How Country Doctors Deal with a Changing World
The People-to-People Health Foundation conducted a national survey of rural physicians in 1993 and 1994 to examine their practice style and supply in medically underserved areas.
- Approximately 40 percent of the 1,601 rural physicians surveyed planned to leave their current practice at some point in the future; 22 percent of them within five years.
- Some 44 percent planned to remain in rural medicine indefinitely, while another 38 percent planned to leave rural medicine altogether.
- The practice patterns of rural physicians and those who practiced in "crisis areas" (areas with extremely low physician-to-population ratios) were similar.
- Rural physicians made use of non-physician providers, such as nurse practitioners and physician assistants, and expected to increase their use of these health care professionals.
The Robert Wood Johnson Foundation (RWJF) provided $316,168 in funding from June 1992 to December 1995 to support the project.
The supply of physicians has increased significantly in the United States in recent decades. Between 1970 and 1987, the number of patient care physicians per 100,000 population in metropolitan areas rose by 61 percent, from 140 to 224. However, during the same period, the physician-to-population ratio in nonmetropolitan areas rose by less than half that rate: 30 percent, from 79 to 103 per 100,000.
This comparison masks even greater differences among rural areas. For example, in 1987 nearly 500,000 people were living in counties without any physicians providing patient care, and 2.5 million Americans lived in 250 counties served by a total of only 330 physicians. Moreover, problems of access associated with inadequate physician supply are often compounded because rural populations are older, jobs tend to be of higher risk, incomes are lower, and relatively fewer persons have health insurance.
In the early 1990s, Congress introduced a number of bills to increase the supply of physicians in rural areas. The Rural Physicians' Incentives Act (H.R. 2230) allowed rural primary care physicians to deduct student loan interest payments from taxable income; permitted rural primary care residents to defer student loan payments until they completed their residencies; and, for rural physicians, eliminated the reduction in Medicare reimbursement rates normally required during the first four years of practice.
Other bills allowed states to conduct demonstration projects to test innovative approaches to increase the Medicaid participation of obstetrician/gynecology providers in rural areas (H.R. 2229), and required the improvement of health professions training programs for health professionals serving in rural medically underserved areas (S. 1148).
At a time when current policy initiatives, such as Medicare and Medicaid payment reforms, were being designed to affect the supply of physicians who practice in underserved areas, this study sought to provide up-to-date information on the practice patterns of physicians in rural areas, and also to identify any early warning signals of changes in practice patterns that would affect access to care.
Research conducted in the late 1980s had suggested that physicians are more likely to locate in those rural areas that offer relatively higher standards of living and quality of life, such as areas with a college or university, a well-educated population, relatively high income levels, and other health resources, including other physicians. Beyond that, though, little was known about how physician behavior and practice styles vary across different types of nonmetropolitan areas.
The purpose of this study was to examine the availability and practice characteristics of physicians working in severely medically underserved nonmetropolitan areas, and to identify related implications for access to basic health care. The initial survey design included three areas of inquiry:
- Questions regarding physicians' rural attachment (how they came to practice where they are currently located) and future practice plans.
- Questions about rural physicians' patient- and case-mix.
- Questions about the rural physicians' practice styles and use of technology.
The principal investigator and his team developed a more extensive list of questions and issues that would be analyzed within each of these three areas of inquiry:
- To what extent are nonmetropolitan physicians planning to relocate in the near future? Do physicians who are planning moves intend to relocate to other rural areas? Do relocation plans vary by type of rural areas, e.g., are physicians who practice in "crisis" areas (defined as the 170 counties with the lowest number of physicians) more likely to anticipate a move to a more urban area?
- What types of non-physician labor are employed by physicians in rural areas and how intensively are these inputs used?
- To what extent do physicians in each type of area treat Medicaid patients? Residents of local nursing homes? The uninsured?
- To what extent are nonmetropolitan physicians planning practice expansions in the near future? Is increased specialization a goal of the expansion?
- How much primary care is provided by specialists in underserved areas? More generally, what is the role of generalists in rural areas?
- How satisfied are rural physicians with their careers? Does satisfaction vary with degree of geographic and professional "isolation"?
There was almost a year's delay in fielding the survey because another survey of rural physicians was being completed in early 1993 and the principal investigator thought such an overlap might harm response rates. He used the delay to enlarge the survey to elicit information from rural physicians about their participation in managed care plans, which were enrolling increasing numbers of patients, and about their attitudes and opinions concerning different components of the national health care reform proposals that were being advanced at that time.
This survey was conducted between August 1993 and May 1994 through a mail questionnaire with telephone follow-up. Rural physicians were drawn from the American Medical Association's (AMA's) Masterfile of Physicians. Three rural physician groups were sampled: a general probability sample of rural physicians (800); young physicians (defined as under age 40) (300); and crisis area physicians (defined as those physicians practicing in the 170 rural counties with the lowest number of physicians per capita in 1990) (501). Physicians from the most underserved areas and younger physicians were over-sampled.
The survey was conducted under a subcontract by a data collection firm, CODA Inc., in Silver Springs, Md. Response rates were approximately 69 percent across the three physician groups sampled. The survey took considerably longer to complete than the three months originally planned because there were problems in locating the sampled physicians, who could not be reached at the mailing addresses provided by the American Medical Association, apparently because these physicians relocate frequently. Significant resources and time were required to locate them.
Because of the delays, all the data had not been analyzed at the end of the grant period. However, the principal investigator had completed the analysis on selected questions within each of the three original areas of inquiry that comprised the survey. In describing the findings, the term "general rural physicians" is used when referring to the general probability sample of rural physicians and the term "crisis area physicians" is used when referring to the data collected for physicians located in the 170 counties with the fewest physicians, as described above.
Findings from the Rural Attachment and Future Practice Plans section of the survey about physicians' plans to stay in the current practice and/or rural medicine:
- More than four in ten physicians plan to stay in rural medicine indefinitely; 44 percent of general rural physicians and 47 percent of crisis area physicians plan to stay in rural medicine indefinitely; 38 percent of general rural physicians plan to leave rural medicine at some point in the future, and 20 percent of those physicians plan to leave within the next five years. Of the crisis area physicians, 35 percent plan to leave rural medicine at sometime in the future, and 21 percent are planning to leave in the next five years.
- Approximately 40 percent of general rural physicians plan to leave their current practice at some point in the future, and 22 percent of those physicians plan to do so within the next five years. Not all these physicians plan to leave rural medicine.
- The characteristics of the sub-sample of crisis area physicians were strikingly similar to those of the general rural physician sample population: 39 percent of crisis area physicians plan to leave their current practice at some point in the future, and 26 percent of those physicians plan to do so during the next five years. Again, not all these physicians plan to leave rural medicine.
Findings from the Patient Care and Case-Mix section of the survey about information on the time physicians spend with nursing home patients:
- Preliminary estimates suggest that crisis area physicians spend significantly more time treating persons in nursing homes (and in all patient care activities) than do general rural physicians.
- There is some evidence that physicians who plan to leave rural areas in the near future are more burdened with treating nursing home patients than physicians who plan to remain in rural medicine.
Findings from the Practice Style and Technology component of the survey about the use of non-physician providers such as physician assistants and nurse practitioners:
- General and crisis area rural physicians make significant use of non-physician providers.
- Of the general rural physicians, 15 percent employ nurse practitioners and 9 percent plan either to increase nurse practitioners' hours or to hire nurse practitioners during the coming year. Of the crisis area physicians, 14 percent employ nurse practitioners, and 10 percent plan either to increase nurse practitioners' hours or to hire additional nurse practitioners during the coming year.
- Compared to physicians without nurse practitioners, physicians who employ nurse practitioners are more likely to be female, general or family practitioners, physicians in large practices, and located in relatively physician-dense markets.
- About 20 percent of general rural physicians employ physician assistants, and 9 percent plan either to increase hours of current physician assistants or to hire them during the coming year. Of the crisis area physicians, 16 percent employ physician assistants, and 12 percent plan either to increase physician assistants' hours or to hire additional physician assistants during the coming year.
- Compared to physicians without physician assistants, physicians who employ physician assistants are more likely to be female, medical specialists, physicians in larger practices, and physicians located in states with "favorable environments" for physician assistants.
A presentation on the design of the survey instrument was made at the American Public Health Association Meeting in November 1992, and presentations on survey results were made at meetings of the American Statistical Association in August 1994, and the American Public Health Association in November 1995. Five articles are in the process of being written. A public use tape, number 6848, tentatively titled "The National Survey of Rural Physicians," is to be released by the Intercollegiate Consortium for Policy and Scientific Research (ICPSR) pending the inclusion of additional survey data. See the Bibliography for details.
AFTER THE GRANT
This grant was helpful in establishing the Project HOPE Walsh Center for Rural Health Analysis. The principal investigator continues to work on the analysis of the data that were collected in the study and is writing two papers. The first paper discusses the extent to which managed care has "arrived" in rural practices and the types of managed care plans with which rural physicians are contracting, and the second paper compares and contrasts the views of general rural and crisis area physicians on subsidizing health insurance for the poor, increasing support for training of primary care physicians, and other health care reforms.
The principal investigator plans to undertake additional work on physician supply in rural areas, supply effects on access to care, and managed care and the use of technology in rural areas. Project HOPE is seeking funding for a study that would re-contact survey respondents to see if they have followed through with their practice plans. No applications have been made to RWJF.
GRANT DETAILS & CONTACT INFORMATION
Study of the Declining Supply of Rural Physicians
People-to-People Health Foundation, Inc. (Millwood, VA)
Dates: June 1992 to December 1995
Curt D. Mueller, Ph.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Mueller CD. "How Much Time Do Rural Physicians Spend with Nursing Home Patients?" In Progress.
Mueller CD. Practice Plans of Rural Physicians. In Progress.
Mueller CD and Berk ML. How Do Rural Physicians Feel About Health Reform? In Progress.
Mueller CD and Brooks S. "The Use of Non-physician Providers in Rural Areas: Evidence from the National Survey of Rural Physicians. In Progress.
Parente ST and Mueller CD. "Has Managed Care 'Arrived" in Rural Physician Practices?" In Progress.
Presentations and Testimony
Mueller CD and Berk ML. "Design of the 1993 National Survey of Rural Physicians," presented at the American Public Health Association Meeting, November 1992.
Mueller CD, Berk M and Ter Matt J. "Where Have All the Rural Physicians Gone? Long Time Passing: Evidence from the 1994 National Survey of Rural Physicians," at the American Statistical Association Meeting, Toronto, Canada, August 1994.
Mueller CD and Brooks S. "The Use of Non-Physician Providers in Rural Areas: Evidence from the National Survey of Rural Physicians," at the American Public Health Association Meeting, San Diego, Calif., November 1995.
Report prepared by: James Wood
Reviewed by: Timothy F. Murray
Reviewed by: Molly McKaughan
Program Officer: Beth A. Stevens