Recommendation 16:
- The federal government should provide
technical assistance to clinics in underserved
areas to enable them to participate
more successfully in managed care programs,
especially under Medicaid managed
care contracts. The current efforts
of the Bureau of Primary Health Care in
this area are a promising start and should
be expanded to include clinics in shortage
areas that are not directly funded under
the 330 program.
- Managed care plans in which Medicaid
beneficiaries are enrolled should be required
to enter into contracts with established
community clinics in shortage areas
and related providers that form the
safety net in these communities.
- The federal government should carefully
monitor managed care programs to evaluate
their direct effects on individuals enrolled
in these programs, their indirect
effects on uninsured individuals in shortage
areas, and their effects on providers
in shortage areas such as community
clinics.
FINDING 15: Many urban community health
clinic sites depend on NHSC funding and
placement programs for an essential
portion of their clinical staff. Retention of NHSC
clinicians after conclusion of their service
obligation depends on developing and
maintaining a mutually supportive
relationship between these professionals and their
clinics.
The recent expansion of the NHSC, in particular
its loan repayment program, has enhanced staffing
at community clinics. CHCs and related primary
care clinics are a significant source of
placement of NHSC scholarship and loan recipients
in urban shortage communities. In urban
underserved areas, the NHSC personnel placements
augment federal and other clinic funding.
Recommendation 17: The Public Health
Service should more closely coordinate section
330 clinic and National Health Service
Corps funding, in order to support staffing
at these sites.
FINDING 16: Minority health professionals
play a unique and important role in serving
populations in urban shortage areas.
Underrepresented minority physicians are
much more likely than majority physicians
to locate their practices in underserved,
pre-dominantly minority communities. Little is
known about other characteristics that may
predict which health professionals are more
likely to practice in underserved
communities.
Racial segregation is a powerful underlying factor
associated with the maldistribution of physicians
in urban areas. Some evidence suggests that the
racial and ethnic characteristics of urban neighborhoods
are stronger predictors of physician supply
than community income level. Because of the tendency
of minority physicians to practice in
underserved areas, increasing the number of minority
physicians who complete training is likely to
have a direct impact on reducing the inequitable
geographic distribution of clinicians in urban areas.
The conclusions in COGME’s Third Report,
Improving Access to Health Care Through Physician
Workforce Reform: Direction for the 21st Century,
are supported by current evidence (COGME,
1992):
“Increasing the percentage of underrepresented
minorities in the medical profession is vital as a
means of improving access to care and health status
of these vulnerable and underserved populations.
. . . Strategies to increase minority enrollment
must emphasize increasing and strengthening the
applicant pool, the acceptance rate from within this
pool, and the student retention rate.”
Factors in addition to race or ethnicity of health
professionals may also dispose individuals to practice
in urban underserved communities. However,
little research has been done to analyze carefully
these putative predictive characteristics.
Recommendation 18:
- Current activities such as the COGME report
on minorities in medicine (COGME,
in press), the “3000 by 2000” initiative by
the Association of American Medical Colleges,
and the initiatives of private foundations
and schools to promote representation
of minorities should continue unabated
(COGME, 1992).
- Federal and state programs that encourage
minority participation in medical education
should be continued and, where
possible, enhanced.
FINDING 17: The shortage of health care
professionals is but one factor in determining
the health status of urban underserved
communities. Other factors include a poor
standard of living, poor educational opportunities,
overt and covert racism, and a widespread
lack of health insurance. Improvement in
overall health status requires coordination
among health professionals, public health,
and social and environmental entities.
A paucity of health professionals is but one of
many barriers to access to care confronting many
inner-city communities. Poverty, racism, lack of
educational opportunity, and substandard living
conditions exact a direct toll on health, independent
of the effect of these social forces on access to
medical care. Residential segregation based on race
or ethnicity remains a fact of urban life. Thus the
need for professional health care workers in these
communities is only a piece of a very complex
puzzle. A coordinated approach is essential to be
even modestly optimistic about the development
of lasting solutions to the problems of urban health.
Recommendation 19: Federal, state, and local
initiatives should coordinate programs
and mutually support efforts to solve the
vexing problem of poor health status among
urban poor.
FINDING 18: There is a paucity of well
documented, statistically valid research on the
many variables that affect the availability and
utilization of health care in urban,
under-served communities.
Although several high-quality research studies
address one or more of the problems of medical
care and health status among urban poor, the field
is so complex and the questions so demanding that
current research efforts barely begin to shed light
on the issues. There is no research available, past
or present, to help answer critical questions about
the impact of managed care, Medicaid managed
care, care for the uninsured poor, and the effect of
these changes on so-called “safety net” facilities.
One of the major obstacles to the study of the
health care workforce is the lack of data on the location
and practice patterns of the current
workforce. Such data are the cornerstones of studies
of the workforce and decisions regarding strategies
that might affect community shortages.
Recommendation 20: The federal government,
perhaps in collaboration with states
and foundations, should provide adequate
resources to support research regarding the
makeup of the health care workforce.
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