ronald e. cossman. ph.d. presented to: applied demography conference january 10, 2014 mississippi...
TRANSCRIPT
Ronald E. Cossman. Ph.D.
Presented to: Applied Demography ConferenceJanuary 10, 2014
Mississippi Center for Health WorkforceSocial Science Research Center
Mississippi State University
Rurality Not the Determinant of Access to
Primary Health Care in Mississippi
Three ways to measure health care workforce
1. Supply2. Demand3. Access
Supply
Simple: Physician-to-population ratio
Complex: Health Professional Shortage Areas (HPSAs) (ratio of physicians-to-population) and other factors such as:
1) Poverty rate (all categories)2) Travel distance/time (all categories)
3) Infant mortality/low birth weight (primary care)3) Fluoridated water (dental)
3) Pop under 18, over 65, alcohol or substance abuse (mental health)
Note: This “assumes” total access to care for patients.
Demand
Via the National Health Interview Survey. “Were you unable to obtain health care in the last
12 months?”
Note: The question is relative, does not ask the reasons, and is not available below the state level.
Access
1. Physician Reimbursement Records (who accepted what kind of patient)Note: This is a retrospective measure.
2. Telephone survey of Primary Care offices (by type of health care insurance)
Assumption/Hypothesis:
Health insurance equates to access to primary care.
and….access is worse in rural places
Methodology
Telephone each primary care physician practice office using G-mail voice-over-internet-protocol (VOIP) to mask calling identity and location.Poise as a new patient to the area asking for a visit to establish a relationship with the physicianVolunteer health insurance status:1. Blue Cross & Blue Shield (the 800-lb gorilla)2. Medicare (automatic insurance for the elderly)3. Medicaid (means-based insurance)
There were 5,098 “licensed” physicians in the state of Mississippi There are 2,138 active “primary care” physicians in the state There are 678 primary care facilities that were used in our study
Local government clinics, hospitals and E.R.s were excluded 88 facilities were excluded because they were walk-in facilities 580 offices were successfully contacted
“Core” Primary Care is comprised of: general practitioner, family practice, and internal medicine. The other two categories are pediatrics and OB/GYN. (Note: HPSA definition of primary care)
Descriptives
FINDINGS:
Private (Blue Cross and Blue Shield of Mississippi)
Core Primary Care**
OB/GYN Pediatrics Total0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AcceptDeclineOther
Note the “Other” category. We may
be significantly understating the
denial rate.
Type of Insurance/Specialty Private (Blue Cross and Blue Shield of Mississippi)
Accept Decline Other*Core Primary Care** 75% 8% 17%OB/GYN 91% 0% 9%Pediatrics 83% 5% 12%Total*** 78% 7% 16%
* Did not resolve an appointment, required call-back, additional information, valid insurance number
** General practitioner, family practice, internal medicine*** May not add to 100% due to rounding
Medicare (elderly)
Core Primary Care** OB/GYN Total0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AcceptDeclineOther
Types of Insurance/SpecialtyMedicare (elderly)
Accept Decline Other*Core Primary Care** 63% 16% 21%OB/GYN 76% 8% 16%Pediatrics N/A N/A N/ATotal 64% 15% 21%
* Did not resolve an appointment, required call-back, additional information, valid insurance number
** General practitioner, family practice, internal medicine
Medicaid (means-based)
Core Primary Care** OB/GYN Pediatrics Total0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AcceptDeclineOther
Decline may range from
43% to 50%
Type of Insurance/SpecialtyMedicaid (means-based)
Accept Decline Other*Core Primary Care** 47% 43% 10%OB/GYN 59% 28% 13%Pediatrics 61% 21% 17%Total 50% 38% 12%
* Did not resolve an appointment, required call-back, additional information, valid insurance number
** General practitioner, family practice, internal medicine
Number of Residents that Practices Serve in Selected* Cities
Amory
Bay Sa
int Louis
Brandon
Carthag
e
Clinto
n
Columbus
Flowood
Greenvil
le
Grenad
a
Hernan
do
Jackso
nLa
urel
Louisv
ille
Mccomb
Moss Point
New Alban
y
Olive B
ranch
Pascag
oulaPeta
l
Picayu
ne
Richlan
dRipley
South
aven
Tupelo
Way
nesboro
Yazo
o City -
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
*Randomly selected cities
Beale Code Frequencies in MS
B1: Metr
o 1 milli
on +
B2: Metr
o area
250k-1 m
illion
B3: Metr
o area
fewer
than
250k
B4: Nonmetr
o urban
20k+ ad
jacen
t to a m
etro
B5: Nonmetr
o urban
20k+ not a
djacen
t to a m
etro
B6: Nonmetr
o urban
2,000-19,999 adjac
ent t
o a metr
o
B7:Nonmetr
o urban
2,500-19,999 not adjac
ent t
o a metr
o
B8: Nonmetr
o rural
or less
than
2,500 adjac
ent t
o a metr
o
B9: Nonmetr
o rural
or less
than
2,500 not adjac
ent t
o a metr
o0
2
4
6
8
10
12
14
16
18
20
Primary Care and Counties by Beale Code
B1: Metro
1 millio
n +
B2: Metro
area 250k-1 millio
n
B3: Metro
area fewer th
an 250k
B4: Nonmetro
urban 20k+ adjacent to
a metro
B5: Nonmetro
urban 20k+ not adjace
nt to a m
etro
B6: Nonmetro
urban 2,500-19,999 adjacent to
a metro
B7: Nonmetro
urban 2,500-19,999 not adjace
nt to a m
etro
B8:Nonmetro
rural o
r less
than 2,500 adjacent to
a metro
B9: Nonmetro
rural o
r less
than 2,500 not adjace
nt to a m
etro
0%
5%
10%
15%
20%
25%
30%
35%
40%
% of primary care offices per Beale code% of counties per Beale code
0%
5%
10%
15%
20%
25%
30%
35%
Metro - 1 million +
Metro - 250 K - 1 million
Metro - <250,000
Nonmetro - >20,000, adjacent
Nonmetro - >20,000, not adjacent
Nonmetro - 2,500-19,999, adjacent
Nonmetro - 2,500-19,999, not adjacent
Nonmetro - <2,500, adjacent
Nonmetro - <2,500, not adjacent
Percent Population by Rural-Urban Continuum Code
Pop 2010
Primary Care
Percent Not Currently Accepting New Patients
B1: Metr
o 1 milli
on +
B2: Metr
o area
250k-1 m
illion
B3: Metr
o area
fewer
than 250k
B4: Nonmetr
o urban
20k+ ad
jacen
t to a
metro
B5: Nonmetr
o urban
20k+ not a
djacen
t to a
metro
B6: Nonmetr
o urban
2,500-19,999 adjac
ent to
a metr
o
B7: Nonmetr
o urban
2,500-19,999 not adjac
ent to
a metr
o
B8:Nonmetro ru
ral or le
ss than
2,500 adjac
ent to
a metr
o
B9: Nonmetr
o rural
or less
than 2,500 not a
djacen
t to a
metro
0%10%20%30%40%50%60%70%80%90%
100%
Decline Rate by County Population and Type Insurance
BC & BSMedicareMedicaid
Perc
ent D
eclin
e
The 2 counties in white (DeSoto &
Lowndes) are not HPSA physician
shortage areas in Mississippi
Primary care offices in only 1 county (Copiah) did
not accept private (BC&BS) insurance. More
than three quarters of MS counties (primary care offices) (77%) had zero decline rates of BCBS.
In one county (Copiah) there was zero
acceptance of new Medicare patients.
There are 5 counties that were not currently
accepting new Medicaid patients.
They are (NE to SW) Itawamba, Tallahatchie,
Attala, Copiah and Lincoln.
Additional Finding:Our results my underestimate the percentage of declines. When the
unresolved calls are factored in, decline of service could be as high as 57%.
Implications of the findings
Health insurance does NOT equate to access to primary care
Implication #1
A Medicaid expansion will not necessarily provide access to primary care to all.Thus, the impact of expansion will be less.
Thus, the non-critical emergency room load will not drop as expected
Implication #2
Since physician offices are a business, a substantial portion have chosen not to accept certain kinds of insurance.
Thus, we need to revisit the payment/reimbursement system
Implication #3
Using physicians ratios treats all physicians as independent. However, if
there are five physicians in a county and they all practice together, a decline of
service from one is a decline from all 5 health care providers.
Thank you for your attention
Ronald E. Cossman, Ph.D.Research Professor
Mississippi Center for Health WorkforceSocial Science Research Center
P.O. Box 5287 Mississippi State University
Mississippi State, MS. 39762 Office: (662) 325-4801
E-mail: [email protected] Web: http://www.ssrc.msstate.edu