COMPARATIVE EVALUATION OF NATIONAL HEALTH SERVICE CORPS ALUMNI RETAINED IN HEALTH MANPOWER SHORTAGE AREAS RESEARCH DESIGN DECEMBER 30, 1983

Transcription

1 COMPARATIVE EVALUATION OF NATIONAL HEALTH SERVICE CORPS ALUMNI RETAINED IN HEALTH MANPOWER SHORTAGE AREAS RESEARCH DESIGN DECEMBER 30, 1983 Submitted t: Submitted by: Office f Evaluatin and Analysis Mathematica Plicy Research, Inc. OPEL/HRSA/DHHS 600 Maryland Avenue, S.W. Parklawn Building, Rm Suite Fishers Lane Washingtn, D.C Rckville, Maryland MPR Reference N This reprt is made pursuant t Cntract N with the Health Resurces and Services Administratin. The amunt charged t the Department f Health and Human Services fr the wrk resulting in this reprt (inclusive f the amunt submitted under the cntract) is $8, The names f the persns emplyed r retained by the cntractr, with managerial r prfessinal respnsibility fr such wrk, r fr the cntent f the reprt, are as fllws: Kathryn M. Langwell, Prject Directr Shelly L. Nelsn, Research Assciate Edward Lenk, Research Assistant

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3 TABLE OF CONTENTS Page I. INTRODUCTION 1 A. Backgrund 1 B. Purpse f this Reprt 2 II. DETERMINANTS OF PHYSICIANS' LOCATION DECISIONS 4 A. Overview 4 B. Individual Characteristics 5 C. Cmmunity Characteristics 1D D. Market Characteristics 18 E. Lcatin Decisins fr shrtage Areas and Decisins f NHSC Alumni 21 F. Discussin 28 III. HYPOTHESES, RESEARCH ISSUES, AND DATA REQUIREMENTS 30 A. Overview 30 B. Rural Chices 31 C. Shrtage Area Chices 35 D. Practice Characteristics 37 E. General Hyptheses, 38 F. Hyptheses,Research Issues, and Data Requirements 39

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5 I. INTRODUCTION A. Backgrund The primary bjectives f the Natinal Health Service Crps Prgram are: (1) t induce physicians t lcate in health manpwer shrtage area, thrugh financial incentives and expsure t practice in such areas; and (2) t directly prvide services t residents in health manpwer shrtage areas. The purpse f this study is t evaluate the retentin f NHSC alumni in Health Manpwer Shrtage Areas, t dcument the distributin and practice characteristics f NHSC alumni, current PPOs, and nn-nhsc physicians, and t examine the characteristics f rural cmmunities which have attracted NHSC and nn- ver the past decade. In additin, this evaluatin will examine the effect f the NHSC experience n subsequent practice patterns (e.g. use f auxiliary persnnel, fee structures, patient characteristics) f alumni. It is anticipated that the results f this evaluatin will be f cnsiderable assistance t the Health Resurces and Services Administratin in its effrts t refine and refcus the NHSC prgram in the current market envirnment characterized by increasing physician supply and strnger cmpetitive pressures influencing new physicians' lcatin patterns. The fcus f this evaluatin is n identifying infrmatin which HRSA may use in selecting, placing, and mnitring the practice characteristics f NHSC physicians in rder t increase retentin and t prvide services t areas 'least likely t btain physicians services independently. 1

6 B. Purpse f this Reprt The research t be cnducted under this cntract falls int three majr categries: descriptive prfiles f rural and shrtage area cmmunities which have lst, retained, and/r attracted new physicians between 1972 and 1981 descriptive examinatin f the relatinship between specific cmmunity characteristics and the prbability f physicians' lcatin descriptive and multivariate analysis f -- the urban-rural lcatin chice f 1979 NHSC physicians - - the HMSA-nn HMSA lcatin chices f NHSC and nn- - - the practice characteristics f NHSC and nn-nhsc physicians This Research Design prvides the fundatin upn which the descriptive and multivariate analyses will be structured. In particular, the hyptheses, research issues and related data needs are specified. These identified data needs will, prvide guidance t the develpment f the data cllectin instrument and prtcl. The prcess thrugh which the Research Design has been prepared has included several steps: A search f the 1975 thrugh present literature has been cnducted using bth cmputerized and manual search methds. This literature has been acquired, reviewed, and incrprated int this reprt. A set f hyptheses related t: (1) rural-urban lcatin chices; (2) HMSA-nn HMSA lcatin chices; and (3) practice characteristics have been develped, drawing upn the findings f the literature and discussin with HRSA persnnel 2

7 Specific research issues within a specific hypthesis are have been elabrated. Required data elements t examine the hyptheses and research issues f interest have been listed identified. The anticipated surce f each required data element is specified The hyptheses and research issues presented here will prvide directin fr the develpment f the Analysis Plans fr the cmmunity prfiles, cmmunity characteristics, and multivariate analyses which will be cnducted.

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9 II. DETERMINANTS OF PHYSICIANS' LOCATION DECISIONS: A REVIEW OF THE EVIDENCE, WITH SPECIAL ATTENTION TO THE EFFECTS OF COMMUNITY CHARACTERISTICS AND OF MARKET FORCES A. Overview Physicians' lcatin decisins and factrs affecting thse decisins have been studied and discussed intensively fr the past tw decades. As a result, there are literally hundreds f citatins which are referenced in this literature. T prvide a fundatin fr the design f a cmparative evaluatin f NHSC alumni retained in HMSAs, hwever, nly a subset f this literature need be examined: studies f individual physician's decisins t lcate in rural r shrtage areas studies examining the distributin f the stck f physicians acrss rural and urban areas studies f flws f physicians int and ut f rural and urban areas ver time. Research that fcuses n intraurban distributin patterns r n the distributin f physicians by state, crss-sectinally r ver time, is nt f interest fr this prject. The emphasis in this review f the literature is n three categries f factrs which may influence lcatin decisins: 1. Individual characteristics f the physician 2. Characteristics f the cmmunity 3. Market characteristics

10 In the sectins which fllw, we review the evidence n the factrs, within each f these categries, which have been fund t be assciated with lcatin decisins f physicians. A final sectin cnsiders the evidence n factrs influencing decisins by NHSC and nn- t lcate in shrtage areas and rural areas. B. Individual Characteristics Much f the research n physicians' lcatin decisins has cncentrated n identifying individual characteristics f the physician which are assciated with the decisin t lcate in a rural r urban area. The majr classes f individual characteristics investigated include: prir cntact factrs backgrund traits prfessinal factrs spuse's backgrund and ther family influences Each f these areas is discussed in this sectin. Prir cntact factrs A number f studies examine the relatinships between physician lcatin decisins and prir expsure t the area f chice. The basic hypthesis tested in these studies is that the greater the number f prir cntacts with an area, the higher is the prbability that a physician will lcate an initial practice in that area. Prir cntact events examined include birth, high schl, medical schl, and internship/residency. Results f these studies have indicated that prir cntact factrs d have a psitive effect n the prbabilities f lcatin and that mre recent -5-

11 events (i.e. internship/residency) have a strnger effect than d mre distant in time events (Held, 1973; Weisktten et al., 1968; Fein and Weber, 1971; Yett and Slan, 1974; Budde and Langwell, 1978; Cper et al., 1975; Crdes, 1978; Grimes et al., 1977; Werner, Wendling, and Budde, 1979; Samuels, 1974); Krman and Feldman, 1977; Hynes and Givner, The available evidence suggests that the greater is the number and duratin f prir cntacts, the mre likely is the physician t establish his/her practice there. While the prir cntact research has fcused n establishing the strength f the bserved relatinship, Yett and Ernst (1975) cnsider a number f avenues thrugh which prir cntact enters the lcatin decisin prcess: Due t the csts f btaining infrmatin, the physician is able t be infrmed abut the ecnmic, medical, and scial aspects f nly a few lcatins, amng them thse with which he/she has had prir cntact. Previus cntact with an area may have a direct effect n the physician's incme ptential if prfessinal relatinships are f use in establishing a new practice. Prir cntact may be clsely related t the physicians' investment in family r scial relatinships. Yett and Ernst als stress that the bserved relatinships between prir cntact and lcatin decisin d nt imply the directin f causality; physicians with strng lcatin preferences may chse medical schl and internship/residency lcatin t facilitate the planned lcatin decisins. The majr issue with respect t the prir cntact hypthesis and rural/shrtage areas is the fact that physicians chsing rural practice lcatins are mre likely t have had prir cntacts with the area, than are physicians chsing urban lcatins, and t have cmpleted bth medical

12 schl and internship/residency in the state in which they eventually lcated. Backgrund Traits Backgrund characteristics f physicians include sciecnmic status f family, age, sex, natinality, marital status, place f rearing. The latter trait is clearly related t the prir cntact hypthesis, while ther factrs may be assciated with the physician's attitude tward lcatins f specific types. Rural upbringing has been fund in a number f studies t be strngly assciated with rural lcatin decisins (Hassinger, 1963; Schaupp, 1969; Champin and Olsen, 1971; Krman and Feldman, 1977; Hynes and Givner, 1983; Hassinger et al., 1979), althugh mst f the studies cnducted are descriptive in nature. Werner et al. (1979) fund that rural rearing is strngly predictive f rural practice lcatin, but less strngly assciated with the decisin t practice in shrtage areas. Family sciecnmic status has been examined, primarily descriptively, t determine whether physicians frm upper middle class r prfessinal families are mre likely t chse urban practice lcatins. Hassinger (1963) reprts that the ccupatinal status f fathers f rural physicians was lwer than fr urban physicians; hwever, nearly 2/3 f physicians in mst rural areas were frm farm families. Other studies supprt this finding, indicating that physicians frm lwer sciecnmic backgrund were less likely t specialize and enter urban practice (Champin and Olsen, 1971). Yett and Ernst (1975) suggest that the linkage between family sciecnmic backgrund and lcatin decisin may be cnsequence f the fact that prfessinals and high sciecnmic back- a

13 grunds are mre ften fund in urban areas; the causal relatinship may be with place f rearing rather than family sciecnmic level. Additinally, physicians frm families f high sciecnmic status may have sufficient surces f incme t permit them t enter a subspecialty which is nt rdinarily practiced in rural areas because it requires a substantial threshld ppulatin. Little research has been cnducted n the influence f the sex f the physician n lcatin decisins. The general ecnmic literature suggests that wmen prfessinals are less likely t lcate in rural areas due t the necessity f selecting a lcatin that maximizes a jint family utility functin (Frank, 1975). Langwell (1980) reprts that wmen physicians wh entered a first year residency in 1968 were less likely t chse nn-urban practice; nly 6 percent f wmen physicians were lcated in nn-smsas by 1975, cmpared with 12.6 percent f the men. Freign medical graduates' lcatin decisins have been examined in a number f studies; in the 1970s they represented ver 30 percent f new licentiates each year. Butter and Schaffner (1971) fund that FMGs are mre likely t lcate in areas with relatively high physician-t-ppulatin ratis. Budde and Langwell (1977) reprt similar findings fr new Illinis FMGs, but als reprt that new FMGs in Illinis were disprprtinately likely t lcate in rural areas and urban areas, but less likely t lcate in the mre attractive suburb and small twn practices. Other studies have supprted this tentative finding with respect t FMGs. Krman and Feldman (1977) cllected data frm physicians wh recently lcated in three rural cunties in New Yrk. Of these 60 physicians, 31 were FMGs. Madisn and Cmbs (1981) similarly reprt that FMGs were heavily represented amng -8-

14 yung physicians wh settled in the mst rural cmmunities between 1973 and Prfessinal factrs Included in this categry are the physicians' specialty bard certificatin status, and his/her attitude tward prfessinal develpment and pprtunities. Specialty f the physician is bviusly strngly assciated with lcatin chices and cnstraints. Werner and Wendling (1979) use a simultaneus lgit mdel t examine the interactins between lcatin chices and specialty chices and find that, althugh the specialty chice is nt significantly influenced by lcatin chice, the lcatin decisin is significantly affected by the specialty chice. Langwell (1979) examines ecnmic incentives t the jint specialty and lcatin decisin f physicians and reprts that primary care specialists (i.e., internists and pediatricians) earn substantially higher lifetime earnings if they lcate in rural areas. The chice f specialty, then, may affect the lcatin decisin thrugh varying ecnmic pprtunities t specific specialties acrss urban and rural markets. The physician's attitude tward prfessinal pprtunities has als been cited as an infuential factr in lcatin decisins. Cper and Heald (1975) indicate that physicians wh were very cncerned abut availability f cntinuing educatin pprtunties were less likely t chse rural practice (where access t cntinuing educatin may be mre difficult). Cncern abut excessively lng wrk hurs and the lack f ther prfessinal cntacts and cnsultatins has been cited as a particular cncern fr rural physicians (Bible, 1970; Heald et al., 1974). Similarly, interest in lcating a practice clse t a medical schl suggests an

15 urban, rather than rural, decisin (Steinwald and Steinwald, 1974; Heald et al., 1974). Spuses' Backgrund Traits and Attitudes Several studies have examined the rle f the spuse in the lcatin decisin f new physicians. In general, a psitive relatinship between spuse's place f rearing and the physician's chice f practice lcatin has been bserved (Schaupp, 1969; Taylr et al., 1973; Heald et al., 1974). Heald et al. reprt that amng 144 physicians in rural practice in their sample, 44 percent had wives f rural upbringing. Mst studies suggest that the wife's lcatin preferences d nt strngly influence the chice f a practice lcatin (Charles, 1971; Cper et al., 1975; Schaupp, 1969; Steward, Miller, and Spivey, 1980). C. Cmmunity Characteristics While it is evident that urban areas are mre attractive t mst physicians than are rural areas, there is a wide spectrum f cmmunity charactristics which make specific rural cmmunities mre r less att.ictive t physicians. These characteristics f nn-metrplitan cmmunities may be classified int several categries: prfessinal characteristics sciecnmic characteristics recreatinal, cultural, and climatic characteristics. 'Much f the research which has been cnducted n physicians' decisins t lcate in rural areas has been attitudinal; physican respndents rank cmmunity characteristics by level f influence n their decisin r simply indicate whether the characteristic was r was nt an influence n their -10-

16 decisin. A few studies have included specific area characteristics as variables in explanatry mdels; hwever, the absence f data t measure many cmmunity characteristics f interest severely restricted these appraches.1 The majr prblem with attitudinal research is that it ffers n mechanism fr measuring tradeffs between different factrs (e.g. hw much incme wuld the physician be willing t give up t gain additinal cultural pprtunities?) In additin, examining respnses acrss surveys is difficult since the phrasing f alternatives, interpretatins, and subjectivity f respnses limits cmparability. Prfessinal Characteristics The prfessinal characteristics f majr interest t physicians cnsidering rural practice are: pprtunities fr interactin and supprt with clleagues presence f hspital facilities and supprting services extent f unmet demand fr health care in the area incme pprtunities Clleagues. A number f studies (Bible, 1970; Heald et al., 1974; Steinwald and Steinwald, 1974; Werner et al, 1979) reprt that rural physicians r thse cnsidering rural practice are particularly cncerned abut prfessinal islatin. The receptivity f established physicians t the pssibility f a new entrant in the market may influence the decisin t lcate (Fein, 1956; Krman and Feldman, 1977; Parker and Srensn, frm. 1 Prir t develpment f the Area Resurce File in its present -11-

17 1978). Interactin with clleagues is imprtant fr several reasns: maintaining knwledge f medical prgress, securing practice cverage t permit uninterrupted leisure time, and availability f cnsultatins n cmplex cases (Heald et al., 1974; Steinwald and Steinwald, 1974; Wlf et al., 1981; Evashwick, 1976). Of particular significance fr rural and shrtage area practice is the recent trend tward grup practice f physicians. Slan (1974) indicates that physicians wh jin grups are strngly attracted by the regular hurs, freedm frm managerial tasks, and cntinual access t clleagues fr referral and cnsultatin. Heald, et al. (1974) reprt that the "pprtunity t jin a desirable partnership r grup practice" was the mst frequently cited factr influencing the lcatin decisins f yung physicians. Evashwick (1976) finds that a majr cntributin t explaining percentage change in the physician-t-ppulatin rati in rural areas between 1960 and 1970 was the pprtunity fr grup practice. Facilities. Hspital facilities have been fund t be strngly 46- assciated with the lcatin decisins f specialists, but have less impact n lcatin decisins f primary care practitiners. Thus, rural lcatin decisins are affected by the presence r absence f hspital facilities, but the absence f a hspital des nt prhibit physician lcatin (Fein, 1956; Bible, 1970; Heald et al. 1974; Steinwald and Steinwald, 1974). Wacht (1972) estimates the impact f hspital facilities n rural physician lcatin patterns and finds that general practitiners are nt influenced by absence f hspital facilities. Yett and Ernst (1975) suggest that the Hill-Burtn prgram may have had a rle in attracting new physicians t rural areas, but evidence n this issue is mixed. They suggest, hwever, -12-

18 that technlgical prgress ver the past tw decades has been rapid, and yung physicians, trained in this technlgy, may be mre reluctant than were past graduates t chse rural practice withut hspital facilities. Unmet Need. Physicians chsing rural practice lcatins are mre likely t indicate that they are interested in prviding services t ppulatins with unmet need fr medical care (Heald et al., 1974, Stamps and Kuriger, 1983). Unmet need fr services des nt necessarily imply that adequate demand fr services is present t supprt a physicians practice since the ppulatin may nt have the financial resurces t pay fr needed services. Unmet demand, hwever, is difficult t disentangle frm ecnmic factrs, since physicians lcating in areas with high unmet demand are able t rapidly establish a full practice and generate a high vlume f receipts. Werner et al. (1979) reprt a strnger assciatin between interest in unmet need and rural practice than with shrtage area practice lcatin. Ecnmic Factrs. Included within this categry are such cnsideratins as incme pprtunities, hurs wrked, the cst f establishing a practice, and related factrs. A number f studies have fcused n incme pprtunities f physicians in rural and urban areas. Langwell (1979) estimates rates f return t the jint specialty and lcatin chice f physicians and reprts that general/family practitiners' incme pprtunities are greatest in urban areas. Indeed, in urban areas GP-FPs exhibit greater earning ptential than d specialists f all kinds. Since GP-FPs are expected t be the majr surce f medical services in rural areas, this finding is f cncern. A related study f ecnmic incentives facing GP-FPs making lcatin decisins reprts -13-

19 substantially higher incme pprtunities fr GP-FPs chsing the largest SMSA lcatins (Lang well and Budde, 1978). Werner et al. (1979) find n significant relatinship between the physicians' expressed interest in incme ptential and the lcatin decisin fr either shrtage-nnshrtage area chices r rural-urban chices. Other attitudinal surveys find that physicians acknwledge that incme ptential is an imprtant factr in their lcatin decisin. Heald et al. (1974) reprt that nearly 20 percent f respndents ranked "incme ptential" amng the three mst imprtant f all factrs. Stamps and Kuriger (1983) reprt that, f current NHSC physicians, a significantly larger number f thse planning t chse an urban lcatin indicated that "incme ptential" was a factr in their decisin. Krman and Feldman (1977) reprt that, f 60 settling in rural areas f New Yrk, 52 percent were given incme guarantees by the cmmunities. Several f the incme studies cited abve have included hurs f wrk in the analyses reprted. There is cnsiderable evidence that physicians in rural practice wrk mre hurs per week than d physicians in urban areas (Yett and Ernst, 1975,Kehrer et al. 1982) Langwell and Werner (1980) examine, jintly, incme and hurs f wrk in rural and urban areas. They cnclude that the current distributins f physicians amng lcatins and specialists are mre cnsistent with a decisin t minimize hurs wrked than with a decisin t select a lcatin t maximize incme. Attitudinal research findings indicate that the expectatin f lng hurs and verwrk influences physicians away frm rural and shrtage area practice. (Crawfrd and McCrmack, 1971; Bible, 1970; Parker and Srensn, 1978). -14-

20 Overall, the evidence n the rle f ecnmic factrs n lcatin chices f new physicians is mixed with respect t rural chice incentives. While incme ptential may be relatively similar, after cst f living adjustment, hurs f wrk and hurs n call are greater. On the ther hand, it is pssible that in areas with unmet demand (assuming ability t pay as well as awareness f need), yung physicians may be able t establish a mature practice in a much shrter time than in bettersupplied areas. Sciecnmic Characteristics f the Cmmunity. The characteristics f the ppulatin in the gegraphic area being cnsidered as a practice lcatin site by a yung physician are imprtant frm tw perspectives: 1. These characteristics are assciated with "tastes" fr medical care, health status (need), and ability t pay fr services btained 2. In rural areas, the physician is chsing bth a practice lcatin and a hme fr his/her family. The practice lcatin decisin and persnal lcatin decisin are mre clsely tied in rural areas than in urban areas where a physician may practice in an inner-city lcatin but live in upper middle-class suburbs. Sciecnmic characteristics which have been examined in studies f physician lcatin include: ppulatin size per capita/per husehld incme age distributin f the ppulatin educatinal level f the ppulatin

21 racial cmpsitin f the ppulatin. In the literature n demand fr physicians' services, each f these characteristics has been fund t be assciated with demand. The aggregate demand fr services shuld increase with ppulatin size, incme, prprtin f elderly and yung, educatinal level, and prprtin f whites in the ppulatin. Similarly, since physicians cme frm families which are disprprtinately white, upper middle incme, prfessinal, and well educated (Hassinger, 1967) it is reasnable t assume that, n average, physicians will prefer t lcate their hmes in areas where the ppulatin has such characteristics. The studies which have examined this issue quantitatively tend t supprt this view. Steele and Rimlinger (1965) reprt that ppulatin increase is ne f the mst influential factrs in attracting new physicians; Marden (1966) reprts similar results. Neither find that incme, educatinal level, r racial cmpsitin f the ppulatin was a significant factr in explaining mvement f physicians int areas ver time. Dugharty (1970) finds physician incme relative t average per capita incme is a significant factr in explaining the distributin f physicians by cunty within a state. Hambletn (1971) reprts that changes in per capita incme are psitively assciated with changes in specialist and GP supply; GPs are attracted by a large ver-65 ppulatin and are less likely t lcate where the nnwhite ppulatin is large. Blair (1975) and Wacht (1972) reprt that physicians (except fr GPs) are attracted bth t areas with higher per capita incmes and areas with higher prprtins f families belw the pverty level. A recent study by Langwell et al. (1983) examined changes in the distributin f specialists ver time amng

22 services t the ppulatin in the market area and, therefre, cmpetitin amng physicians fr patients in these areas is nt an issue f particular interest. The extent f cmpetitin amng physicians in the health care system, as a whle, has substantial implicatins fr lcatin patterns f physicians wh are nw emerging frm medical schls and residency training prgrams. During the 1960s, it appears that demand fr physicians' services -- stimulated by grwing third party payment fr services -- was rising mre rapidly than was the supply f physicians. Cnsequently, yung physicians in mst specialties culd chse a practice lcatin n the basis f factrs ther than cmpetitive envirnment. While incme ptential was a cnsideratin, there were a wide range f lcatins and practice alternatives which culd be reasnably expected t yield an "acceptable" r "target" incme level. Thus, cmpetitive factrs were weighted less heavily in the decisin prcess. The supply f physicians has increased dramatically during the past decade and is expected t grw by an additinal 35 t 40 percent by As a result, cmpetitive pressures n yung physicians may be expected t affect their lcatin decisins and shifts in these patterns may ccur. Early evidence that this is ccurring is presented fr the perid by Newhuse et al. (1982). They find that, as the supply f physicians grew during the 1970s, physicians diffused int smaller cmmunities. In their 23 state sample, by 1979, nearly every cmmunity with 2500 r mre ppulatin had access t physicians. The diffusin effect was, in general, strnger fr mre generalized physicians, wh culd he regarded as being "pushed" ut f mre desirable areas by the cmpetitive pressure generated by specialists wh can prvide specialized 13

23 services, in additin t primary care. Newhuse et al. cnclude: The data strngly suggest that cmpetitive frces play a majr rle in determining where physicians chse t practice. As the pl f physicians expands during the 1980s, a wide range f services will becme increasingly available t ppulatins utside metrplitan areas. A related study by Schwartz et al. (1980) examines the diffusin f bardcertified physicians int smaller cmmunities as the supply f bardcertified physicians increases. Bth the Newhuse et al. and Schwartz et al. studies are f limited usefulness fr the current study, hwever, since bth limit their examinatin t mre ppulus rural areas. Newhuse et al. investigated the supply f physicians in twns f 2,500 r mre ppulatin; Schwartz et al. (1980) lked at rural twns f between 10,000 and 20,000 ppulatin. Rural areas f this size have had relatively little difficulty attracting physicians in the past. The rural cmmunities mst likely t experience shrtages are thse which have nt been included in these studies. Anther recent study by Langwell et al. (1983) prvides supprting evidence fr these bservatins. The changing lcatin patterns by cunty f phthalmlgists and ptmetrists were examined fr the perid t determine whether there was mvement tward rural practice and whether cmpetitive pressures culd be bserved in these patterns and, if s, the strength f this factr. Ophthalmlgists (M.D.$) and ptmetrists (O.D.$) prvide services which substantially verlap and, therefre, cmpete fr patients ver this range f similar services. In additin, bth prfessins have substantially increased in numbers during the 1970s and there is evidence that an versupply in sme areas may have already existed 14

24 in the 1970s. Findings reprted by Langwell et al. indicate that the relatinship between changes in the supply f phthalmlgists and the supply f ptmetrists were unifrmly negative ver this perid, suggesting that cmpeting prfessinals during the 1970s were affected by the degree f cmpetitin expected in lcatin alternatives cnsidered. The descriptive findings f this study als supprt the diffusin hypthesis with ptmetrists diffusing t mre rural areas and phthalmlgists increasing their cncentratin in urban areas and less rural. Althugh the evidence available is nt extensive, it seems evident that the changing cmpetitive envirnment within which new physicians are chsing practice lcatins will have substantial effects n thse decisins. Cnsequently, the relative imprtance f the factrs which were identified as influential during the 1950s and 1960s may change. The design f research t examine lcatin patterns f NHSC alumni and ther physicians shuld be cnducted within a cntext which recgnizes these changing market frces. rea 15

25 chice mdel is specified t explain the shrtage-nnshrtage chice and the urban-rural chice and is estimated using prbit analysis. Results strngly supprt the authrs' hypthesis. Rural chices were influenced by: Preceptrships Lan frgiveness Cmmunity recruitment effrts Specialty Rural rearing Prir cntact High medical need f area Cncern ver CME pprtunities Cultural advantages By cntrast, a much shrter list f factrs influences the shrtage area lcatin decisin: Specialty Rural rearing Cncern ver CME pprtunities High medical need f area Interestingly, prgrams designed t induce physicians int shrtage area practices (i.e. preceptrships, lan frgiveness) are significant in the rural lcatin decisin but are nnsignificant in the shrtage area lcatin decisin. Madisn and Cmbs (1981) examine the lcatin patterns f yung physicians wh settled in rural cmmunities between 1973 and They reprt that yung physicians settling in rural areas are mst likely t Al.-lcate in twns where there is already a medical cmmunity. They nte that yung physicians avid areas which have nly 0 t 3 ther physicians; indeed, ver tw-thirds settled in twns which already had 4 r mre -22-

26 physicians. When Madisn and Cmbs lk at the characteristics f NHSC cmmunities, they find that few nn-nhsc settlers lcate in cmmunities similar t these areas which have small ppulatin and lack a medical cmmunity. HRRC (1975) prvides a critical review f the evidence n the effectiveness f plicies t influence physicians t lcate in shrtage areas. These plicies include: (1) preferential admissin t medical schl fr thse students mst likely t practice in medically underserved areas; (2) preceptrships; (3) lan frgiveness tied t service bligatins; (4) decentralizatin and/r deurbanizatin f medical educatin; (5) the Hill-Burtn Hspital Cnstructin Act; and (6) recruitment effrts f cmmunities. The evaluatin f the effectiveness f lan frgiveness tied t service bligatin prgrams is f particular interest fr this effrt.1 Review f the findings f a number f pre-1975 studies (Cnsad, 1973; Masn, 1971; Michigan Medical Manpwer Study, 1974) yields the fllwing cnclusins: Between 40 percent and 60 percent f lan recipients under state prgrams established practices in shrtage areas in rder t btain frgiveness. Of these, "mst" remained in practice in the shrtage area after cmpletin f this bligatin. There was sme evidence in the mid-1970s that a shift in demand frm state lans (with mandatry frgiveness 1At the time the HRRC review review was underway, there were a s-number f state prgrams which ffered lans t medical students which culd be repaid (in mst cases) r frgiven by establishing a private practice in a state-designated shrtage area. These prgrams are cmparable t the current Private Practice Optin in the NHSC prgram. The federal prgram under the Health Prfessins Educatin Assistance Act had nt been in existence fr a sufficient perid fr its effectiveness in inducing physicians t settle in scarcity areas t be evaluated. -23-

27 features and penalties) t HPEAA lans (with ptinal frgiveness and n penalties) was ccurring. It is pssible that physicians wh achieved lan frgiveness under this prgram received windfall gains (i.e. they wuld have established practice in a shrtage area withut the prgram). Overall, the review f the evidence suggests that the early PPO-type prgrams perated by states were quite effective in placing physicians in scarcity areas; less is knwn abut retentin rates ver a lnger perid f time. Other plicies reviewed by HRRC indicate that individuals wh lcate in scarcity areas may have specific characteristics and experiences: Preferential admissin t medical schls fr individuals frm medically underserved areas appears t be an effective mechanism (Mattsn et al, 1974), prviding supprt fr the prir cntact hypthesis. Medical students frm urban areas wh participate in a perceptrship in rural areas are mre likely t lcate in a rural cmmunity (Steinwald and Steinwald, 1973); but n infrmatin n shrtage area practice lcatin decisins is available. Effrts made by underserved cmmunities t attract new physicians can be quite successful, especially thse which include ecnmic incentives such as an ffice and equipment and guaranteed incme level. The evidence n these prgrams, hwever, is nearly all anecdtal -- "success" stries. The HRRC review cncludes that the evidence n the effectiveness f plicies designed t induce physicians t lcate in scarcity areas is weak. This cnclusin is cnsistent with the Werner et al. findings which suggest that these plicies may induce physicians t practice in rural areas, but have n effect n the decisin t lcate in shrtage areas. GAO (1974) prvides further evidence that decisins t lcate in -24-

28 shrtage areas are nt influenced by prgrams designed t affect these decisins. A survey f the 183 (f 30,000 lan recipients) physicians and dentists wh lcated in shrtage areas t btain frgiveness f lans was cnducted; 82 percent f respndents stated that they wuld have lcated in the shrtage area withut the lan frgiveness inducement. These physicians indicated that the mst imprtant factrs influencing their decisin t lcate in a shrtage area were (by rank): 1. Gegraphic preference 2. Desire t serve where mst needed 3. Opprtunity fr experience 4. Influence f family r friends 5. Assciatin with clleague 6. Availability f facilities 7. Lan cancellatin 8. Financial attractiveness Of the schlarship recipients wh were repaying lans, the GAO survey asked that factrs cnsidered unattractive abut rural shrtage area practice be ranked. The respndents ranked these undesirable cnditins in the fllwing rder: 1. Lack f CME pprtunities 2. Lng hurs f practice 3. Distance t supprt facilities 4. Lack f cnsultative surces 5. Limited cultural and scial activities 6. Preference fr a large cmmunity -25-

29 7. Necessity f engaging in general practice 8. Lack f desirable living cnditins 9. Financially unattractive It is interesting t nte that financial attractiveness r unattractiveness f the area was nt f great imprtance in the scarcity area decisin fr either grup. GAO cncludes that the HPSAP prgram was nt effective in inducing physicians t lcate in shrtage areas; a finding clearly cnsistent with the respndents' self-reprted lack f emphasis n financial incentives. A subsequent GAO (1978) study f the effectiveness f the NHSC prgram in inducing physician t permanently lcate in shrtage areas prduced similar cnclusins -- nly 42 f 800 NHSC alumni had been retained in shrtage areas as private practitiners by July Thse NHSC alumni wh were nt planning n shrtage area practice indicated that a desire fr further educatin and training was the majr reasn fr leaving shrtage area practice. Other reasns fr leaving included prfessinal and scial islatin, and persnal, family, and financial needs. Family Health Care, Inc. (FHC) (1977) reprts n a study f retentin and attitudes f and spuses in first turs f duty and fund that 38 percent intended t remain in the shrtage areas fr at least ne year after cmpletin f their bligatin. Thse intending t remain were mst influenced by their spuses' pinins f the area, and by the high demand fr services in the area bserved during the NHSC service. On the ther hand, thse nt planning t remain frequently -26-

30 reprted that lw demand fr services in the area was a factr in their decisin. This finding suggests that shrtage areas with unmet demand may be successful in retaining NHSC alumni; areas with relatively few physicians but with lw effective demand fr additinal services will be perceived (apprpriately) t be unable t supprt anther private practice. A recent study (Stamps and Kuriger, 1983) reprts n a survey f 100 in 10 East Cast states designed t btain infrmatin n their lcatinal plans after cmpletin f the NHSC bligatin and n the factrs influencing their decisins. Results indicate that 56 planned t lcate in a rural area after cmpletin f NHSC service. Thse prefering rural practice were mre likely t be in primary care specialties and mre likely t rank persnal and cmmunity factrs highly than prfessinal factrs as influences n the decisin prcess. Physicians riginally frm rural areas were mre inclined t rural practice (76 percent versus 47 percent frm urban areas). In summary, evidence available n shrtage area lcatin decisin prcesses suggests that factrs influencing this decisin are different than factrs influencing rural lcatin decisins. Plicies designed t influence the decisin t lcate in shrtage areas may be effective in inducing physicians int rural practice, but appear t be an ineffective mechanism fr eliciting shrtage area practice decisins. There is sme evidence that many -- r mst -- NHSC alumni wh lcate in shrtage areas did s because they had a prir preference fr the area and were nt influenced by the prgram. In additin, there is sme limited evidence that nt all shrtage areas are identical -- sme may have relatively few

31 physicians, but NHSC alumni are uninterested in lcating permanently in areas which have insufficient demand t supprt a new practice. Other areas have bth a need fr and the ability t supprt additinal practices; these cmmunities may be expected t be mre successful bth in attracting nn, and in retaining NHSC alumni. F. Discussin This review f the evidence n lcatin decisins f physicians and the factrs which influence them is intended t prvide a framewrk fr the develpment f hyptheses and research questins fr the cmparative evaluatin f NHSC alumni retained in Health Manpwer Shrtage Areas. The findings f this literature review suggest the fllwing majr issues fr the Research Design: The rural-urban lcatin decisin is a distinctly different ne than the shrtage-nnshrtage chice. research design shuld address this distinctin. The The physician chsing a rural and/r shrtage lcatin may have made this decisin prir t invlvement in NHSC. It will be imprtant t cmpare the timing f the lcatin decisin fr the NHSC and nn and characteristics f these physicians t determine whether the physician participated in NHSC because f a prir decisin/tendency r whether the decisin was influenced by the NHSC prgram. If prir cntact factrs r ther characteristics f the physician fully explain shrtage area chices, this shuld be determined. Shrtage area cmmunities have different degrees f unmet demand. It is highly unlikely that physicians will lcate in areas with need, but lw effective demand. On the ther hand, NHSC may be very effective as a means t acquaint physicians interested in rural practice with areas with high unmet demand and pprtunities fr rapid establishment f a new practice. An bjective f this study shuld be t identify characteristics f cmmunities with high unmet demand and cmmunities with need but lw demand in rder t (1) facilitate retentin by placing -28-

32 in sites which can absrb the services f an additinal private practice physician; and/r (2) t identify the characteristics f cmmunities which need physicians' services but are highly unlikely t attract a permanent physician in rder t permit the NHSC t develp pririties fr placement f persnnel. Over the past decade, patterns f female wrk frce participatin and ccupatinal chice have changed substantially. Cnsequently, spusal backgrund, characteristics, and attitudes may be mre imprtant in the decisins f current medical schl graduates than was the case in the past. This issue is reinfrced by the fact that nearly 30 percent f new medical schl entrants are wmen;1 their lcatin decisin prcesses may be significantly differently frm thse f male physicians. The cmpetitive envirnment facing new physicians establishing a practice is cnsiderably different than that facing new market entrants prir t the mid 1970s when much f the earlier research n physician lcatin decisins was cnducted. Cnsequently, it will be imprtant t fcus attentin in this study n the effect f market frces and cmpetitive factrs n the lcatins decisins f new entrants t the market. These issues and the specific factrs identified as influential n physician's lcatin decisins prvide the fundatin upn which we have develped the hyptheses and research issues described in Chapter ver 90 percent f the physicians surveyed in the RAND-AMA study f 1965 graduates, fr instance, were male. -29-

33 III. HYPOTHESES, RESEARCH ISSUES, AND DATA REQUIREMENTS A. Overview specific areas: The analyses t be cnducted during this study fcus n three (1) the rural-urban lcatin decisins f 1979 NHSC physicians surveyed by MPR; (2) the shrtage-nnshrtage area lcatin decisins f all NHSC and nn- chsing a practice lcatin between 1972 and 1981; (3) the practice characteristics f NHSC and nn-nhsc physicians lcated in rural areas. T address these isues, data must be cllected frm NHSC alumni, current PPO physicians, and frm nn- wh have chsen rural practice lcatins between 1972 and The discussin f the literature presented in Chapter II suggests that there are specific factrs which influence the rural lcatin chices f physicians; the decisin t lcate in a rural shrtage area is a subset f the rural decisin but is influenced by a smewhat different set f factrs. It is likely that the impact f certain factrs n the lcatin chices f NHSC alumni and ther yung physicians will vary in magnitude and significance. Based upn the literature review and the evidence presented there, it is evident that the rural lcatin chice must be cnsidered separately frm the shrtage area lcatin chice. Within each f these decisin categries, the individual characteristics f the physician and the characteristics f cmmunities and markets will be expected t influence the decisin prcess.

34 In this sectin, a set f hyptheses are presented fr the analytic areas f interest: rural chices shrtage area chices practice characteristics chices It is emphasized that the majr thrust f this evaluatin is designed t btain infrmatin n issues and experience that will be f assistance t HRSA in its future plicy making. Thus, each majr issue area belw is briefly described with respect t the bjective and ptential usefulness f findings. General hypthesis n the effect f current trends in physician supply n future distributinal patterns is als stated here. B. Rural Chices The primary bjective f the NHSC prgram is t prvide services t areas with insufficient physician resurces either temprarily, directly, r permanently, thrugh retentin f placed physicians. Thus, the fcus f this evaluatin is n the characteristics f physicians and cmmunities which result in decisins t lcate physician practices in shrtage it, areas. The decisin t lcate in a rural health manpwer shrtage area, hwever, is a subset f the rural lcatin chice; i.e. the physician

35 interested in rural shrtage area practice will be interested in rural practice, generally. T examine the relatinships amng persnal characteristics, cmmunity characteristics, and shrtage area lcatin chices, it is necessary t explre thse factrs which influence yung physicians t lcate in rural areas. There are six majr areas which distinguish rural-urban chices f yung physicians: Timing f the lcatin decisin: If sme physicians make permanent lcatin decisins early in their training, subsequent actins by the NHSC designed t influence these lcatin decisin will be ineffective. Examinatin f the timing f decisins by physicians with different characteristics will permit HRSA t identify physicians wh may be least likely t be induced t remain in shrtage area practice. Prir cntact factrs: It is generally agreed that prir cntact is an imprtant factr in lcatin chice. Infrmatin n the influence f prir cntact n the rural and the shrtage area chice, and the degree f this influence n these tw separate decisins, will be f use t the Crps in recruitment and placement plicy decisins. Spusal r family influence: Characteristics f the spuse, and family backgrund, are expected t influence the physicians' lcatin chice. Again, the degree f this influence n physicians with a particular set f characteristics may be useful infrmatin fr placement decisins, depending upn the bjectives f Crps' placements.

36 Persnal characteristics: Physicians with selected persnal characteristics may be mre r less likely t be retained in shrtage areas. Identificatin f these factrs, and the cmbinatins f these factrs, will allw assignment f thse mst likely t be retained t areas mst in need f permanent physician resurces. Prfessinal factrs: The physicians' training and prfessinal rientatin is expected t strngly influence lcatin preferences. The strength f this influence and the particular prfessinal factrs which are mst imprtant t yung physicians will determine which rural and shrtage areas are able t attract and retain yung physicians. Infrmatin n this issue will enable the Crps t identify cmmunities which are mre r less likely t attract permanent physician resurces. Cmmunity characteristics: Amng rural and shrtage area cmmunities there are wide variatins in characteristics which cause the cmmunity t be mre, r less attractive t yung physicians. As the supply f physicians increases and diffusin int less ppulus areas ccurs, thse rural and shrtage area cmmunities with specific types f characteristics will attract new physicians. Other less attractive cmmunities, hwever, will cntinue t experience a shrtage f physician services. It is particularly imprtant that the NHSC prgram have infrmatin which will permit it t identify the characteristics f cmmunities which are expected t have lng term need fr medical services. With this infrmatin, the Crps can develp and implement placement plicy t meet particular bjectives with respect t bth access t services and retentin f alumni. The research which is planned t examine the rural-urban lcatin chices will be cnducted using nly the 1979 sample f surveyed by MPR fr the earlier NHSC evaluatin study. Thus, these hyptheses are stated fr nly. Hyptheses which distinguish amng the characteristics f rural cmmunities, n the ther hand, will be examined using the entire sample f NHSC and nn

37 Timing f Decisins in urban and rural lcatins will nt differ in the reprted timing f their lcatin decisins. Prir Cntact Factrs with rural rearing will be mre likely t chse rural lcatins. with prir prfessinal expsure t rural practice (i.e. thrugh the NHSC service, residencies, preceptrship prgrams, r ther mechanisms) will be mre likely t chse rural practice. Spuse's Backgrund/Family wh are married will be mre likely t chse rural practice if their spuse is frm a rural area r has a preference fr rural life style. wh are married will be mre likely t chse rural practice if their spuse is nt cncerned abut career pprtunities. Physcians with family ties t a specific area will be mre likely t lcate in that area. Persnal Characteristics Male will be mre likely t lcate in rural areas than female. wh are lder than average at the time f an initial lcatin decisin will be mre likely t lcate in rural areas. U.S. medical graduates will be mre likely t lcate in mre ppulus rural areas than freign medical graudates; FMGs will be mre likely t lcate in least ppulated rural areas. Prfessinal Factrs wh are less cncerned abut cntinuing medical educatin pprtunities will be mre likely t lcate in rural areas. wh fulfill their NHSC service as PPOs in a private practice setting are mre likely t be retained in a shrtage area. -34-

38 wh are able t jin a grup r partnership practice will be mre likely t chse a rural lcatin. Cmmunity Characteristics Physicians will be mre likely t chse a rural practice in a cmmunity that ffers gd quality educatinal resurces. Physicians will be mre likely t lcate in rural cmmunities which have adequate prfessinal persnnel and facilities. Physicians will be mre likely t lcate in rural cmmunities that have sufficient unmet effective demand t ensure that an additinal practice can be supprted (i.e. that incme ptential is present). Physicians are mre likely t lcate in rural cmmunities with ppulatin characteristics similar t sciecnmic backgrund f the physician's parents. Physicians will be mre likely t lcate in rural cmmuniites which have relatively high per capita incme levels. Physicians will be mre likely t lcate in a rural cmmunity which ffers recreatinal, cultural, and/r gegraphic features that are generally attractive. C. Shrtage Area Chices It is assumed fr this study that the physician wh chses a rural shrtage area practice will have made a prir cmmitment t rural practice. Therefre, the hyptheses related t rural lcatin chices apply t the physician chsing a shrtage area practice. This aspect f the study is f greatest interest and ptential usefulness t Crps plicy makers since the Crps' primary bjectives are t prvide services t cmmunities with a shrtage f physician resurces and t place physicians in HMSAs where they will decide t remain after cmpleting their -35-

39 bligatin. The diffusin f physicians t rural areas desn't ensure that shrtage areas will receive new physician resurces. Hwever, as the supply f physicians in the mst attractive rural areas increases, cmpetitive pressures may frce new physicians int areas which are less attractive and which have been in shrtage fr sme perid. Sme cmmunities, hwever, may never attract a permanent physician even when subtantial medical need exists; there may be insufficient effective demand t supprt a physician's practice, prfessinal resurces available may be inadequate t prvide a fundatin fr a practice, r the cmmunity characteristics may be s uninviting that n ne chses t live there. Recgnizing these prblems, it remains imprtant t identify factrs that may influence yung physicians t chse shrtage area practice and/r t remain in an NHSC site after cmpletin f an bligated service. Based upn prir literature, these factrs are mre ften persnal and prfessinal than cmmunity characteristics. In additin, it is anticipated that the NHSC experience, and the type f NHSC experience (i.e. NHSC site r PPO placement) may be f imprtance in this decisin. The hyptheses listed here fcus n thse research issues which are expected t distinguish the shrtage area lcatin decisin frm the rural lcatin decisin. NHSC Physicians wh are NHSC alumni wll be mre likely t chse a shrtage area lcatin as a result f cntact with the area. PPOs wh cmpleted their bligatin in a private practice setting will be mre likely than ther NHSC alumni t be retained. -36-