The United States has a widely acknowledged problem of medical “underservice”, responses to which include programs that provide incentives for physicians to practice in “underserved areas”. This research study investigates the impact of these programs while viewing underservice as a complex and ill-defined phenomenon. Lack of definition of underservice inhibits the alignment of incentive programs with wider strategies for improving healthcare systems and outcomes.
The study focuses on state programs, where the bulk of incentive program capacity is administered, where greater flexibility in how participating physicians are deployed can be exercised than in the National Health Service Corps’ federal program, and where much of the strategic effort to overcome problems in healthcare delivery is taking place. Recognizing that states have limited resources to monitor incentive program impact in order to align the programs more closely with wider state health policies, the study seeks to facilitate better alignment by developing a new measure of underservice, the Medicare Index of Service to the Underserved, that enables program impact to be monitored more accurately and efficiently than at present.
Based on the case mix of individual primary care physicians, the new measure departs from traditional reliance on data aggregated across geographic areas. It expands beyond the traditional HPSA concept by incorporating, in addition to the rural/urban location that weighs heavily in the HPSA designation, measures of medical risk and socioeconomic status of Medicare patients treated that are derived from Medicare data.
In the main analysis of this study the new index is used to assess the impact of Maryland’s physician loan repayment and visa waiver programs, using program participation data supplied under a Data Transfer and Use Agreement with Maryland Department of Health’s Office of Population Health Improvement. This data, extending from 2002 through 2017, permits long-term as well as short-term impact to be assessed. Utilizing both difference-in-means and difference-in-difference methods to quantify, understand and describe program impact, the study finds that primary care physicians participating in visa waiver and loan repayment programs are significantly and substantially more active in providing care to underserved populations than other primary care physicians in the state, but that the nature of this service varies between programs and through time. Specific findings include:
• a greater tendency of waiver than loan repayment physicians to serve populations with high medical need;
• a greater tendency of loan repayment physicians to remain working in rural areas;
• high career mobility among waiver physicians, with substantial loss of waiver program participants to non-primary care specialties and/or to other states;
• low career mobility among loan repayment physicians, resulting in longer-term commitment to underserved populations but with uncertainty about whether that commitment might have been in place even absent participation in the program.
The study concludes with recommendations for research and for policy that would, firstly, address important data limitations identified during the study, and, secondly, assist in improving alignment between state physician incentive programs and wider policies for improving healthcare systems and outcomes.
|Advisor:||Ku, Leighton C.|
|Commitee:||Pittman, Patricia M., Chen, Candice P.|
|School:||The George Washington University|
|Department:||Public Policy & Administration|
|School Location:||United States -- District of Columbia|
|Source:||DAI-B 81/11(E), Dissertation Abstracts International|
|Keywords:||Health workforce, Loan payment, Physician workforce, Underservice, Visa waiver|
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