals. In general, greater involvement of physicians and governing board members in hospital decisions was found to enhance program adoption rates, but the influence varied by type of involvement in the hospital and program content.

A program to support small rural hospitals.

Rural hospitals continue to face the threat of closure. Congress passed legislation in 1989 and 1990 to offer an alternative for small rural hospitals; the legislation encourages hospitals to form networks comprising an essential access community hospital (EACH) and one or more rural primary care hospitals. This legislation is a tightly focused program that will affect no more than an estimated 150 hospitals in seven states; implementation of the program has been controversial, as this DataWatch demonstrates. The authors describe the profile of rural hospitals that are likely to apply to participate in the program, based on distances between hospitals and number of beds.

Does capitation affect the health of the chronically mentally ill? Results from a randomized trial.

OBJECTIVE: To determine the effect on health outcomes of enrollment of chronically mentally ill Medicaid recipients in prepaid plans vs traditional fee-for-service Medicaid. DESIGN: A randomized controlled trial. Clients who were randomly assigned to prepaid care were then permitted to choose among four capitated health plans. Clients returned to fee-for-service care at the end of the demonstration. SETTING: The Medicaid Demonstration Project in Hennepin County, Minnesota, the urban center of which is Minneapolis. PATIENTS: Seven hundred thirty-nine Medicaid clients who were classified as having chronic mental illness on the basis of Medicaid claims. Clients were interviewed at baseline (time 1) and at two follow-up points. Data were available for 96% of participants at the end of the intervention (time 2). Average duration of follow-up was 11 months. A subset of 370 clients with schizophrenia was followed up 11 months after the return of the prepaid group to fee-for-service care (time 3). MAIN OUTCOME MEASURES: General health status, physical functioning, social functioning, and psychiatric symptoms, assessed using the Schedule of Affective Disorders and Schizophrenia-Change version, the Global Assessment Scale, and indicators of community function. RESULTS: No significant differences between prepaid and fee-for-service groups in general health or psychiatric symptoms from baseline to time 2. After regression adjustment, 12% fewer clients in the prepaid group reported being victimized (P less than .01). At the end of time 3, the regression-adjusted Global Assessment Scale scores had worsened by 7.6 points more in the prepaid group in comparison with the fee-for-service group (P less than .02). CONCLUSION: There was no consistent evidence of harmful effects of enrolling chronically mentally ill Medicaid clients in prepaid care, at least in the short run. The generalizability of these findings may be limited to plans that control utilization by methods similar to those used in this study setting. Longer-term outcome studies should be undertaken to clarify the strength of the findings.

Use of community-based mental health programs by HMOs: evidence from a Medicaid demonstration.

BACKGROUND: Proposals to enroll Medicaid beneficiaries in health maintenance organizations (HMOs) have raised concerns that community-based mental health treatment programs would be adversely affected. METHODS: In Hennepin County (Minnesota) 35% of Medicaid beneficiaries were randomly assigned to prepaid plans. Random samples of individuals with severe mental illness with selected from the prepaid enrollees and from beneficiaries remaining with traditional Medicaid. The two groups were compared with respect to their use of community treatment programs and the write-off (the proportion of patient charges for which payment was not received) experienced by those programs for members of the study sample. RESULTS: There was no strong evidence that Medicaid beneficiaries with severe mental illness who were randomly assigned to prepaid plans used community-based mental health treatment programs differently than did other Medicaid beneficiaries. However, write-offs were consistently higher for enrollees in prepaid plans. CONCLUSIONS: In the short run, the use of community-based mental health treatment programs need not be affected by enrollment of Medicaid beneficiaries in prepaid plans, providing that Medicaid program administrators take steps to minimize the disruption of ongoing treatment, offer beneficiaries a choice among prepaid plans, and encourage community treatment programs to contract with plans to serve beneficiaries.

Quality assurance issues raised by proposed limited-service rural hospitals.

This article explores quality assurance issues that are likely to arise related to limited-service rural hospitals, an institutional alternative to existing rural hospitals. In exploring these issues, we use as an example, the Montana Medical Assistance Facility, a limited-service rural hospital model about to be implemented by the Health Care Financing Administration as a demonstration. While such medical assistance facilities will need to meet licensure and certification requirements, it is not reasonable to expect them to meet regulations that are designed for large hospitals. Also, because of their limited resources, medical assistance facilities will likely need outside help from a larger institution to perform quality assurance activities, particularly peer review activities. A key challenge for the medical assistance facility will be to define the nature of this relationship, while retaining ultimate responsibility for quality of patient care. Assuring quality of care is a particularly important issue for medical assistance facilities since community acceptance and financial viability will depend critically on establishing a record for quality of care that is at least comparable to existing small, rural hospitals.

Modeling the costs of case management in long-term care.

A conceptual approach to developing models for analyzing cost is applied to case management in long-term care. This conceptual approach uses four dimensions to classify case management programs. The application results in identifying five case management cost models. Empirical measures of case management costs and a set of determinants of the within-model variation in these costs are suggested for each model. This article discusses several policy relevant hypotheses that could be addressed by the empirical implementation of these cost models.

Institutional alternatives to the rural hospital.

An important aspect of the ongoing debate on rural health policy is how to deliver inpatient care in sparsely populated rural areas. One alternative is to create a new classification of rural inpatient facility that would deliver more limited services than available in a rural hospital, have more flexibility in staffing requirements, and possibly be reimbursed differently. The support of the Health Care Financing Administration for the concept of a limited service rural hospital is critical, since such a facility would not be financially viable without Medicare payment. Several organizational and public policy issues that merit consideration in the design and implementation of institutional alternatives to rural hospitals are discussed, including licensure and certification, scope of services, personnel, quality assurance, and payment.

Rural hospitals: a literature synthesis and health services research agenda.

The economic decline of rural America and an inability to respond to pressures created by the evolving American health care system are making it increasingly hard for rural hospitals to survive.

The hospital role of family physicians.

This paper examines the hospital role of a random sample of all general and family physicians in the state of Washington. Of the 287 physicians in our sample, 81% admitted at least one patient to hospital during the two-week study period, and the average physician admitted six patients. The majority of the admitting diagnoses fell within the realm of internal medicine. Residency-trained and board-certified respondents were more likely to admit patients to hospital, and residency-trained and rural practitioners were much less likely to refer patients to other physicians for hospital care than their urban counterparts. Residency-trained physicians, in particular, were much more likely to practice hospital obstetrics than those without formal residency training. These data demonstrate the broad and significant hospital role of the family physician. Given the increased scope and intensity of hospital practice of residency-trained family physicians, and barring major changes in admitting privileges or new regulatory constraints, we predict that this group of physicians will continue to have a significant inpatient role in the United States.

The physician as gatekeeper. Determinants of physicians' hospitalization rates.

The authors studied differences in the rate of hospitalization of a random sample of all general and family practitioners in the state of Washington. The study was designed to identify nonmedical factors that affect the rate at which physicians hospitalize ambulatory patients. They found that the hospitalization rate varied greatly among physicians and that this rate appeared to be sensitive to nonmedical factors. The following independent variables were significantly associated with higher rates of hospitalization while controlling for other factors: low hospital occupancy rates, low per capita income in the county, group practice, a broader scope of outpatient practice, and a busier outpatient practice. They conclude that physicians are sensitive to a range of nonmedical factors in their decision to utilize hospital resources. These findings suggest that a substantial proportion of all hospitalizations are discretionary, and that changes in practice organization or hospital occupancy rates will affect the rate of hospital use.

Interspecialty variation in office-based care.

Analysis of national survey data on physician-patient encounters raises questions about physician education and manpower policy. Data compiled by the University of Southern California Medical Activities and Manpower Projects and the United States Bureau of Health Professionals reveal differences among internists, cardiologists, family practitioners, and pediatricians in procedures used for diagnosing and treating several frequently encountered conditions. Differences are observed in expenditure of time and use of a broad range of diagnostic and therapeutic techniques. These differences remain significant even after several important characteristics of individual physicians, patients, and the practice environment have been controlled. Findings from this study underscore the necessity of reviewing the content of medical education and policies that encourage a broad range of specialists to provide primary care. The findings also emphasize the need to address the physician's knowledge base in promoting changes in practice patterns.

Rural health care delivery amidst federal retrenchment: lessons from the Robert Wood Johnson Foundation's Rural Practice Project.

This paper examines the experience of the Robert Wood Johnson Foundation's Rural Practice Project (RPP), a major non-governmental effort in the last decade concentrating on the direct delivery of rural health services. The nine RPP sites started prior to 1977 showed a slow but steady increase in their utilization levels and improvement in their financial status during their initial operational years. The tempo of their development was remarkably similar to that of federally sponsored practices in underserved rural areas. After four years of operation, all of the practices had completed their period of grant support; the practices survived in all cases, with almost all of the practices still retaining community sponsorship, salaried physicians, and a commitment to comprehensive care. Practices in sparsely populated rural areas and in areas with fewer hospital beds grew more slowly than those set in rural areas with higher population density and more ancillary resources. We conclude that the use of time-limited initial subsidies is an effective strategy in starting new rural practices in underserved areas and that those practices have a good chance of surviving their start-up phase.