The effect of Medicaid managed care on rural public health departments.

Medicaid managed care programs are now operating in more than half of all rural counties in the United States. This study examines how rural health departments that have historically provided clinical services have responded to and been affected by the implementation of Medicaid managed care. To the extent that rural health departments have changed, the effect of this change on the health department and the rural populations that these providers serve is assessed. Site visits were made to four rural public health departments in each of five study states, for a total of 20 case studies. At each site, in-person interviews of county public health department directors were conducted using semistructured interview protocols. In recent years, the majority of health departments decreased or discontinued provision of well-child services, causing many to lose Medicaid revenue. None of the health departments appeared to be in danger of closing, but most lost income security. Medicaid managed care appeared to have increased the number of children with medical homes in the private sector, but adequacy and continuity of care remains an issue. Privatizing Medicaid managed care has not decreased fragmentation, as public health functions such as tracking and screening represent an important facet of comprehensive health services for poor rural populations.

Using the American Medical Association physician masterfile to measure physician supply in small towns.

The goal of this study was to describe the magnitude, direction and sources of error of the American Medical Association's (AMA) masterfile (MF) in estimating physician supply in small towns. A random sample of nonmetropolitan towns in the United States was selected, and physicians with AMA MF (MFMDs) addresses in these towns were listed. Local pharmacists were asked to confirm or disconfirm the identities and locations of practice for the listed physicians and to add any unlisted physicians who were there. We took pharmacist confirmed or identified local source physicians (LSMDs) to be the "gold standard." The sample of 57 towns yielded 1,341 potential physician names. In these towns, there were 377 physician listings only from the MF, 188 only from local pharmacists, and 776 from both sources. About 80 percent of physicians identified by local informants were also listed on the MF; only 67 percent of physicians listed on the MF were identified by local informants as currently practicing in the town where they were listed. The error in these measures declined with increasing town size. The aggregate ratio of MFMDs to LSMDs was 1.20, ranging from 1.10 to 1.28 across size classes of towns. Given the persistence of local shortages of physicians, despite a national oversupply, accurate measurement of physician supply should be a priority of rural health care planners and advocates. Although the MF is the most comprehensive available national physician database, reliance on it alone to make local estimates of physician supply might lead one to believe that there are 20 percent more physicians in small rural communities than are actually there. Local pharmacists can be valuable informants about rural physician availability and their in- and out-migration.

Access to care for rural Medicare beneficiaries.

This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.

Medicare graduate medical education funding and rural hospitals.

To assess the importance of medical residents to rural hospitals, and to predict the possible effect of reductions in Medicare graduate medical education (GME) payments, data from Medicare hospital cost reports and from a telephone survey of rural hospitals with residency programs are analyzed. In prospective payment system year 11, 70 rural hospitals received more than $80 million in Medicare GME payments. The presence of rural training programs enhanced staff physician recruitment and retention and led to increased numbers of physicians settling in communities surrounding the facilities. Many survey respondents felt that elimination of GME funds would results in downsizing or outright elimination of their training programs. The results support the contention that rural training programs are important to hospitals and their surrounding communities and provide an essential component of the physician supply pipeline to rural areas.

The role of critical access hospital status in mitigating the effects of new prospective payment systems under Medicare.

This article examines rural hospitals that potentially qualify as critical access hospitals (CAH) and identifies facilities at substantial financial risk as a result of Medicare's expansion of prospective payment systems (PPS) to nonacute settings. Using Health Care Financing Administration (HCFA) cost reports from the federal year ending Sept. 30, 1996, combined with county-level sociodemographic data from the Area Resource File (ARF), characteristics of potential CAHs were identified and their finances analyzed to determine whether they could benefit from the cost-based reimbursement rules applicable to CAH status. Rural hospitals were identified as potential CAHs if they met a combination of federal and state criteria for necessary providers. Rural facilities were classified as "at risk" if they had poor financial ratios in conjunction with high levels of dependence on outpatient, home-care or skilled nursing services. Almost 30 percent of all rural hospitals were identified as potential CAHs. Ninety percent of potential CAH facilities were identified as "at risk" by at least one of five possible risk criteria, and one-third were identified by at least three. Of those classified "at risk," 48 percent might not benefit from conversion to CAH because their inpatient Medicare reimbursement would likely be less under CAH payment rules than under their current PPS payment rules. Many potential CAHs were doing well under inpatient PPS because they were sole community hospitals (SCH) and were therefore eligible for special adjustments to the PPS rates. The Rural Hospital Flexibility Act would be more beneficial to the population of isolated rural hospitals if those eligible for both CAH and SCH status were given the option of retaining their SCH inpatient payment arrangements while still qualifying for outpatient cost-based reimbursement.

Costs of developing childhood immunization registries: case studies from four All Kids Count projects.

We conducted case studies using structured interviews at four sites to understand the financial resources needed to implement childhood immunization registries. The total cost of planning and implementing a central registry ranged from $2.4 million to almost $7 million over the first five years. In addition, substantial investment by individual or group providers often was required. Registries are large information systems that require considerable investment of developmental resources, regardless of the number of children eventually entered into the system. Given the substantial investment that a registry represents, the realistic anticipation of such resource needs is important to successful planning and implementation.

The role of state policies and programs in buffering the effects of poverty on children's immunization receipt.

OBJECTIVES: This study assessed the influence of public policies on the immunization status of 2-year old children in the United States. METHODS: Up-to-dateness for the primary immunization series was assessed in a national sample of 8100 children from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-Up. RESULTS: Documented immunization rates of this sample were 33% for poor children and 44% for others. More widespread Medicated coverage was associated with greater likelihood of up-to-dateness among poor children. Up-to-dateness was more likely for poor children with public rather than private sources of routine pediatric care, but all children living in states where most immunizations were delivered in the public sector were less likely to be up to date. Poor children in state with partial vaccine replacement programs were less likely to be up to date than those in free-market purchase states. CONCLUSIONS: While state policies can enhance immunization delivery for poor children, heavy reliance on public sector immunization does not ensure timely receipt of vaccines. Public- and private-sector collaboration is necessary to protect children from vaccine-preventable diseases.

Medicaid managed care programs in rural areas: a fifty-state overview.

Interviews with state Medicaid officials reveal that although managed care programs have been implemented in rural areas, participation remains behind that of urban areas. Many states aim to create a statewide Medicaid managed care program and are struggling to overcome barriers that are greater in rural areas, including providers' resistance, lack of commercial managed care, and inadequate supply of providers. Many have modified contracting strategies and shown flexibility regarding interpretations of travel standards, twenty-four-hour coverage requirements, and primary care case management requirements, to implement programs in rural environments.

A resident-based reimbursement system for intermediate care facilities for the mentally retarded.

In this article, the authors present a resident-based reimbursement system for intermediate care facilities for the mentally retarded (ICFs-MR), which represent a large and growing proportion of the medicaid budget. The statistical relationship between resident disability level and the expected cost of caring for the individual is estimated, allowing for the prediction of expected resource use across the population of ICF-MR residents. The system incorporates an indirect cost rate, a base direct care rate (constant across all providers), and an individual-specific direct care rate, based on the expected cost of care.

Public-sector immunization coverage in 11 states: the status of rural areas.

This report uses county-level immunization data generated by state public health agencies to explore the rural-urban variation in the delivery of childhood immunizations in the public sector. Public health department-documented immunization coverage rates for 1995 were obtained from 882 counties in 11 states east of the Mississippi River. To assess the possible association between public health department immunization coverage rates and county rurality, descriptive statistics were calculated. A multiple regression model then was estimated. In all states except West Virginia, nonmetropolitan counties averaged higher completion rates than metropolitan counties. Consistent with the descriptive statistics, in the regression analysis nonmetropolitan counties had average immunization rates 2.47 percentage points higher than metropolitan counties, even when controlling for county socioeconomic characteristics. For the 11 states in the analysis, rural children immunized in the public sector had higher completion rates compared with urban children. These data reflect the dependence of rural families on the public health system and the potential for successful health care delivery through public clinics. As new health care systems are brought into rural areas, the success of this existing avenue for care must not be overlooked.

A prospective study of the impact of patient preferences on life-sustaining treatment and hospital cost.

OBJECTIVES: Ethicists advise that life-sustaining treatment decisions should be made in keeping with patient preferences. Until recently, there has been little systematic study of the impact of patient preferences on the use of various life-sustaining treatments or the consequent cost of hospital care. This prospective study was designed to answer the following questions: a) Do patient treatment preferences about the use of life-sustaining treatment influence the treatments they receive? and b) Do patient treatment preferences influence the total cost of their hospitalization? DESIGN: A prospective, cohort study. SETTING: A university teaching hospital. PATIENTS: Hospitalized patients, at least 50 yrs of age, with short life expectancy due to end-stage heart, lung, or liver disease, metastatic cancer, or lymphoma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were interviewed to determine their desire for life-sustaining treatment and other characteristics and then were followed for 6 months to determine life-sustaining treatment use and costs during hospitalization. Two hundred forty-four patients were interviewed. Fifty-eight percent of patients expressed a desire for life-sustaining treatments to prolong life for 1 wk. During 245 subsequent hospitalizations, there were 20 episodes of mechanical ventilation, 63 episodes of intensive care, and 66 cancer treatments given. Bivariate and multivariate analyses showed no significant association between patient desire to receive treatment to prolong life and either life-sustaining treatment use (p = .59) or hospital costs (p = .20). CONCLUSION: In a university teaching hospital setting, there is no systematic evidence that patient preferences determine life-sustaining treatment use or hospital costs.

Migration of obstetrician-gynecologists into and out of rural areas, 1985-1990.

This study sought to determine if county-level demographic, health care resource, policy, and competitive factors are associated with the movement of obstetrician-gynecologists (ob-gyns) into and out of rural areas. County-level descriptive data from the Area Resource File, the American Medical Association Physician Masterfile, and the American Hospital Association Guide were used for hospital descriptions. This was a correlational study that measured the association of ecologic indicators of nonmetropolitan counties with indicators of gain or loss of ob-gyns. Descriptive statistics characterize the supply and movement of ob-gyns by size and location of the counties. Multinomial logistic regression models describe the net effect of the ecologic indicators on physician movement. During the period 1985 to 1990, a total of 962 patient care ob-gyns moved out of 531 nonmetropolitan counties, and 979 ob-gyns moved into 528 counties. Counties in the southern Atlantic states experienced the greatest net inflow, whereas Illinois, Missouri, and Texas had the greatest net outflow. Counties that retained ob-gyns during this period were in the mid-range of population. Positive correlates of outward migration were adjacency to a metropolitan county and loss of hospital bed supply; negative correlates with outward migration were the supply of hospital beds and total population. Inward migration was positively correlated with retention or gain of county family physicians and with adjacency; negative correlates were overall population and total family physician supply. The movement of ob-gyns in nonmetropolitan counties is influenced by state policies, local resources, and relative location. No clear evidence shows that there are competitive relations between family physician supply and ob-gyn supply.

Cisplatin-based chemotherapy in renal transplant recipients. A case report and a review of the literature.

BACKGROUND: Renal transplant recipients have a high incidence of cancer. The main side effect of cisplatin, nephrotoxicity, has special implications in renal transplant recipients. This is particularly true in view of the routine use of cyclosporine as an immunosuppresant. Nephrotoxicity is also one of the main side effects of cyclosporine. METHODS: We report a patient with a renal allograft who was receiving cyclosporine for immunosuppression and developed metastatic transitional cell carcinoma of the bladder and was treated with cisplatin-based chemotherapy. The literature regarding cisplatin-containing chemotherapy in patients with different cancers and a single transplanted kidney is reviewed. RESULTS: The patient received four cycles of methotrexate, vinblastine, doxorubicin, and cisplatin while on continuous cyclosporine therapy. His renal function remained stable. He responded to chemotherapy initially, but this response was short. Ten patients with renal transplants and cancer who were treated with cisplatin have been reported previously. Two were maintained on cyclosporine for immunosuppression throughout chemotherapy. No patient developed renal failure during or shortly after administration of cisplatin. Two of five patients treated for testicular cancer developed renal failure at 3 and 6 years after completion of chemotherapy. However, in both cases the cause of renal failure was attributed to chronic rejection of the transplanted kidney. CONCLUSION: Renal transplant recipients usually tolerate cisplatin-based chemotherapy well. It should be offered to patients with potentially curable cancer (e.g., germ cell tumor). This case and a review of the literature suggest that these patients retain baseline renal function even if cisplatin-based chemotherapy and cyclosporine are given simultaneously.

Potential effects of managed competition in rural areas.

This article assesses the extent to which managed competition could be successful in rural areas. Using 1990 Medicare hospital patient origin data, over 8 million rural residents were found to live in areas potentially without provider choice. Almost all of these areas were served by providers who compete for other segments of their market. Restricting use of out-of-State providers would severely limit opportunities for choice. These findings suggest that most residents of rural States would receive cost benefits from a managed competition system if purchasing alliances are carefully defined, but consideration should be given to boundary issues when forming alliances.

State risk pools and mental health care use.

State risk pools provide an opportunity for persons with mental health and substance abuse (MH/SA) problems to purchase health insurance. This study uses data from eight risk pools during the period 1988-1991 to analyze the utilization and enrollment experience for persons who submit claims for MH/SA treatment. Special consideration is given to the effect of variation in inpatient benefits across risk pools. The experience of Connecticut's risk pool differs markedly from that of the other risk pools. Given that two states (Connecticut and Florida) have restricted MH/SA benefits over time, we discuss the ability of risk pools to maintain comprehensive MH/SA benefits.

Patterns of health maintenance organization service areas in rural counties.

This study analyzes the 1993 National Directory of HMOs to determine the extent to which rural counties are included in health maintenance organization (HMO) service areas. Two specific questions are addressed: (1) How do the patterns of service areas differ across HMO model types? (2) What are the characteristics that distinguish rural counties served by HMOs from those that are not? Although a majority of rural counties are in HMO service areas, substantially fewer are served by non-individual practice association (non-IPA) models. Access to HMO services is found to decrease with county population density, and adjacency to metropolitan areas is an important predictor of inclusion in service areas.

The role of thrombolysis in hemodialysis access occlusion.

Thirty-eight occluded hemodialysis accesses were infused with urokinase on 43 occasions. In 49% of the cases, the access patency was reestablished for a week or longer, although 38% of this subset subsequently rethrombosed. Postthrombolysis angiography detected a stenotic segment in 14 of 22 angiograms (64%). Local bleeding was common, but the thrombolytic therapy was generally well tolerated. Percutaneous thrombolysis in conjunction with angiography and access revision provides a clinically useful means of access preservation.