FINDING 9: Although IMGs have made an
important contribution to the provision of
medical care in some rural areas, training IMGs is
an inefficient way to expand physician
supply in rural areas. Although many inner-city
hospitals are dependent on IMGs for
providing care for underserved urban populations,
more direct avenues exist for meeting the
needs of these hospitals. The funds would
be better targeted to programs that increase
the flow of USMGs to underserved rural
areas (Mullan, 1997).
General consensus exists that an oversupply of
physicians is emerging. The engine behind this development
has been the number of entry level residency
positions in the country’s GME system,
which has expanded rapidly in recent years. Most
of this expansion is due to the increase in the number
of IMGs coming to this country for training.
Although some of these foreign-born IMGs ultimately
practice in underserved rural areas, most
become permanent residents in metropolitan areas.
Just as expansion of the total physician supply is a
very inefficient way to address problems of geographic
maldistribution, depending on IMGs to
practice in rural areas is a suboptimal solution for
persistent rural shortages. Because these first-year
residency positions are supported by DME and
IME payments by Medicare, we are in the paradoxical
situation where an emerging oversupply of
physicians is being stimulated by governmental
subsidies.
Proven methods exist that can increase the number
and proportion of USMGs that practice in rural
areas and involve both educational and service interventions.
Redirecting federal money to these
programs has a potential dual benefit: improving
geographic maldistribution while addressing the
emerging problem of a physician oversupply.
Recommendation 11: Eliminate Medicare
DME and IME payments for new exchange
visitor (J-1 visa) residents as part of the process
of reducing the number of first-year
residency positions to 110 percent of 1993
U.S. medical graduates.
Recommendation 12: Use a portion of the
savings realized to increase funding for
medical student and residency programs
which prepare USMGs for service in rural
and urban underserved areas and to support
targeted expansion of community and mi-grant
health centers and the NHSC.
FINDING 10: Generalist-trained PAs and NPs
play an important role in providing medical
care in rural underserved areas; the exact
dimension of this contribution and the
opti-mal interrelationship among the various
disciplines is not well understood.
Many PA programs have long been focused on
producing graduates who are likely to serve in
underserved rural areas, and evidence has shown
that a substantial number of PAs have settled in rural
areas. Information is less available about NPs, but
it is clear that they also make an important contribution.
Relatively little work has been done that
shows how these clinicians and providers work together,
the extent to which they substitute for one
another, and what constitutes optimal collaboration
in different types of rural areas. It is important that
research be done in this area.
FINDING 11: Reimbursement strategies that
provide incentives for providers settling and
practicing in rural areas, such as the
Medicare Incentive Payment program, show
promise in attracting rural providers.
Financial incentives have a powerful effect on
physician behavior, although the independent effect
of incentives is difficult to isolate from other
simultaneous interventions designed to increase the
rural physician supply. When coupled with educational
programs that augment the number of providers
interested in—and trained for—rural practice,
incentives increase the flow of providers to
rural areas.
The optimal structure of the incentive is as yet
undetermined, though the current 10 percent
supplement to the usual Medicare fee scale in certain
rural areas appears to have an impact. Better
research is needed to determine the best use of the
incentive pools as inducements for the recruitment
and retention of rural providers.
Recommendation 13: Continue enhanced
Medicare payments to rural providers in
underserved areas; this process should be
coupled with more research to determine the
best way to construct the incentives so as to
optimize their influence.
FINDING 12: Telemedicine offers promise as
a way to extend new services into
under-served areas, but the lack of standardization
threatens the widespread applicability of
these new technologies.
Telemedicine has great promise in rural medicine
and may magnify the effectiveness of local
providers by making sophisticated services and
consultation available from a distance. During this
early phase in the development of these new technologies,
there is little consensus on how these innovations
should evolve. Problems with the hardware
and software compatibility, licensing and
reimbursement of providers who offer services
across state lines, malpractice issues, and the difficulty
of forging collaborative professional interrelationships
hinder the further development of this
area.
Recommendation 14: Support continued experimentation
in rural telemedicine efforts,
while forging consensus on how these services
should be provided, licensed, and paid for.
FINDING 13: CHCs and related group
practice arrangements appear to be the most
viable model for bringing health care services
to underserved urban communities.
Reliance on independent, private practice in
office-based settings is unlikely to be effective in
addressing the health care needs of most under-served
urban communities. In poor, inner-city communities,
such practice settings have marginal, if
any, economic viability for health professionals.
The increase in Medicaid physician fees has not
led to an influx of physicians into these neighborhoods.
Patterns of residential segregation based on
race, ethnicity, and class will likely perpetuate the
shortages of physicians in these areas. Available
research has not disclosed a strong association between
access to office-based physicians and measures
of health care access and health outcomes.
Finally, the system of health care in the United
States is moving away from independent, solo, and
small-group practice toward more organized systems
of care and larger group practices.
Numerous clinic models have been developed
since the inception of the federal neighborhood
center program, in which clinics function as autonomous
sites administered by a nonprofit board with
federal funding. Although many clinics continue
to function in this fashion, other models have
emerged as collaborations between local health
departments, community hospitals, neighborhood
associations, academic medical centers, and other
involved parties. Some clinics are involved in managed
care programs, either directly or through affiliations
with other provider groups. These clinic
arrangements have had a positive impact on some
measures of health access and health outcomes.
Recommendation 15:
- Federal policy should recognize the effectiveness
of community health centers in
addressing the problems of underserved
urban populations and should emphasize
these models in health care funding decisions.
- Partnerships should be forged between
government at federal, state, and local levels
and private and academic groups to
develop innovative community-based primary
care group practices in underserved
urban areas. Federal policy should encourage
these partnerships, and any disincentives
to their creation should be removed.
FINDING 14: Because of the rapid, dramatic,
and not entirely predictable changes
occur-ring in the United States health care system,
there is a need for careful monitoring of the
dramatic growth of managed care and the
more competitive medical care market,
especially as it relates to Medicaid enrollees
and the uninsured.
The health care system in the United States is
in the midst of major transformation related to the
ascendancy of managed care and a more competitive
medical care marketplace. This transformation
has the potential to have both adverse and beneficial
effects on underserved communities. Key factors
in this evolving system will be policies concerning
managed care for Medicaid enrollees and
the uninsured, in particular policies that may affect
whether traditional providers in shortage areas are
integrated into provider networks serving these
patients.
Many elements of managed care emphasize
objectives consistent with those of traditional programs
in underserved communities. The increasing
appreciation of the clinical importance of comprehensive,
continuous, coordinated primary care
may enhance awareness of the value of primary care
providers in underserved areas. Reorganizing care
under a primary care model and reallocating Medicaid
dollars from hospital-based care to primary
care under a capitated payment method hold the
promise of offering better delivery of care than traditional
Medicaid arrangements. Research has not
consistently shown, however, that a managed care
model necessarily results in improved process or
outcomes of care for Medicaid patients. Efforts to
improve delivery of care to inner-city populations
under a managed care model may be undermined
by a number of factors, including lack of a so-called
“safety net” of providers in their provider network.
Loss of Medicaid patients could result in closure
of many sources of care that form a part of the safety
net in communities where residents lack health insurance
coverage. Further reductions in government
expenditures for Medicaid may threaten the beneficial
features of primary care and create excessive
pressures on primary care “gatekeepers” to
limit access to appropriate services.
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