Physician Supply and Access to Care in Urban Communities

Health Affairs

Volumn 16, Issue 1, 1997, Pages 71-86

  Grumbach, Kevin ^a   Vranizan, Karen ^a   Bindman, Andrew B ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; FEMALE; HEALTH CARE DELIVERY; HEALTH INSURANCE; HEALTH SERVICE; HEALTH SERVICES RESEARCH; HUMAN; INFORMATION PROCESSING; MALE; MANPOWER; PHYSICIAN; SOCIAL CLASS; STATISTICS; UNITED STATES;

CALIFORNIA; DATA COLLECTION; FEMALE; HEALTH SERVICES ACCESSIBILITY; HEALTH SERVICES RESEARCH; HUMANS; INSURANCE, HEALTH; MALE; PHYSICIANS; SOCIAL CLASS; URBAN HEALTH SERVICES;

EID: 0346673036     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.16.1.71     Document Type: Article

References (48)

1. Council on Graduate Medical Education, Improving Access to Health Care through Physician Workforce Reform-Directions for the Twenty-first Century (Washington: U.S. Government Printing Office, 1992); and K. Grumbach and P. Lee, "How Many Physicians Can We Afford?" Journal of the American Medical Association 265, no. 18 (1991): 2369-2372.
2. Council on Graduate Medical Education, Improving Access to Health Care through Physician Workforce Reform-Directions for the Twenty-first Century (Washington: U.S. Government Printing Office, 1992); and K. Grumbach and P. Lee, "How Many Physicians Can We Afford?" Journal of the American Medical Association 265, no. 18 (1991): 2369-2372.
3. M.L. Barer and G.L. Stoddart, "Toward Integrated Medical Resource Policies for Canada: 1. Background, Process, and Perceived Problems," Canadian Medical Association Journal 146, no. 3 (1992): 347-351; and S.A. Schroeder, "Western European Responses to Physician Oversupply," Journal of the American Medical Association 254, no. 3 (1984): 373-384.
4. M.L. Barer and G.L. Stoddart, "Toward Integrated Medical Resource Policies for Canada: 1. Background, Process, and Perceived Problems," Canadian Medical Association Journal 146, no. 3 (1992): 347-351; and S.A. Schroeder, "Western European Responses to Physician Oversupply," Journal of the American Medical Association 254, no. 3 (1984): 373-384.
5. COGME, Improving Access; K. Grumbach et al., The Problems of Shortages of Physicians and Other Health Professionals in Urban Areas, Report prepared for the Council on Graduate Medical Education (San Francisco: University of California, San Francisco, Center for the Health Professions, 1995); R.A. Cooper, "Perspectives on the Physician Workforce to the Year 2020," Journal of the American Medical Association 274, no. 19 (1995): 1534-1543; and R. Politzer et al., "Primary Care Physician Supply and the Medically Underserved," Journal of the American Medical Association 266, no. 1 (1991): 104-109. See also M.L. Barer and G.L. Stoddart, "Toward Integrated Medical Resource Policies for Canada: 8. Geographical Distribution of Physicians," Canadian Medical Association Journal 147, no. 5 (1992): 617-623.
6. COGME, Improving Access; K. Grumbach et al., The Problems of Shortages of Physicians and Other Health Professionals in Urban Areas, Report prepared for the Council on Graduate Medical Education (San Francisco: University of California, San Francisco, Center for the Health Professions, 1995); R.A. Cooper, "Perspectives on the Physician Workforce to the Year 2020," Journal of the American Medical Association 274, no. 19 (1995): 1534-1543; and R. Politzer et al., "Primary Care Physician Supply and the Medically Underserved," Journal of the American Medical Association 266, no. 1 (1991): 104-109. See also M.L. Barer and G.L. Stoddart, "Toward Integrated Medical Resource Policies for Canada: 8. Geographical Distribution of Physicians," Canadian Medical Association Journal 147, no. 5 (1992): 617-623.
7. COGME, Improving Access; K. Grumbach et al., The Problems of Shortages of Physicians and Other Health Professionals in Urban Areas, Report prepared for the Council on Graduate Medical Education (San Francisco: University of California, San Francisco, Center for the Health Professions, 1995); R.A. Cooper, "Perspectives on the Physician Workforce to the Year 2020," Journal of the American Medical Association 274, no. 19 (1995): 1534-1543; and R. Politzer et al., "Primary Care Physician Supply and the Medically Underserved," Journal of the American Medical Association 266, no. 1 (1991): 104-109. See also M.L. Barer and G.L. Stoddart, "Toward Integrated Medical Resource Policies for Canada: 8. Geographical Distribution of Physicians," Canadian Medical Association Journal 147, no. 5 (1992): 617-623.
8. COGME, Improving Access; K. Grumbach et al., The Problems of Shortages of Physicians and Other Health Professionals in Urban Areas, Report prepared for the Council on Graduate Medical Education (San Francisco: University of California, San Francisco, Center for the Health Professions, 1995); R.A. Cooper, "Perspectives on the Physician Workforce to the Year 2020," Journal of the American Medical Association 274, no. 19 (1995): 1534-1543; and R. Politzer et al., "Primary Care Physician Supply and the Medically Underserved," Journal of the American Medical Association 266, no. 1 (1991): 104-109. See also M.L. Barer and G.L. Stoddart, "Toward Integrated Medical Resource Policies for Canada: 8. Geographical Distribution of Physicians," Canadian Medical Association Journal 147, no. 5 (1992): 617-623.
9. COGME, Improving Access; K. Grumbach et al., The Problems of Shortages of Physicians and Other Health Professionals in Urban Areas, Report prepared for the Council on Graduate Medical Education (San Francisco: University of California, San Francisco, Center for the Health Professions, 1995); R.A. Cooper, "Perspectives on the Physician Workforce to the Year 2020," Journal of the American Medical Association 274, no. 19 (1995): 1534-1543; and R. Politzer et al., "Primary Care Physician Supply and the Medically Underserved," Journal of the American Medical Association 266, no. 1 (1991): 104-109. See also M.L. Barer and G.L. Stoddart, "Toward Integrated Medical Resource Policies for Canada: 8. Geographical Distribution of Physicians," Canadian Medical Association Journal 147, no. 5 (1992): 617-623.
10. J. Wennberg and A. Gittelsohn, "Small Area Variations in Health Care Delivery," Science (December 1973): 1102-1108; J. Holahan, R.A. Berenson, and P.G. Kachavos, "Area Variations in Selected Medicare Procedures," Health Affairs (Winter 1990): 166-175; W.P. Welch et al., "Geographic Variation in Expenditures for Physicians' Services in the United States," The New England Journal of Medicine 328, no. 9 (1993): 621-627; and D.H. Mark et al., "Medicare Costs in Urban Areas and the Supply of Primary Care Physicians," Journal of Family Practice 43, no. 1 (1996): 33-39.
11. J. Wennberg and A. Gittelsohn, "Small Area Variations in Health Care Delivery," Science (December 1973): 1102-1108; J. Holahan, R.A. Berenson, and P.G. Kachavos, "Area Variations in Selected Medicare Procedures," Health Affairs (Winter 1990): 166-175; W.P. Welch et al., "Geographic Variation in Expenditures for Physicians' Services in the United States," The New England Journal of Medicine 328, no. 9 (1993): 621-627; and D.H. Mark et al., "Medicare Costs in Urban Areas and the Supply of Primary Care Physicians," Journal of Family Practice 43, no. 1 (1996): 33-39.
12. J. Wennberg and A. Gittelsohn, "Small Area Variations in Health Care Delivery," Science (December 1973): 1102-1108; J. Holahan, R.A. Berenson, and P.G. Kachavos, "Area Variations in Selected Medicare Procedures," Health Affairs (Winter 1990): 166-175; W.P. Welch et al., "Geographic Variation in Expenditures for Physicians' Services in the United States," The New England Journal of Medicine 328, no. 9 (1993): 621-627; and D.H. Mark et al., "Medicare Costs in Urban Areas and the Supply of Primary Care Physicians," Journal of Family Practice 43, no. 1 (1996): 33-39.
13. J. Wennberg and A. Gittelsohn, "Small Area Variations in Health Care Delivery," Science (December 1973): 1102-1108; J. Holahan, R.A. Berenson, and P.G. Kachavos, "Area Variations in Selected Medicare Procedures," Health Affairs (Winter 1990): 166-175; W.P. Welch et al., "Geographic Variation in Expenditures for Physicians' Services in the United States," The New England Journal of Medicine 328, no. 9 (1993): 621-627; and D.H. Mark et al., "Medicare Costs in Urban Areas and the Supply of Primary Care Physicians," Journal of Family Practice 43, no. 1 (1996): 33-39.
14. T. Nesbitt et al., "Access to Obstetric Care in Rural Areas: Effect on Birth Outcomes," American Journal of Public Health 80, no. 7 (1990): 814-818;
15. D. Allen and J. Kamradt, "Relationship of Infant Mortality to the Availability of Obstetrical Care in Indiana," Journal of Family Practice 33, no. 6 (1991): 609-613;
16. and W.L. Larimore and A. Davis, "Relation of Infant Mortality to the Availability of Maternity Care in Rural Florida," The Journal of the American Board of Family Practice 43, no. 1 (1995): 392-399.
17. M.L. Berk, A.B. Bernstein, and A.K. Taylor, "The Use and Availability of Medical Care in Health Manpower Shortage Areas," Inquiry (Winter 1983): 369-380. See also G.Y. Chiu, L.A. Aday, and R. Andersen, "An Examination of the Association of Shortage and Medical Access Indicators," Health Policy Quarterly 1, no. 2 (1981): 142-158; and J. Kleinman and R. Wilson, "Are 'Medically Underserved Areas' Medically Underserved?" Health Services Research (Summer 1977): 147-162.
18. M.L. Berk, A.B. Bernstein, and A.K. Taylor, "The Use and Availability of Medical Care in Health Manpower Shortage Areas," Inquiry (Winter 1983): 369-380. See also G.Y. Chiu, L.A. Aday, and R. Andersen, "An Examination of the Association of Shortage and Medical Access Indicators," Health Policy Quarterly 1, no. 2 (1981): 142-158; and J. Kleinman and R. Wilson, "Are 'Medically Underserved Areas' Medically Underserved?" Health Services Research (Summer 1977): 147-162.
19. M.L. Berk, A.B. Bernstein, and A.K. Taylor, "The Use and Availability of Medical Care in Health Manpower Shortage Areas," Inquiry (Winter 1983): 369-380. See also G.Y. Chiu, L.A. Aday, and R. Andersen, "An Examination of the Association of Shortage and Medical Access Indicators," Health Policy Quarterly 1, no. 2 (1981): 142-158; and J. Kleinman and R. Wilson, "Are 'Medically Underserved Areas' Medically Underserved?" Health Services Research (Summer 1977): 147-162.
20. H. Traxler, "Physician Supply Modeling in the United States of America and Its Uses in Assisting Policymaking," World Health Statistics Quarterly 47, no. 3-4 (1994): 118-125; and R. Rosenblatt and D. Lishner, "Surplus or Shortage? Unraveling the Physician Supply Conundrum," Western Journal of Medicine 154, no. 1 (1991): 43-50.
21. H. Traxler, "Physician Supply Modeling in the United States of America and Its Uses in Assisting Policymaking," World Health Statistics Quarterly 47, no. 3-4 (1994): 118-125; and R. Rosenblatt and D. Lishner, "Surplus or Shortage? Unraveling the Physician Supply Conundrum," Western Journal of Medicine 154, no. 1 (1991): 43-50.
22. J. Weiner, "Forecasting the Effects of Health Reform on U.S. Physician Workforce Requirement," Journal of the American Medical Association 272, no. 3 (1994): 222-230.
23. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services, Vol. 1, GMENAC Summary Report, Pub. no. 1980-0-721-748/266 (Washington: U.S. GPO, 1981). See also Rosenblatt and Lishner, "Surplus or Shortage?"
24. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services, Vol. 1, GMENAC Summary Report, Pub. no. 1980-0-721-748/266 (Washington: U.S. GPO, 1981). See also Rosenblatt and Lishner, "Surplus or Shortage?"
25. R.C. Lee, "Current Approaches to Shortage Area Designation," Journal of Rural Health 7, no. 4 (1991): 437-450;
26. and D. Taylor et al., The Measurement of Underservice and Provider Shortage in the United States: A Policy Analysis (Chapel Hill, N.C.: North Carolina Rural Health Research Program, December 1994).
27. A.B. Bindman et al., "Preventable Hospitalization Rates and Access to Health Care," Journal of the American Medical Association 274, no. 4 (1995): 305-311;
28. and M. Komaromy et al., "Physician Practice Style and Rates of Hospitalization for Chronic Medical Conditions," Medical Care 34, no. 6 (1996): 594-609.
29. Bindman et al., "Preventable Hospitalization Rates."
30. J. Roback, L. Randolph, and B. Seidman, Physician Characteristics and Distribution in the U.S., 1992 (Chicago: American Medical Association, 1993).
31. Because the distribution of the number of visits was highly skewed, we transformed this variable by using the log(10) of visits in regression analyses and then converting the results back into a nonlog format for presentation. We also performed a Poisson regression analysis using the untransformed visit variable, with results similar to those found on linear regression analysis using the log transformed variable.
32. Additional detail on the regression analysis is available from the authors at the University of California, San Francisco, Box 1364, San Francisco, CA 94143-1364.
33. Population density was measured as total population per square mile in each study area. Our variable for managed care penetration at the level of our small areas derived from a separate survey of primary care physicians practicing in the study areas that queried physicians about the proportion of their patients in managed care plans. See Komaromy et al., "Physician Practice Style." Also, because our respondents were clustered in particular geographic areas because of our sampling method, we reanalyzed our data using the Generalized Estimation Equation statistical software program to account for clustering phenomena. As expected, p values were larger (that is, less "significant") when adjusting for clustering, but the overall pattern of the results remained the same.
34. Berk et al., "The Use and Availability of Medical Care."
35. E. Ginzberg, "Improving Health Care for the Poor: Lessons from the 1980s," Journal of the American Medical Association 271, no. 6 (1994): 464-467.
36. Berk et al., "The Use and Availability of Medical Care;" and Kleinman and Wilson, "Are 'Medically Underserved Areas' Medically Underserved?" For explorations of the relationship between physician supply and mortality, see also M.K. Miller, D.E. Voth, and D.M. Danforth, "The Medical Care System and Community Malady: Rural, Urban, and Suburban Variations in Impact," Rural Sociology 47, no. 4 (1982): 634-654.
37. Berk et al., "The Use and Availability of Medical Care;" and Kleinman and Wilson, "Are 'Medically Underserved Areas' Medically Underserved?" For explorations of the relationship between physician supply and mortality, see also M.K. Miller, D.E. Voth, and D.M. Danforth, "The Medical Care System and Community Malady: Rural, Urban, and Suburban Variations in Impact," Rural Sociology 47, no. 4 (1982): 634-654.
38. Berk et al., "The Use and Availability of Medical Care;" and Kleinman and Wilson, "Are 'Medically Underserved Areas' Medically Underserved?" For explorations of the relationship between physician supply and mortality, see also M.K. Miller, D.E. Voth, and D.M. Danforth, "The Medical Care System and Community Malady: Rural, Urban, and Suburban Variations in Impact," Rural Sociology 47, no. 4 (1982): 634-654.
39. H.N. Nguyen, M.J. O'Sullivan, and A.M. Fournier, notice of retraction, "The Impact of National Health Service Corps Physicians in the Lowering Prenatal Mortality Rate in Dade County, Florida" (Retraction of H.N. Nguyen, M.J. O'Sullivan, and A.M. Fournier, Obstetrics and Gynecology [September 1991]: 385-390), Obstetrics and Gynecology (November 1991): 888.
40. H.N. Nguyen, M.J. O'Sullivan, and A.M. Fournier, notice of retraction, "The Impact of National Health Service Corps Physicians in the Lowering Prenatal Mortality Rate in Dade County, Florida" (Retraction of H.N. Nguyen, M.J. O'Sullivan, and A.M. Fournier, Obstetrics and Gynecology [September 1991]: 385-390), Obstetrics and Gynecology (November 1991): 888.
41. L.I. Hochheiser, K. Woodward, and E. Charney, "Effect of the Neighborhood Health Center on the Use of Pediatric Emergency Departments in Rochester, New York," The New England Journal of Medicine 285, no. 3 (1971): 148-152. See also S. Rosenbaum and A. Dievler, A Literature Review of the Community and Migrant Health Centers Programs (Washington: The George Washington University Center for Health Policy, 1992); and F. Goldman and M. Grossman, "The Impact of Public Health Policy: The Case of Community Health Centers," Eastern Economic Journal 14, no. 1 (1988): 63-72.
42. L.I. Hochheiser, K. Woodward, and E. Charney, "Effect of the Neighborhood Health Center on the Use of Pediatric Emergency Departments in Rochester, New York," The New England Journal of Medicine 285, no. 3 (1971): 148-152. See also S. Rosenbaum and A. Dievler, A Literature Review of the Community and Migrant Health Centers Programs (Washington: The George Washington University Center for Health Policy, 1992); and F. Goldman and M. Grossman, "The Impact of Public Health Policy: The Case of Community Health Centers," Eastern Economic Journal 14, no. 1 (1988): 63-72.
43. L.I. Hochheiser, K. Woodward, and E. Charney, "Effect of the Neighborhood Health Center on the Use of Pediatric Emergency Departments in Rochester, New York," The New England Journal of Medicine 285, no. 3 (1971): 148-152. See also S. Rosenbaum and A. Dievler, A Literature Review of the Community and Migrant Health Centers Programs (Washington: The George Washington University Center for Health Policy, 1992); and F. Goldman and M. Grossman, "The Impact of Public Health Policy: The Case of Community Health Centers," Eastern Economic Journal 14, no. 1 (1988): 63-72.
44. C. Brellochs and A.B. Carter, Building Primary Health Care in New York City's Low-Income Communities (New York: Community Service Society of New York, 1990).
45. M. Komaromy et al., "The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations," The New England Journal of Medicine 334, no. 20 (1996): 1305-1310; E. Moy and B.A. Bartman, "Physician Race and Care of Minority and Medically Indigent Patients," Journal of the American Medical Association 273, no. 19 (1995): 1515-1520; and J.C. Cantor et al., "Physician Service to the Underserved: Implications for Affirmative Action in Medical Education," Inquiry (Summer 1996): 167-180.
46. M. Komaromy et al., "The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations," The New England Journal of Medicine 334, no. 20 (1996): 1305-1310; E. Moy and B.A. Bartman, "Physician Race and Care of Minority and Medically Indigent Patients," Journal of the American Medical Association 273, no. 19 (1995): 1515-1520; and J.C. Cantor et al., "Physician Service to the Underserved: Implications for Affirmative Action in Medical Education," Inquiry (Summer 1996): 167-180.
47. M. Komaromy et al., "The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations," The New England Journal of Medicine 334, no. 20 (1996): 1305-1310; E. Moy and B.A. Bartman, "Physician Race and Care of Minority and Medically Indigent Patients," Journal of the American Medical Association 273, no. 19 (1995): 1515-1520; and J.C. Cantor et al., "Physician Service to the Underserved: Implications for Affirmative Action in Medical Education," Inquiry (Summer 1996): 167-180.
48. G.L. Stoddart and M.L. Barer, "Toward Integrated Medical Resource Policies for Canada: 2. Promoting Change - General Themes," Canadian Medical Association Journal 146, no. 5 (1992): 697-700.