Access to Care

The Aging of the Rural Generalist Physician Workforce: Will Some Locations Be More Affected than Others?

This study will identify rural locations with high proportions of generalist physicians nearing retirement age. As fewer young physicians choose generalist careers, the retirement of older physicians may place additional strain on rural generalist supply. This study is quantifying the extent to which rural generalist physician shortages may be exacerbated by physician retirement, focusing on known shortage locations. The study uses data from the American Medical Association and American Osteopathic Association 2005 Masterfiles. This study is funded by HRSA’s Office of Rural Health Policy.

Are Rural Perinatal Care Systems Deregionalizing?

The regionalization of rural perinatal care during the 1980’s significantly lowered neonatal mortality among infants born to rural residents, yet recent trends could disrupt the efficiency of regionalized systems of care. This national study is determining whether there is evidence of deregionalization of rural perinatal care for high-risk women and infants and whether deregionalization has adversely affected neonatal mortality among infants born to rural residents. We are analyzing National Linked Birth Death Data Set data over a 10-year period. The study population includes all low-birthweight infants born to rural residents. This study will demonstrate the impact of managed care on the rural health care delivery system and outcomes. Funded by HRSA's FORHP. (In Progress)

Economic Impact Analysis of HRSA's Rural Health Care Services Outreach and Rural Health Network Development Grant Programs

This study analyzes the economic impact created by HRSA Network Development and Outreach grantees. The analyses are being conducted with the goal of creating transparent and easy-to-use tools that can be used by grantees and HRSA in future program efforts. While the project analyses focus on a cohort of grantees, the study is using methods and data that potentially could be extended to other HRSA grantees and programs. The WWAMI RHRC has a subcontract to carry out this project in collaboration with The Lewin Group, through a grant from HRSA’s Office of Rural Health Policy.

The Future of Family Medicine and Implications for Primary Care Physician Supply

This study investigates the implications of declining medical school interest in primary care careers as it impacts rural and underserved areas. The study will examine data from the American Association of Medical Colleges, the 2005 American Medical Association Masterfile and the American Osteopathic Association Masterfile as well as survey data from residency directors and students to describe recent trends in medical school interest and national match rates for family medicine and primary care. Funded by HRSA's FORHP.

Trends in Access to Health Care Among Rural Residents: A National Study

This study uses national data from the Behavioral Risk Factor Surveillance System (BRFSS) to ascertain the extent to which rural residents lack adequate health care access. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. The study will explore trends in having a personal health care provider, being unable to see that provider, and the influence of costs on access in rural compared to urban areas. Funded by HRSA's ORHP. (In Progress)

Problem Drinking: Trends Among Rural Veterans—A National Study

This study will use national data to measure recent trends in problem drinking among VA-eligible adults in rural and urban locations and couple these data with the locations of VA services and substance abuse treatment facilities to identify rural locations where alcohol treatment services are limited. This project is funded by the Veterans Administration Office of Rural Health, through a contract with the northwest Portland, Oregon, Veterans Affairs Medical Center.

Do Rural Patients with Early Stage Prostate Cancer Gain Access to All Treatment Choices?

This research will use cancer registry data from 10 states to examine the degree to which rural residents diagnosed with early-stage prostate cancer access the full range of surveillance, surgical, and radiation treatment options. Study findings will inform cancer centers, advocacy groups, rural program planners, and policymakers about services and programs needed to ensure that rural prostate cancer patients can choose from among all treatment options.

Use of Recommended Radiation Therapy in the Rural U.S.

This study will use cancer registry data from 10 U.S. states to examine which rural cancer patients are receiving recommended radiation therapy and what factors influence receipt of recommended treatment. Identifying gaps in radiation therapy will inform cancer centers, rural program planners, and policy makers in rural cancer service location and cancer support program development. Funded by HRSA's ORHP.

Policy Analyses of Rural Issues Related to Health Care Reform

Health care reform provides an array of opportunities to improve health care access and quality for rural Americans. The WWAMI RHRC will support HRSA’s efforts to inform this process by summarizing existing evidence characterizing the rural health care workforce and rural health care delivery and will conduct analyses exploring the potential impact on rural populations of proposed and newly-enacted health care reform legislation. Funded by HRSA's ORHP.

WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) Rural Health Workforce Monograph: Guide for State Legislators Regarding Rural Workforce Information and Issues

This project will compile and present state-level information about the rural health workforce in the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region. Information will be derived from many sources, such as the American Medical Association and American Osteopathic Association, the National Sample Survey of Registered Nurses, the American Academy of Physician Assistants, and the American Dental Association. The monograph will illustrate issues such as the shortage of different types of health care providers in various kinds of rural locations. This information can be used by policymakers, legislators, and others as a basis for making informed workforce decisions that affect rural areas, such as allocating funding, enhancing training at state institutions, and implementing strategies to address provider shortages. The Web site and multicolored monograph that result will provide national data as a comparison for this information and will present some intrastate rural workforce supply data. (In Progress)

Relationship Between Access to Obstetrical Care and Process and Outcome of Care

Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical care in rural communities and birth outcomes (see working paper #4). The Obstetrical Process and Outcome of Care Study compared rural versus obstetrical care and outcomes from birth certificates. This study examined the relationship between access to and availability of care (number of local providers available who provide obstetrical care and who care for pregnant Medicaid women) and quality and cost of care. Sources of data included Washington State birth certificates and hospital discharge abstracts, supplemented with information on hospitals, communities, and provider supply. Findings from this study further illuminate the connection between poor geographic access, Medicaid access, and poor quality care.

Ambulatory Care and the Rural Elderly

Diabetes is a common serious chronic disease where careful clinical monitoring can improve the quality of care and patient outcomes. This study examined the extent to which Medicare patients in Washington State receive care that adheres to clinical guidelines and the extent to which the rural or urban residence affects the quality of care received. Medicare patients 65 years and older with two physician encounters for a diabetic condition in 1994 were included in this study. Patient residence was determined by using the ZIP code of the patient’s dwelling as listed in the Medicare National Claims History File. Adherence to guidelines was measured by determining the extent to which patients received three tests recommended by the major authoritative bodies during the study year: glycated hemoglobin, an eye examination, and a cholesterol measurement. 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Urban patients received virtually all their medical care in their local communities, as did over 80% of rural patients who lived in rural communities with more than 10,000 people; people living in smaller rural towns received almost half their outpatient care in other communities. Most diabetic care in all locations is provided by generalists. Patients living in large rural towns remote from metropolitan areas received higher quality care on these measures than all other groups, while those living in large communities adjacent to metropolitan areas had the lowest adherence rates. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. Even though clear guidelines exist for certain routine monitoring tests—and even though Medicare pays for these tests—most patients do not get all the recommended interventions. Large rural towns remote from cities seem to have higher quality of care. Given that most diabetic care is given by generalists, the challenge is to create a system where patients and their primary care physicians can work together to improve the care of serious chronic conditions. Funded by HRSA's ORHP.

Perinatal Risk Factors, Prenatal Care Use, Birth Outcomes, and Infant Mortality of Rural and Urban American Indian Women

While American Indians (AIs) constitute a substantial minority population in many rural areas, population-based research on the health status of AI women and infants is limited. This study used the National Linked Birth Death Certificate Data Set for 1989 and 1991 to compare the perinatal risk factors, prenatal care use, birth outcomes, and infant death rates of rural AIs, urban AIs, and whites. Results from this study should help administrators and policy makers to better understand the health care needs of this population, as well as the targeted interventions needed to improve birth outcomes and infant health status. Funded by HRSA's ORHP.

Access to Cancer Services for Rural Colorectal Cancer Medicare Patients: A Multi-State Study

This study compiled a comprehensive database linking Surveillance Epidemiology and End Results (SEER) cancer registry, Medicare claims, American Medical Association Masterfile, and other data to examine access to cancer services in a sample of rural, Medicare-insured colorectal cancer patients of different racial and ethnic groups. Funded by HRSA's FORHP.

Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: Does Proximity to a Metropolitan Area Matter?

This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to explore the prevalence and trends in screening for four types of cancer (breast, colorectal, cervical, and prostate) among survey respondents from urban and various types of rural areas and among white compared to minority populations. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA's FORHP.

Health Care for the Uninsured: How Do the Uninsured Use the Rural Safety Net?

This study described the contributions of family and general practice physicians from Wyoming to the health care safety net. We surveyed family and general practice physicians in Wyoming about provider demographics, practice composition, and policies for treating the underinsured or uninsured. From a 50% response rate, 61% made less than the national mean family physician income ($130,000), and women were less likely than men to make this mean income, even when controlling for hours worked. Close to two-thirds claimed bad debt of over $10,000, and 29.3% noted forgiven debt of over $10,000. Physicians with less income than the prior year were more likely to decrease their charity care. Wyoming family physicians provide significant amounts of informal safety net care, which is threatened by income loss. Funded by HRSA's ORHP.

Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project

Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals, yet there were no projections of key health professions staffing needs for HCs and proposed new HCs. This collaborative study with the South Carolina RHRC described the staffing needs of rural HCs and ascertained the staffing, recruitment, and retention issues that HC CEOs regarded as most critical. The National Association of Community Health Centers administered a mail questionnaire to the CEOs of all CHCs in the nation (about 845) that profiled their current staff vacancies, projected staffing needs, recruitment and retention issues, center site expansion plans, and CEO perception of policies that would facilitate recruitment and retention. This joint center project was a collaborative one between HRSA’s FORHP, BPHC, and BHPr.

Impact of Hospital Closures on Physician Supply

This study determined whether the supply of physicians decreased subsequent to a rural hospital closure during a nine-year period ending in 1988. The study (1) examined changes in physician manpower before, after, and at the time of the closure and (2) examined the association of town size, hospital size, and distance to other hospitals with hospital closure. The hospital closure towns most likely to lose physicians had few physicians before closure, were relatively remote from both urban areas and other hospitals, were located in sparsely populated counties, and tended to have for-profit ownership.

Persistent Primary Care Health Professional Shortage Areas (HPSAs) and Health Care Access in Rural America

This study examined the degree to which persistence of primary care health professional services area (HPSA) designation in rural counties is associated with lower population socioeconomic status and deficiencies in access to health care services. It used a five-level classification of rural counties measuring partial- vs. whole-county persistence of primary care HPSA designation that stratified rural populations by socioeconomic status (SES), race/ethnicity, primary care supply, health insurance uptake, and access to needed health care services. The study found that those U.S. rural counties that were persistently designated as whole-county HPSAs had much lower SES, and adults residing in these counties reported substantial financial obstacles to obtaining needed health care services. Rural counties that were persistently designated as whole-county HPSAs also faced severe provider shortages, and adults residing in these locations were less likely to have a regular primary care provider. This study was funded by HRSA’s Office of Rural Health Policy.

Impact of Malpractice Claims

We studied all family physicians (470) who purchased obstetrical malpractice insurance from the largest malpractice insurer in Washington State (WSPIEA) from 1982 to 1988. One-third discontinued obstetrics but remained in practice, and these physicians were older, more likely to practice in an urban area, and more likely to be in solo practice. Rural family physicians were less likely to quit practicing obstetrics than their urban colleagues. Obstetrically related malpractice claims against family physicians were relatively infrequent and are not a factor in the decision of most family physicians who stop practicing obstetrics.

Physician Assistant Location and Geographic Trajectories: A National Study

Despite the need for generalist care providers in rural areas experiencing shortages of generalist physicians, the percentage of physician assistants (PAs) that practice in small towns has been decreasing. This study examined PA rural and urban location behavior and their geographic trajectories over time based on national PA data collected in an earlier study. Data from sources such as the Area Resource File were used to characterize the areas where PAs were located. Factors such as PA demography, educational program type and location, preceptorship location, and previous health care provider status were examined. As the American health care delivery system changes, with workforce policies that focus more sharply on generalist care, the need to better understand PA practices is crucial. Funded by HRSA's ORHP.

Low-Risk Obstetric Care Resource Use

This study, which was predominantly funded by AHCPR but was also supported through the HRSA's ORHP, was part of a large multifaceted project that examined low-risk obstetric care in Washington State through surveying obstetric providers and abstracting detailed information about their patients. This study used the provider as the unit of analysis. Differences in resource use (e.g., visits, tests, and procedures) between rural and urban obstetricians and between rural and urban family physicians were examined in detail.

Mayor Perceptions of the Closing of their Small Rural Hospitals

This project involved a survey of 130 mayors of rural towns whose sole small general hospitals closed between 1980 and 1988. Mayors attributed the closure of their hospitals primarily to government reimbursement policies, poor hospital management, and lack of physicians. They reported that they had little warning that their hospitals were in imminent danger of closing. Well over three-fourths of the mayors felt that access to medical care and health status had deteriorated in their community after hospital closure, and over 90% indicated that the hospital closure had substantially impaired the community’s economy.

Physician Perceptions of the Closing of their Small Rural Hospitals

This project surveyed the physicians of rural towns whose sole small general hospitals closed between 1980 and 1988. All locatable physicians who were practicing in the hospital closure towns at the time of the closures were surveyed with a questionnaire similar to that employed in a parallel survey of hospital closure town mayors. The study concentrated on physician perceptions of the reasons the hospitals closed, the consequences of the hospital closures, and the role the physician played in the closure process. Government reimbursement policies and poor hospital management were cited as principal reasons for hospital closures.

Medicare Bonus Payments for Physician Care in HPSAs

Medicare’s Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in areas where there is a federally designated shortage of generalist physicians. This study examined the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program using a retrospective cohort design utilizing 1998 Medicare Part B data. Physician specialty was determined through American Medical Association Masterfile data. Rural status was determined by linking this ZIP code to its Rural-Urban Commuting Area Code (RUCA). There were 39,780 providers in the study cohort: 24.9% generalists, 53.5% medical and surgical specialists, and 21.6% nonphysician providers. Over $4 million in bonus payments were made to providers in the Health Professional Service Area (HPSA) sites, with a median overall payment of $173. Specialists and urban providers received 58% and 14% of the bonus reimbursements respectively. Nearly a third of the potential bonus payments ($2 million) were not distributed because the providers did not claim them. Over $2.8 million in bonus claims were distributed to providers who likely did not work in approved HPSA sites. Many providers who should have claimed the bonus did not, and many who likely did not qualify for the bonus claimed and received it. Consideration should be given to focusing and enlarging the bonus payments to specific providers as well as a system that prospectively determines provider eligibility. Funded by HRSA's ORHP.

National Health Service Corps Evaluation

A major impediment to access to care is the shortage of primary care physicians in rural locations and inner cities. This extension of an earlier study evaluated the National Health Service Corps (NHSC) scholarship program through a mail survey with phone encouragement of NHSC scholarship recipients who graduated from medical school during 1975-83. The study examined their retention experience, locational career patterns, demographic and practice characteristics, and service in rural sites. Funded by HRSA's ORHP.

Obstetrical Access in Washington State

A survey of all potential providers of obstetrical care in Washington State was conducted in 1989, and results were compared to an earlier survey to assess the extent to which obstetrical access had changed. Although the massive exodus of family physicians from obstetrical practice appeared to have slowed during the follow-up period, there was still substantial net attrition among this group of providers. By contrast, the supply of obstetricians and midwives seemed to be stable. Despite the greater obstetrical participation rate of rural practitioners, members of this group were also quitting obstetrics faster than they could be replaced.

The Contribution of Generalist Nurse Practitioners and Physician Assistants to Primary Care in Rural Washington State

Quantified estimates of the total contribution of nurse practitioners (NPs) and physician assistants (PAs) to primary care made by these non-physician clinicians (NPCs) are rare. This study used productivity data from the NPC and physician populations in Washington State to assess the contribution to generalist care made by NPCs, the role of NPCs in rural and underserved areas, and the role of women NPCs in the female provider population. Data on demography, medical specialty, place of practice and outpatient visits from license renewal surveys were used to estimate the productivity of generalist physicians and generalist NPCs. Head counts of physicians, NPs and PAs were adjusted for missing specialty and productivity data and converted into family physician full-time equivalents (FTEs) to facilitate comparisons and estimation of total contribution to care made by each provider type. A total of 4,189 generalist physicians produced only 2,760 family physician FTEs (1 FTE = 105 outpatient visits per week). Overall, generalist NPCs made up 23.4% of the generalist provider population and performed about 21.0% of the generalist outpatient visits in Washington State. NPC contribution was higher in rural areas of the state, about 24.7% of all generalist visits, and a bit lower in urban parts of the state, about 20.1% of generalist visits. In rural areas, female physicians provided 49.3% of the visits provided by female providers; female NPCs provided the remaining 50.3%. In urban areas, female physicians provided about 63.5% of the generalist care provided by women and female NPCs provided 46.5%. NPCs made similar contributions to total care in rural Health Professional Shortage Areas compared to rural non-shortage areas, though PAs appeared to contribute somewhat more care in HSAs with severe shortages of providers. NPs and PAs provided over 20% of the generalist outpatient visits in Washington State. Accurate estimates of available generalist care must take into account the contribution of NPs and PAs. Funded by HRSA's ORHP and BHPr.

Diffusion of New Perinatal Technology into Rural Areas of Washington State

One of the major issues confronting rural health care providers is the problem of acquiring complex and expensive new medical machinery, because of the relatively low volume of patients and encounters. This study described the patterns through which new perinatal technologies are adopted, the extent to which they are utilized in communities of varying sizes and levels of medical sophistication, and the impact of these technologies on obstetrical care in rural communities. We used surveys to determine which technologies are available in inpatient and ambulatory practice settings (100% response rate).

Access to Physician Care for the Rural Medicare Elderly

Patients in rural areas may utilize less medical care than urban patients because of differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. This study compared travel times, distances, and physician specialty mix of Medicare patients in Alaska, Washington, North Carolina, South Carolina, and Idaho. We used a retrospective design, utilizing 1998 Medicare billing data. Travel time was determined by computing the road distance between the patient’s and the provider’s ZIP codes. There were 39,780 providers in the cohort: 16.1% generalists, 62% specialists, and 21% nonphysician providers. The median overall one-way travel distance and time was 7.7 miles and 11.7 minutes. Rural residents traveled two to three times farther to see medical and surgical specialists than urban residents. Rural residents with cancer, heart disease, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was related to decreased visits to specialists and increasing reliance on generalists. The majority of visits by those living in large rural areas were in large rural areas or the patients’ home ZIP codes. Residents of rural areas have increased travel distance and time compared to their urban counterparts, particularly true of rural residents with specific diagnoses or those undergoing specific procedures. Funded by HRSA's ORHP.

Physician Residency Rural Training Baseline Study

The supply of rural physicians is in part determined by the number of family physicians who receive residency training in rural areas. This study explored what proportion of all family medicine residency experience actually takes place in rural areas in the United States. Questionnaires were mailed to all 453 civilian family practice residencies in the United States in 2000. Programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas, the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. Only 33 family medicine residency programs (7.4%) were located in rural areas. Most of the training sponsored by these rural programs occured in rural areas. Although over one-third of the urban programs listed rural training as an important part of their mission, only 2.3% of the training they supported took place in rural areas. For the nation, 7.5% of family medicine residency training occurred in rural areas, although 22.3% of the U.S. population lives in rural places. This study concluded that very little family medicine residency training actually took place in rural areas. To the extent that there was a link between the place of training and future practice, the lack of rural training contributed to the shortage of rural physicians. Funded by HRSA's ORHP.

The Rural/Urban Practice Location Patterns of Women Medical School Graduates

While women are becoming an increasingly large percentage of the graduates of medical schools and of the generalist specialties in particular, they are much less likely to locate their practices in rural towns. If this trend were to persist, implications for access to care in rural areas would be substantial. This study involved a survey including questions about where the residents preferred to locate and how much they thought they would be practicing in the future. The study first examined national physician location patterns by medical school graduation cohort per gender differences. The second phase dealt with the production of female generalist physicians by medical schools. Funded by HRSA's ORHP.

The Process and Quality of Rural Perinatal Care: A National Study

The equitable provision of high-quality obstetric care is a major priority of our health care system, and nowhere is access to such care more threatened than in rural areas. This project determined whether rural mothers receive less care and experience worse outcomes than their urban counterparts, whether racial and ethnic minorities living in rural areas experience different outcomes than their counterparts, and what other factors are associated with less care and poorer outcomes. Data were compiled from the National Center for Health Statistics’ Linked Birth/Death set and the Bureau of Health Professions’ Area Resource File. Measures of process of care included late or no prenatal care, lack of care in the first trimester, and inadequate care as measured by the Kotelchuck Index. Outcome measures included infant mortality and the percentage of children born at low and very low birthweight. This study also compared birth outcomes and process of care for minorities across rural areas and with their urban counterparts. Funded by HRSA's ORHP.

Best Strategies for Recruiting Women Physicians to Rural Practice

This study examined differences in the factors female and male generalist physicians considered influential in their rural practice location choice and identified the practice arrangements that successfully recruited female generalist physicians to rural areas. We mailed questionnaires to generalist physicians recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest. Compared to men, recruited women were younger, less likely to be married, had fewer children, and worked fewer hours. Women were more likely than men to have been influenced by issues related to spouse/personal partner, flexible scheduling, family leave, and availability of child care, as well as the interpersonal aspects of recruitment. Commonly reported themes reflected the desire for flexibility regarding family issues and the value placed on honesty during recruitment. Men and women were equally likely to consider community factors, practice content, practice partner compatibility, and financial issues. The most common methods for obtaining information about practice opportunities were personal networking, prior training experience, recruiters, and outreach by medical practices. This study concluded that rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse/partner, and interpersonal issues if they want to achieve a gender-balanced physician workforce. Funded by HRSA's ORHP.

Rural C-Sections and Family Physicians

This project provided information on how physician training, community specialty mix and other factors are related to the provision of c-sections in rural communities. We examined the percentage of the c-sections performed on rural service area residents that were done in small rural hospitals, whether family physicians did most of these procedures in rural hospitals where there are no obstetricians, their competence in performing c-sections, and factors associated with their performance of this procedure. Data were obtained through Computerized Hospital Discharge Database (CHARS) inpatient hospital abstracts supplemented by a telephone survey of all Washington State rural hospitals and a mail survey of rural physicians. Funded by HRSA's ORHP.

Regionalization of Rural Emergency Medical Services (EMS)

This study retrieved data on every vehicular injury accident occurring in Okanogan County, Washington, in 1990. Information was collected on location of accident, type and severity of injury, initial pre-hospital response, initial transportation, involvement of local health care system, transfer to facility outside county, patient outcomes, and demographics. The study included (1) a description of the type and nature of crashes and injuries and the involvement of local and distant components of the EMS, (2) an examination of the extent to which the existing rural EMS is regionalized, and (3) policy-oriented recommendations.

Accessibility of Family Planning Services to Rural Residents

Considerable controversy exists about the types of family planning services that should be available in rural areas. This study constructed an inventory of family planning services available in rural Idaho, determined the factors associated with observed variations in the range of available services, and examined the policy implications of the findings. A questionnaire was sent to physicians who were the potential providers of such services to determine service volumes and access issues.

National Rural Hospital Flexibility Program Tracking Project

In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of the Balanced Budget Act (BBA). This program provides for cost-based reimbursement under Medicare to eligible small, relatively remote hospitals. A companion grant program supports state emergency medical services systems (EMS) and hospital participation in the program. The reimbursement component is the responsibility of the Center for Medicare and Medicaid Services (CMS), while the grant program is the responsibility of the Federal Office of Rural Health Policy (FORHP). Funding to support the monitoring efforts of the Flex Program Tracking Team was provided under the grant program appropriation. The Tracking Team was a consortium of six rural health research centers. Each Center had lead responsibility for several research components of the study. In 2002/2003, the WWAMI Rural Health Research Center took responsibility for assessing state program evaluations, evaluating a number of workforce issues faced by critical access hospitals (CAHs, and looking at the intersection of CAHs) and another federal program, the Mississippi Delta Hospital Performance Improvement Initiative. WWAMI also provided overall project direction and coordination to the participating centers. The main national goals for implementation of the grant component of the Flex Program in the states and participating hospitals included (1) preparing a state rural health plan, (2) converting eligible and willing hospitals to critical access hospital (CAH) status, (3) improving quality of care, (4) promoting networking among hospitals, and (5) improving emergency medical services.

The Provision of Anesthesia Services in Rural Hospitals

Key to the ability of rural hospitals to maintain a surgery service is the availability of anesthesia personnel, yet anecdotal evidence indicates that their supply is limited and their salary costs are high. This study surveyed administrators from rural hospitals in Washington and Montana regarding their experience in recruiting and retaining nurse and physician anesthetists. Aspects of anesthesia coverage such as financial arrangements, professionals working at multiple sites, outpatient and inpatient surgery, inter-provider type professional rivalries, and licensure constraints were examined. Funded by HRSA's ORHP.

Surgical Capacity of Rural Washington State Hospitals

This study examined the availability of several elective and urgent surgical procedures at rural hospitals, identified the specialties of rural surgery and anesthesia providers, and determined where rural residents obtained surgical services and how the utilization of services is influenced by the presence of local services. Data were obtained from telephone interviews with hospital administrators, directors of nursing services, and/or operating room charge nurses. Washington State complete hospital discharge data provided the number of selected and aggregate procedures for each hospital by diagnosis and procedure codes, as well as hospital reimbursement for surgical procedures.

A Comparison of Obstetrical Technology at Rural Hospitals in Washington and Wales

This study compared the approach to neonatal care in Wales and Washington State, studying the extent of perinatal regionalization, the distribution of neonatal technologies, and birthweight-specific neonatal outcomes. In Wales, most District General Hospitals (DGH) had all the neonatal equipment recommended for a maximal neonatal intensive care unit, whether or not the DGH was a designated regional or subregional center. Sophisticated neonatal technology in Washington was concentrated in designated referral hospitals. Almost every Welsh DGH cared for infants weighing less than 1,000 grams at birth, while in Washington State most very-low-birthweight neonates were born in referral centers and the few born elsewhere were transferred immediately after birth. Despite differences in the extent of regionalization, birthweight-specific neonatal mortality rates were similar in the two countries.

Pediatric Inpatient Care in Rural Hospitals

This study described the distribution of rural practitioners in Washington State who provide inpatient care to pediatric patients, elucidated the major diagnostic categories for which children are hospitalized in rural versus urban areas, contrasted the roles of pediatricians and family physicians providing pediatric care, and assessed the effectiveness of the system. The major source of data for this study was CHARS, which was linked to information on the training and discipline of the providers who cared for each of the patients in the study. Funded by HRSA's ORHP.

National Rural Physician Assistant Content of Care Study

Background: In the 1970s, graduates of physician assistant (PA) programs practiced largely in primary care settings serving rural and other underserved populations. By the 1990s, PAs were practicing in a much wider variety of settings in many medical specialties. Aim: To describe the demography, practice arrangements and content of practice of a nationally representative sample of PAs collected in the 1990s. Methods: A stratified random sample of PAs was surveyed in 1993-1994. The demography, practice characteristics and content of PA practice were analyzed across practice location and medical specialty. Results: Of all the living PAs ever trained, 95% were active in the health care delivery system at the time of the survey. Eighty-seven percent of those trained were practicing as PAs, nearly all of whom were practicing full time. Rural PAs were more likely to be white and male than their urban counterparts and had lower levels of education prior to entering PA training. Generalist PAs performed many more outpatient visits than specialist PAs, and fewer inpatient visits. In urban areas, PAs were making a large contribution to surgical care. About three-fourths of the rural PAs were generalists. Conclusions: The broader scope of practice of generalist PAs, especially those serving rural populations, points to the need to ensure that training programs, especially those emphasizing generalist care for rural and underserved populations, provide sufficient breadth in medical training to meet those needs. Funded by HRSA's ORHP.

Who Are the Generalists in Rural and Urban Areas?

This two-year project used Medicare data provided by HCFA to describe the content of practice of physicians in rural and urban areas of Washington State. The population studied included board-certified physicians in the 12 largest ambulatory medical specialties in Washington State who were in active medical practice in 1994 and who provided ambulatory care to at least ten Medicare patients per year during that period. The diagnostic and procedural breadth of rural and urban physicians in all specialties was found to be similar, with the exception of rural general surgeons and obstetrician-gynecologists, who were more likely to care for patients outside their specialty area. Funded by HRSA's ORHP.

Availability of Specialty Health Care for Rural American Indians (AIs) and Alaska Natives (ANs)

Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native (AI/AN) health services is less than half that spent per year on the U.S. civilian population. Many AI/ANs, especially in rural areas, depend on the IHS as their only source of funding for health care. Specialty services may be limited by a low level of contract funding. Aim: To examine access to specialty services among rural AI populations. Methods: A mail survey addressing access to specialty physicians, perceived barriers to access, and access to nonphysician clinical services was sent to primary care providers in rural Indian health clinics in Montana and New Mexico and primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics. Results: Substantial proportions of rural Indian clinic providers in Montana and New Mexico reported fair or poor access to nonemergent specialty services for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in most frequently cited financial barriers to specialty care. Indian clinic providers in both states reported better access to several nonphysician services than non-Indian clinic providers. Conclusions: Access to specialty care for rural Indian patients is limited, and is influenced by the organization of care systems and financial constraints. Funded by HRSA's FORHP.

Physician Staffing of Small Rural Hospital Emergency Departments

All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how rural emergency departments were staffed by physicians and to estimate rural hospital payments for these services. Study data were collected through telephone interviews with hospital administrators or directors of nursing services. Results indicated that 86% of rural hospitals contracted for emergency department coverage and 59% obtained some or all of this service from nonlocal physicians.

State Rural Health Workforce Monograph

The uneven distribution of health care providers across rural and urban areas of the United States continues to impede access to care for millions of rural residents. This book profiles that workforce with comparisons of the supply of health professionals across the 50 states and within the rural areas of each state. In addition to individual state workforce profiles, the book includes discussion of key policy and methodological issues in workforce analysis. The data and analysis show that the nature and magnitude of rural health workforce problems vary substantially both across states and within them, suggesting the dangers of "one-size-fits-all" policy solutions. This book provides a picture of the rural health workforce that will serve analysts and policy makers well as they search for workable solutions to the problem of inadequate supply of health care providers in rural America. Funded by HRSA's FORHP.

Distribution and Retention of General Surgeons in Rural Areas of the U.S.

Background: General surgeons form a crucial component of the medical workforce in rural areas of the United States. Any decline in their numbers could have profound effects on access to adequate health care in such areas. Aim: To determine the numbers, characteristics, and distribution of general surgeons currently practicing in the rural United States. Methods: The American Medical Association's Physician Masterfile was used to identify all clinically active general surgeons as well as their location and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas (RUCAs). Results: Nationally, the number of general surgeons per 100,000 population varies from 6.53 in urban areas to 7.71 in large rural areas and 4.67 in small/isolated rural areas. Only 10.6% of the nation's general surgeons were female. General surgeons in the smallest rural areas were more likely than those in urban areas to be male (92.7% versus 88.3%), 50 years of age or older (51.6% versus 42.1%), or international medical graduates (25.2% versus 20.1%). Conclusions: The overall size of the rural general surgical workforce has remained static, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. This project was funded by HRSA's FORHP, with the publication Thompson et al. 2005 and Final Report #77 as deliverables.

Tort Reform and the Obstetrical Access Crisis

As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of this study had modified the existing tort and/or professional liability systems in their states. This project reviewed recent studies of physicians' obstetrical practices and major changes in tort legislation and regulation. The majority of general and family physicians in the WAMI region no longer provided obstetrical care, while over 80% of the obstetrician/gynecologists in this area still practiced obstetrics. Most rural family physicians in all four states continued to deliver babies. The majority of physicians in these states limited the amount of care they provide to Medicaid patients. All four states adopted tort reforms, yet the cost of malpractice premiums and concerns over liability continued to limit the number of physicians willing to provide obstetrical care.

Rural Dentistry: Availability, Practice, and Access

This study used secondary data sources such as the Area Resource File, American Dental Association data, and state-level professional licensure data to describe the supply of dental providers in several states, with particular attention to the supply of providers in rural areas. Surveys were administered to rural dentists in California, Maine, Missouri, and Alabama to describe the rural dental provider population in those states with respect to demography, practice characteristics, practice satisfaction, use of dental hygienists, Medicaid and CHIP practices, and attitudes towards the use of alternative sources of dental care such as using medical providers to apply sealants in the pediatric population. The study elucidates, from the dental provider perspective, the barriers to access to dental care for rural residents and what can be done to promote rural dental practice. Funded by HRSA's ORHP.