Practicing with the urban underserved. A qualitative analysis of motivations, incentives, and disincentives.

OBJECTIVE: To investigate the personal characteristics and professional experiences of medical providers working with medically underserved urban populations. DESIGN: Focus groups of primary care providers. SETTING: Public and private clinics in Salt Lake City, Utah, in which the providers had ongoing relationships with medically underserved patients. PARTICIPANTS: Twenty-four providers (11 men and 13 women), including 12 physicians (three family physicians, seven pediatricians, and two psychiatrists), one dentist, three physician assistants, and eight nurse practitioners participated in three focus groups. MAIN OUTCOME MEASURE: Interpretative analysis of verbatim quotations regarding personal beliefs, feelings, and practice experiences. RESULTS: Participants revealed a strong sense of service to humanity and pride in making a difference. They thrive on the challenge of creatively dealing with their patients' complex human needs with limited health care resources. Factors critical to survival in an urban underserved setting include a hardy personality style, flexible but controllable work schedule, and multidisciplinary practice team. The camaraderie and synergy of teams generate personal support and opportunities for continuing professional development. CONCLUSIONS: Increasing the numbers of health care professionals wanting to work with the medically underserved may be facilitated through refining admissions criteria to schools for health care professionals to include values and personality characteristics, emphasizing within curricula the important skills and practice styles necessary to work with underserved patients, and ensuring that underserved practice environments provide support through multidisciplinary teams and structured work hours. These potentially effective approaches could increase success in recruiting and retaining health care professionals to work with medically underserved patients.

Using patient focus groups for new patient services.

BACKGROUND: This article is intended to illustrate the usefulness of patient input in the strategic planning process and to demonstrate in particular the use of focus groups in concept development, concept testing, and program evaluation. INTERACTIVE PLANNING: Three areas of patient services were designed partly on the basis of patient input. "Service Teams with Appropriate Resources" (STARs) were conceived as basic organizational units to deliver interdisciplinary care to meet the needs of specific groups of patients. A patient services "menu" was envisioned to allow the patient or caregiver to decide which service would most appropriately and efficiently meet patient needs. The "Service Expectation Program" was formulated to ease entry into the hospital by providing information on what patients should expect from the hospital experience. CONCEPT TESTING: Focus groups were used again to test and refine the concepts developed during the interactive planning stage. General themes included the need for improved communication, the desire to be treated with respect and dignity (personhood), the need for coordination across the continuum of care, and the desire for more personal choice and control. ONGOING EVALUATION: Sources of patient feedback used in the ongoing evaluation process included a patient satisfaction survey and a telephone survey. Additional focus groups and telephone surveys are planned. MANAGEMENT ISSUES: The focus group discussions with patients introduced useful data into the quality improvement and interactive planning process. Findings were disseminated to all levels of hospital management and program staff through newsletters, reports, and in-service training sessions. Data were useful in interactive planning, program concept testing, and the development and implementation of new services.

Big fish in a small pond: advantages and disadvantages of a first-mover strategy.

The case of a free-standing psychiatric hospital moving into a small rural market as the sole provider of hospital-based psychiatric services is examined as an example of a first-mover strategy. The theoretical bases for a first mover advantage are considered together with an analysis of the situational factors necessary to the strategy's success. The case study illustrates some of the potential consequences of success, namely the attraction of a new competitor with a broader scope of services. The case also illustrates other lessons for market niche competitors in enhancing their likelihood of survival and success in their selected market.

The role of "free" mammograms in motivating first-time screening: a community experiment.

Despite the fact that many women understand the value of preventive screenings in the early detection of breast cancer, and despite the fact that some women "know" the recommended guidelines for timing and frequency of screenings over a woman's life, less than 2/3 of the eligible women have ever had a mammogram. Among several factors that may inhibit women's adherence to recommended screening regimens, the cost of such screenings is often cited as a major problem, especially for low-income women and women from ethnic minorities. This study reports the results of a survey conducted with women who received a "Gift Certificate" for a no-cost mammogram at a hospital-based breast care center or its affiliated mobile mammography van. Data point to some important--both positive and negative--"side effects" of a no-cost screening. Implications for communications encouraging women to receive mammograms, for pricing and incentives, and for insurance reform are discussed.

Improving client satisfaction and clinic revenues through systems simulation: the case of a university nutrition clinic.

A client-responsive strategy was developed based upon input from nutrition clinic personnel, administrators, and clients. Systems simulation identified the strategy most likely to lead to client satisfaction while also meeting the needs of clinic personnel and administration. The strategy was subsequently introduced into the clinic and patient satisfaction and operating revenues were monitored following implementation. Both measures of impact demonstrated significant improvement.

Understanding physicians' decisions to practice in rural areas as a basis for developing recruitment and retention strategies.

The shortage of providers in rural areas is threatening the quality and availability of health care in many communities. The causes of the provider shortage are many and varied-from economic to social to personal. Government programs have addressed the issue of provider supply by offering scholarships and loan repayment programs for medical students who then must fulfil service obligations in underserved settings, among which are rural areas. Experience has shown that once providers complete their obligations under these grant programs, retention of providers in rural areas becomes an even more critical issue. Using focus group research, this study explores the practice setting choices of a group of physicians currently practicing in rural areas. The discussion reveals that personal values are one of the primary motivators for choosing to practice in rural settings while lack of availability of career opportunities for spouses and educational opportunities for children are major obstacles. The health care system poses barriers to success for providers in rural settings. The key rewards from rural practice are the ability to become integrated into the local community and the provider/patient relationships that develop in such settings. These findings are used as the basis for proposing recruitment and retention strategies for providers to improve access to medical care by patients in rural areas.

The management of upstream and downstream risk through selective contracting.

Common strategies employed by many organizations include designating certain suppliers as primary sources and targeting certain customers who are appealing competitively. Such selective strategies are appearing more frequently in the health care sector today. This paper examines the use of selective contracting by managed care programs to simultaneously increase control over costs (provider selection) and decrease risk (subscriber selection).

Mammography screening services: market segments and messages.

Mammography has become a vital tool for the early detection of breast cancer. Although many organizations and health care facilities are working to educate and motivate women to take advantage of the life saving opportunity that is offered through screening mammography, only twenty percent of women who should be screened actually have the procedure performed. In order to reach women who have not been screened, it is important to learn which factors most strongly motivate those women who do choose to have a mammogram. Depth interviews with 18 women attending a mobile mammography unit were conducted to explore the decision making process of women obtaining mammography screening services and to develop a profile of prevalent emotions, attitudes, and feelings associated with receiving breast cancer screening services. Analysis of the interview transcripts revealed several important themes to which health care professionals can direct marketing and health promotion strategies.

Importance/performance analysis: a tool for service quality control by clinical laboratories.

A study of customer satisfaction with clinical laboratory service is used as the basis for identifying potential improvements in service and more effectively targeting marketing activities to enhance customer satisfaction. Data on customer satisfaction are used to determine the aspects of service most critical to customers, how well the organization is doing in delivery of service, and how consistent service delivery is. Importance-performance analysis is used to highlight areas for future resource reallocation and strategic emphasis. Suggestions include the establishment of performance guidelines for customer contact personnel, the enhancement of timely delivery of reports via electronic transmission (computer and fax), and the development of standardized graphics for request and report forms to facilitate identification of appropriate request forms and guide clients to key items of information on reports.

Self-funded health benefits plans: marketing implications for PPOs and employers.

Self-insurance is explored as a cost-containment strategy increasingly being used by employers. Experiences of employees for whom the option of an employer self-funded health benefits plan was available are studied. Health plan decisions, health care provider decisions, experiences in the receipt of care, and provider switching behavior are examined. Implications for structuring and marketing self-funded PPOs are discussed.