physicians practicing in rural and underserved areas of mississippi

2009 PHYSICIANS PRACTICING IN RURAL AND UNDERSERVED AREAS OF MISSISSIPPI DEBRA STREET JERALYNN COSSMAN C. CALEB BUTTS SARAH H. SMITH

ABOUT THE AUTHORS Debra Street, an Associate Professor of Sociology at the State University of New York at Buffalo, is an alumna of the Robert Wood Johnson Scholars in Health Policy Research Program and a member of the National Academy of Social Insurance. Jeralynn S. Cossman, Clinton Wallace Dean’s Eminent Scholar and Associate Professor of Sociology at Mississippi State University, is the Director of the Mississippi Center for Health Workforce. C. Caleb Butts, is a summer research associate at the Northeast Mississippi Area Health Education Center at Mississippi State’s Social Science Research Center and a medical student at the University of South Alabama. Sarah H. Smith, is a PhD student in the Sociology department, SUNY at Buffalo. Her research interests include sociology of adolescence, gender and sexuality, organizational studies, and social theory. Sarah was recently appointed Managing Editor of Sociological Inquiry.

Questions concerning the report can be directed to Lynne Cossman at [email protected] or Debra Street at [email protected].

MIGMH Report #1 July 31, 2009

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PHYSICIANS PRACTICING IN RURAL AND UNDERSERVED AREAS OF MISSISSIPPI

EXECUTIVE SUMMARY •

Data from the 2007/08 MSMD survey (including minority and rural oversample) are analyzed to document how place shapes the experiences of physicians who practice in rural and/or medically underserved areas of Mississippi

•

Rural physicians’ experiences differ from non-rural physicians on issues like malpractice experiences and the practice of defensive medicine, and on several measures related to professional relationships and work/life balance. However, rural and non-rural physicians have similar experiences with patient relationships, concerns about recruiting and resource availability, and autonomy. Highlights of some comparisons: o Just over a third of rural physicians in the sample practice in underserved (HPSA) counties, while only 3 percent of non-rural physicians practice medicine in underserved counties. o The average age of physicians is the same in both rural and nonrural practice settings. o Rural physicians treat more Medicare and Medicaid patients while non-rural physicians treat more privately insured patients. o Rural physicians are sued more often than non-rural physicians. While the number of lawsuits declined from 2004 to 2006, the gap between rural and urban physician experiences is growing. o Urban doctors were significantly more likely to respond that they needed to work where there were research opportunities, and to say that recognition for their work was important than were rural physicians. Rural physicians were significantly more accepting than non-rural physicians of their position as role models in their communities.


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•

Physicians who practice in underserved areas designated as Health Professional Shortage Areas (HPSAs) are different in several ways from physicians who practice in better served areas of Mississippi: o Practitioners in HPSA communities treat an average of 121 patients per week compared to 89 for non-HPSA practitioners. o Medicare and Medicaid are a share of patients’ payments in underserved areas compared to practices in non-HPSA locations. o The most frequently cited source of satisfaction, no matter whether a physician practiced in an underserved area or not, was having high quality patient relationships. o While HPSA providers perceive less control over treatmentrelated practices, they report greater control over contextually related dimensions of their practice. o Nearly 25 percent more non-HPSA providers (compared to physicians who practice in underserved areas) would recommend their community as a good practice site to future physicians. o Despite their very different experiences with lawsuits and the practice of defensive medicine, there were no significant differences in the impressions of the current malpractice climate or availability of liability insurance associated with whether or not a physician practiced in an underserved area. o Considering the most central relationship associated with medical practices, there were few differences in terms of patient relationships associated with practicing in underserved areas. o Non-HPSA providers have better professional relationships with other physicians compared to physicians who practice in underserved areas.


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TABLE OF CONTENTS Executive Summary............................................................................iii Table of Contents ............................................................................... v Acronyms ........................................................................................ vi List of Tables ....................................................................................vii List of Figures................................................................................... ix Acknowledgements............................................................................. x Section 1:

Introduction.............................................................. 1

Section 2:

Background .............................................................. 5

Section 3:

Data and Methods ................................................... 11

Section 4:

Physician Experiences in Rural Areas .......................... 16

Section 5:

Physician Experiences in Underserved Areas................ 38

Section 6:

Conclusion and Implications ...................................... 60

Section 7:

References ............................................................. 62 APPENDICES

Appendix A

Mississippi Counties, by Rural and HPSA Designation ............................................................ 65

Appendix B

2007/08 MSMD survey ............................................. 66


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Acronyms AAMC

Association of American Medical Colleges

AHRQ

Agency for Healthcare Research and Quality

CDC

Centers for Disease Control

HPSA

Health Professional Shortage Area

HRSA

Health Resources and Services Administration

IMG

International Medical Graduate

IOM

Institute of Medicine

MCHW

Mississippi Center for Health Workforce

MS

Mississippi

MSMD

Mississippi Physician Workforce Survey

MSBML

Mississippi State Board of Medical Licensure

MUP

Medically Underserved Populations

NACRHHS National Advisory Committee on Rural Health and Human Services SCHIP

State Children’s Health Insurance Program

SPSS

Statistical Program from the Social Sciences

USDHHS

United States Department of Health and Human Services


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List of Tables Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5 Table 4.6 Table 4.7 Table 4.8 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8

Analytic Sample Descriptive Statistics by Rural/Urban Practice Location Patient Characteristics, by Rural/Urban Practice Location Changes in Patient Access, by Rural/Urban Practice Location Control over Practice Conditions, by Rural/Urban Practice Location Likelihood of Recommendations to Medical School Graduates, by Rural/Urban Practice Location Malpractice Concerns and Defensive Medicine, by Rural/Urban Practice Location Assessment of Physician Practice Climate by Rural/Urban Practice Location Patient Relationships by Rural/Urban Practice Location Table Professional Relationships by Rural/Urban Practice Location Practice Patient and Administrative Resources, by Rural/Urban Practice Location Autonomy, Prestige, and Career Satisfaction, by Rural/Urban Practice Location Specialty and Career Satisfaction, by Rural/Urban Practice Location Perspectives on Family and Personal Life, by Rural/Urban Practice Location Community Perspectives, by Rural/Urban Practice Location Analytic Sample Descriptive Statistics by HPSA/non-HPSA Practice Location Patient Characteristics, by HPSA/non-HPSA Practice Location Changes in Patient Access, by HPSA/non-HPSA Practice Location Control over Practice Conditions, by HPSA/non-HPSA Practice Location Malpractice Concerns and Defensive Medicine, by HPSA/non-HPSA Practice Location Assessment of Physician Practice Climate by HPSA/nonHPSA Practice Location Patient Relationships by HPSA/non-HPSA Practice Location Professional Relationships by HPSA/non-HPSA Practice Location


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Table 5.9 Table 5.10 Table 5.11 Table 5.12 Table 5.13

Practice Patient and Administrative Resources, by HPSA/non-HPSA Practice Location Professional Autonomy and Prestige, by HPSA/non-HPSA Practice Location Specialization and Career Satisfaction, by HPSA/non-HPSA Practice Location Perspectives on Family and Personal Life, by HPSA/nonHPSA Location Community Perspectives, by HPSA/non-HPSA Practice Location


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List of Figures Figure 2.1 Rural/non-Rural Counties in Mississippi Figure 2.2 HPSA/non-HPSA Counties in Mississippi Figure 2.3 Rural and Underserved Counties in Mississippi Figure 4.1 Sources of Patient Payment, by Rural/Urban Practice Location Figure 4.2 Physicians Sued in the Previous Year, by Rural/Urban Practice Location Figure 5.1 Sources of Patient Payment, by HPSA/non-HPSA Practice Location Figure 5.2 Advice to Medical Graduates about Specialization and Practice Location, by HPSA/non-HPSA Practice Location Figure 5.3 Percentage of Physicians Named in a Lawsuit in the Previous Year, by HPSA/non-HPSA Practice Location


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Acknowledgements We thank the Mississippi Institute for the Improvement of Geographic Minority Health for providing resources to support this research and to the Social Science Research Center at Mississippi State University for their infrastructural support. We benefited from the assistance of several talented graduate and professional research assistants, including Jamie Boydstun, Caleb Butts, Sarah H. Smith, Diana Pehlic and the able administrative assistance of Katherine Harney. The State Program Office of the Mississippi Area Health Education Center also supported this project, fiscally and administratively. We appreciate the generosity and candor of Mississippi physicians who spent valuable time completing the 2007/08 MSMD survey, and especially those physicians who agreed to be interviewed for this research. The survey data, by its nature, is anonymous and depicts a generalized snapshot of physician experiences in Mississippi. And although we have taken care to conceal interviewee identities to protect the confidentiality of the data, it was their comments that helped us put flesh on the survey data bones. Funding for the initial phase of the 2007/08 MSMD survey was from several funders: The Mississippi Physician Care Network, the Mississippi Academy of Family Physicians and the American Academy of Family Physicians, with matching support from the Mississippi State University Social Science Research Center. Without their original investment in the systematic study of the Mississippi physician workforce, there would be no foundation upon which to build this study.


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SECTION 1

INTRODUCTION Healthy People 2010 (www.healthypeople.gov) set national objectives for health care, advocating disease prevention and setting goals for health care delivery in the first decade of the 21st century. A major concern of the report was the Healthy People 2010 goal to eliminate health disparities among different segments of the U.S. population. Health disparities are a matter of national attention, with some groups (especially low income individuals, rural residents, members of racial or ethnic minority groups, and immigrants) at predictably higher risk of poor health outcomes that range from earlier onset of chronic conditions to premature death. Despite nationwide concerns about health disparities, Mississippi represents a place of multiple health disadvantages. Mississippi is among the states experiencing the greatest risk of multiple determinants of population health disadvantages. Compared to residents in most other states, Mississippians rank lower on many measures of health and wellness (United Health Foundation 2008). Alongside well-documented state population health challenges and endemic health disparities, Mississippi also confronts physician workforce shortages (Butts and Cossman 2008; Butts, Cossman and Welford 2008; Cossman 2003). Mississippi ranks last in the United States in terms of physician supply (AAMC 2007), reflecting a historic and chronic shortage of health care professionals in the state. In Mississippi's rural areas, inequalities in access to health care are worsened by high rates of individuals living in poverty (21%) and high proportions of racial and ethnic minorities (39%), mostly African-Americans (37%) (U.S. Census Bureau 2008) for whom systematic barriers to access to care are well-documented (AHRQ 2004; CDC 2005; MIGMH Report #1 July 31, 2009

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IOM 2003). Solutions to the rural inequality in access to health care have largely focused on federal subsidies to encourage development of rural clinics, placement of international medical graduates (IMGs) in rural areas, bolstering the National Health Service Corps, and increasing numbers of non-physician providers (Baer et al. 1998; Shi et al. 1994). Such strategies make sense, to the extent that insufficient rural access or provider supply is associated with poorer health outcomes. Rural residents have higher risks of health complications, linked in part to access issues, compared to residents of urban areas (Auchincloss and Hadden 2002). But poor rural health is not just a matter of place, since care access and health disparities are also closely tied to individual socio-demographic characteristics, like race, income and education, regardless of the location of patient populations (Link and Phelan 2005; Williams and Jackson 2005; Williams and Collins 1999; Link and Phelan 1995). Purpose of the Study For these reasons, a comprehensive analysis of health care provision and physician workforce experiences in Mississippi is incomplete without explicit attention to issues associated both with place and with race. The umbrella project (of which this report is one component) supplements the most recent Mississippi Physician Workforce Survey (hereafter 2007/08 MSMD) by extending its focus to document experiences and perspectives of Mississippi physicians that are associated with place and race. The broad purpose of the survey and qualitative data we analyze in a series of reports (described below) is to provide the foundation for an analytic strategy for systematic social scientific evidence for stakeholders seeking to understand Mississippi physician workforce experiences as minority and rural health care providers, particularly physician perspectives on their experiences and the patients they serve. More specifically, we sought to document and analyze the experiences of physicians practicing in underserved and/or rural areas of Mississippi, and to document how conditions affecting Mississippi’s physicians varied by race and gender. Analytic Strategies for Rural and Minority MDs in Mississippi We used three strategies to acquire data for the research for this project. First, we leveraged existing resources from the 2007/08 MSMD statewide survey, boosting responses among actively practicing minority physicians in the state. Second, we linked cross-sectional 2007/08 MSMD data to two MIGMH Report #1 July 31, 2009

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available secondary databases. Linking the 2007/08 MSMD survey data to physician licensure data supported a limited amount of trend analysis. Linking the 2007/08 MSMD to Census data maximized the analytic value of the quantitative data by providing a foundation for analysis using place and race associated variables available in both data sets. Third, we acquired qualitative data from focused interviews with a purposive sample of physicians whose practices were rural or who served traditionally underserved (poor and/or minority) patient populations. Focus and Organization of the Research Place (in both its geographic and social manifestations) is an important component of the Mississippi health care puzzle, since disadvantages or disproportionate levels of poverty, health disadvantage, and concentrations of race/ethnic minority residents vary across communities of physicians and their patients in rural and urban areas. Such differences, anchored in place, shape both physicians’ and patients’ experiences. In this first report, Physicians Practicing in Rural and Underserved Areas of Mississippi, we use data from the 2007/08 MSMD survey to explore how place shapes the experiences of physicians who practice in rural and/or medically underserved areas of Mississippi compared to physicians who practice in urban areas and/or communities with sufficient primary health care providers.1 Race-based differences in individual opportunity and experience of health disparities are realities of the US health care landscape, and as such are another important influence on both the physician workforce and patient populations. Our exploration of race considers the experiences of diverse Mississippi physicians, some who are members of minority groups, as well as the experiences of Mississippi physicians with other varying personal characteristics that may bear on their experiences of medical practice. Race is one of several foci associated with physicians’ personal characteristics analyzed in the second report from this project (Characteristics of Minority Physicians in Mississippi). The final report, Rural and Minority MDs in Mississippi: An Overview, considers place and race together. There we present analysis of the relationships among physician workforce characteristics, where physicians practice, and the characteristics of the populations they serve alongside their narrative characterizations of health care provision in their communities. We 1

The criteria used to distinguish rural and medically underserved communities from nonrural and adequately served communities are discussed in greater detail in Section 3 of this report.


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supplement the statistical analyses presented in the first two reports with systematic analysis of qualitative interview data, to achieve a deeper contextual understanding of the main quantitative findings from the earlier two reports. Physicians Practicing in Rural and Underserved Areas of Mississippi This report, Physicians Practicing in Rural and Underserved Areas of Mississippi is the first of three, organized in six main sections. Following the introduction provided here (Section 1), Section 2 reviews some background from the research literature on place as it relates to health care in rural areas and underserved communities of the United States. It documents the experiences of physicians practicing in Mississippi communities designated as rural by the Census and/or that have federal designation as medically underserved. The background provides a broader national context for the analysis that follows of Mississippi’s unique state-specific experiences associated with place (rural and underserved communities), health care, and physician experiences. Section 3 provides details about the sample, data and analytic approach we used to create this report. It includes detailed information about how the data were acquired and how variables were defined for analysis. Findings from analysis of these data are presented in the following two sections of this report. First, Section 4 explores the experiences of Mississippi physicians who practice in rural areas compared to physicians who do not. Then, Section 5 presents findings that compare physician experiences in communities that are medically underserved (by primary health professionals) versus more adequately served communities in Mississippi. Section 6 summarizes the main findings of the analysis, including a discussion of limitations of the research and some of the main implications of the findings associated with the Mississippi places that physicians serve in their practices.


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SECTION 2

BACKGROUND Concerns about the associations between health care delivery (both quality and quantity) and place are an enduring feature of U.S. health services research. Health Care in Rural Areas of the United States The Mississippi experience is part of a broader context of health services in rural communities nationwide. Rural communities face many challenges in acquiring and maintaining an adequate supply of health services professionals. More than one-third of rural residents in the U.S. live in a HPSA (Rabinowitz et al. 2008), and more rural than urban counties are designated as a mental health or dental HPSA (NACRHHS 2008). These conditions interact with other socio-cultural characteristics to render minority populations living in rural areas especially vulnerable to the myriad problems associated with individual health status, health care access and service delivery. In a report by the National Advisory Committee on Rural Health and Human Services (NACRHHS 2009), the committee examined three key topics in health and human services that affected children and older Americans and which had disproportionate effects in rural areas. The committee made recommendations concerning workforce and community development, creating viable patient-centered medical homes (mainly serving the elderly), and devising programs and services for at-risk children. The NACRHHS made a series of recommendations to address weaknesses in delivery of services to elderly residents and children.


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As the NACRHHS report documents, rural areas across the United States are home to a larger share of the nation’s geriatric population compared to more urban areas. For example, in 2004, 15 percent of nonmetropolitan residents were 65 or older, compared to 11.7 percent of metropolitan residents. This age gap in rural/non-rural residency is expected to increase, as rural elderly “age in place” and some non-rural elderly relocate to rural areas in retirement (Jones et al. 2007). This magnifies provider shortage issues in rural areas because elderly patients tend to require more services (Families USA 2000). The NACRHHS report also emphasizes the need to address child health care issues. Of particular importance is the issue of child abuse and/or neglect. Due to a lack of readily available social services in rural areas, rural children who may have been abused or neglected may not be identified or linked to the appropriate services. The lack of treatment and services to intervene in child abuse and neglect is compounded by the absence of preventative services. Because rural areas are underserved by mental health and social service professionals (NACRHHS 2009), the burden of identification and treatment of abused and neglected children is shifted to primary care providers and their staff. Meeting these additional service demands effectively would require supplemental resources for rural primary care providers (Cooper 2008), who typically work from small practices. Failures to meet the health care needs of rural populations (whether geriatric care or the needs of at-risk children) create lived experiences with lifelong consequences that are shaped, to a great extent, by place. Because geographic remoteness is an impediment to service delivery—whether it is the proximity of specialized services to meet routine health care needs of elderly patients, or to intervene to prevent and address child abuse and neglect—rural residency can be especially isolating. Rural communities may promote values of self-reliance, but self-reliance is inadequate when specific services that are needed to preserve healthfulness cannot be accessed. Health conditions that can be quickly and effectively treated in urban areas with an array of specialized health services may escalate for individuals who are reluctant to leave rural communities to seek health care far from home in unfamiliar settings or with unfamiliar providers. In the instance of abused or neglected children, rural self reliance may be combined with other place specific factors, such as the lack of anonymity or the influence of preexisting relationships in a small community, and these values may prevent individuals and families from reaching out for help (Slama 2004). The implications of rural living reach beyond the health status of elderly individuals and beyond the childhoods of at-risk rural children. MIGMH Report #1 July 31, 2009

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In addition to these examples of how rural residency can have disproportionate effects on outcomes associated with age (children and the elderly), rurality has more general health effects on the entire rural population. A recent report (Bennett et al. 2008) found that residents in any rural county were more likely to report lower health status than residents of urban counties, and at the same time more likely to be uninsured than urban residents. Rural adults were more likely than urban adults to: be obese, report having diabetes, and defer treatment due to cost (especially the case for Black, Hispanic and American Indian residents as compared to Whites). Additionally, rural residents are less likely than urban residents to meet CDC recommendations for moderate or vigorous physical activity, a factor that contributes to the increased health risks for rural black adults (Bennett 2008). Higher prevalence of overweight and chronic diseases create high demands for primary care. However, similar to patterns in the general population, where more Americans live in non-rural than rural areas, more physicians practice in non-rural settings rather than rural ones. The result is a rural population with high levels of routine primary health care needs, and an inadequate supply of physicians to meet them. Health Professional Shortage Areas: The National Context The U.S. Department of Health and Human Resources Health Resources and Services Administration (HRSA) Shortage Designation Branch is the federal agency that defines Health Professional Shortage Areas (HPSAs) as places with shortages of primary medical care, dental or mental health providers.2 The HPSA designation criteria identify a geographic entity (a county or service area) as having insufficient providers to meet population health needs; for primary care providers, this is defined as 1 practitioner per 2,000 in the population (http://bhpr.hrsa.gov/shortage/index.htm). HPSAdesignated areas are eligible for health care-related incentives and extra resources from the federal government, earmarked to improve availability of health care providers in underserved areas. Of course, beyond place as a conceptual category for professional shortage areas, certain populations are at risk of being medically underserved, wherever they live. Data from specific demographic groups, such as the elderly, low income populations, or groups with cultural or linguistic barriers to routine access to health care, may be designated as Medically Underserved Populations (MUP). For more details and precise definitions used by the federal government to designate medically underserved places 2

This report focuses on physicians and primary care shortages only.


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and people, see http://bhpr.hrsa.gov/shortage/index.htm which provides additional information. HPSA designation matters, as a measure of health care provider supply and resources available in HPSA communities. For example, when a given area is HPSA-designated (whether entire counties, groups of adjacent counties, minor civil divisions, or census tracts), Medicare pays providers in such areas a 10% reimbursement incentive on allowed services. The service must be rendered in a HPSA area to receive the incentive payment. Efforts to redress care provider undersupply also includes visa programs which permit international medical school graduates (IMGs) to receive US visas for permanent residency after serving a specified term in an underserved area. The Mississippi Case About 60 percent of Mississippi’s 3 million residents (around 1.65 million people), live in rural areas of the state. Just over a million people, around 37 percent, live in Mississippi communities that are designated by the Federal government as medically underserved. Figure 2.1 Rural/non-Rural Counties in Mississippi Figure 2.1 shows counties in Mississippi designated as rural or not, using Census code definitions to dichotomize counties into rural (meeting criteria for any one of three non-metro classifications) or non-rural [the term urban is used interchangeably](areas meeting one of six metro classifications). The Census definitions we used to identify rural counties are described in more detail in the next section of the report.


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Figure 2.2 HPSA/non-HPSA Counties in Mississippi Figure 2.2 shows counties in Mississippi conventionally described as underserved (having Federal designation as a HPSA). HPSA designation is one approach to understanding which communities have shortages of medical providers insofar as primary health care is concerned. The definitions we used to identify underserved counties are described in more detail in the next section of the report. Figure 2.3 depicts the spatial distribution of rural and HPSAdesignated counties in Mississippi alongside non-rural and non-HPSA counties. Mississippi’s rural counties (shaded gray) and urban (shaded maroon) counties are not perfectly contiguous with counties that are medically underserved. Overlaid on the rural/urban map is the distribution of counties with federal HPSA designation (patterned) and places with adequate primary health professional supply (no pattern). Insufficient population density to economically sustain an abundance of medical services and relative isolation combine throughout both the United States and Mississippi to create “predisposing conditions” that create obvious risks of also being medically underserved places. Put another way, rural areas are disproportionately likely to have federal designation as HPSA communities. However, as Figure 2.3 shows, in Mississippi (as elsewhere) HPSA status and rurality are not one and the same. Some rural counties have adequate supplies of primary care health professionals (21 of 65 rural counties), while some more densely populated non-rural counties in Mississippi are designated as HPSA areas (8 of 17 nonurban counties), characterized by primary care provider shortages.


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Figure 2.3 Rural and Underserved Counties in Mississippi

Given the spatial distinctions that the map in Figure 2.3 depicts, it is obvious that HPSA-designated and rural places are not precisely analogous. Consequently, our research on Mississippi physician experiences also makes the analytic distinction between whether physicians practice in rural or nonrural locations and whether their practice is located in a HPSA designated or non-HPSA county. After first describing the data and methods we used in Section 3, we then present findings related to physician experiences in rural and underserved communities in Sections 4 and 5 respectively.


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SECTION 3

DATA AND METHODS Most of the data used in the descriptive analyses in Sections 4, 5, and 6 are from the 2007/08 MSMD survey (Appendix B), conducted as part of the 2008 Mississippi Physician Workforce Study at the Social Science Research Center at Mississippi State University. Practice county and specialization are from the Mississippi State Board of Medical Licensure. County level data are from the U.S. Bureau of the Census and the U.S. Department of Health and Human Services. Data Individual level data Approximately 15 percent of Mississippi’s licensed physicians responded to the 2007/08 MSMD survey. The original administration of the survey occurred in spring/summer 2007 and yielded responses from 988 physicians. An additional 430 surveys were returned in summer/fall 2008 as a result of outreach associated with this project, in which we targeted physicians from minority groups and physicians who worked in rural or underserved areas for participation in intensive interviews.3 Consequently, the total number of respondents to the 2007/2008 MSMD is 1,418, including not only physicians in active practice (the focus of this study) but also physicians who are 3

Physicians who met particular criteria (minority physicians, physicians practicing in rural Mississippi, physicians practicing in underserved areas) were asked to participate in face-toface interviews regarding their experiences meeting the unique needs of their patient communities. If they had not already completed the 2007/08 MSMD survey, researchers left a blank form and asked them to return it. In this report, we analyze only survey data, which includes data from the original administration of the survey and the additional survey responses from physicians who participated in this particular research initiative. The interview data from this research initiative are analyzed in a later report.


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licensed to practice in Mississippi but who are not currently practicing in state. The total number of 2007/08 MSMD respondents who are actively practicing in Mississippi is 834 (120 practice part-time and 714 practice full-time). The 2007/08 MSMD survey replicated many questions from an earlier 2002 study of the Mississippi physician workforce (Cossman 2003) to permit tracking broad trends. New modules of questions about physicians’ practice experiences, explicit questions about minority physician experiences and recruitment, malpractice issues, the effects of Hurricane Katrina and its aftermath were topics added to items from the original 2002 survey. Funding for 2007 MSMD data collection was pieced together with support from the Mississippi Physician Care Network, Mississippi Academy of Family Physicians and the American Academy of Family Physicians, with some matching support from the Mississippi State University Social Science Research Center. The 2007/08 MSMD sampling frame was all physicians licensed to practice medicine in Mississippi (provided by the Mississippi State Board of Medical Licensure [MSBML]) which included email addresses for approximately 90 percent of physicians who renew licenses online, mailing addresses, and several standard demographic and professional (i.e., primary practice address, primary and secondary specialization) data. The MSMD survey was pre-tested in November of 2006, refined, and fielded online and in paper form from February to August 2007, acquiring 988 respondents. Data collection was timed to capitalize on the window of opportunity determined by external circumstances: time elapsed since Katrina and malpractice experience changes after tort reform (2004). With additional funding from the Mississippi Institute for the Improvement of Geographic Minority Health, we were able to supplement the data for the 2007/08 MSMD survey. We contacted physicians who worked in rural counties and Health Professional Shortage Areas, particularly physicians who were women or members of racial or ethnic minority groups. These respondents were underrepresented in the initial data collection efforts, so targeting them explicitly in a second wave of data collection was designed to increase their representation in the Mississippi physician workforce sample. We met in person with physicians who agreed to be interviewed at their offices (or similarly convenient public location at their request). Once interviewed, we requested that they complete and return the MSMD survey (if they had not previously completed the survey).


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Data from the original wave of the 2007/08 MSMD survey were not completely representative. When comparing physician characteristics in 2007 MSMD sample to 2006-2007 MSBML licensure data, we determined that 18 percent of white full-active MS physicians responded to the survey, compared to only 11 percent of African American full-time active physicians. Other racial categories are represented among the 2007 MSMD sample of physicians (Native Americans with a 21 percent response rate and Asians with a 17 percent response rate), but African American physicians were the least likely to respond to the 2007 MSMD. Therefore, this intensive and more personalized data collection effort was undertaken to reach those physicians who are minorities and who are serving minority and/or rural populations. An examination of response rates by gender and race indicates the analytic sample is demographically comparable to the population of MS physicians, establishing confidence in generalizeability of findings in this report. For example, 78 percent of all active physicians in Mississippi in 2008 were male; 79 percent of respondents in the MSMD2007/08 were men. The population of minority physicians is relatively small; therefore, approaching perfect representativeness is more difficult. Of all active physicians in the state, 81 percent are white (2008), nine percent are black, six percent are Asian, three percent report an “other” race and less than one percent are Native American. In the survey population, 86 percent of respondents reported that they are White, seven percent Black, five percent Asian, two percent other and less than one percent Native American. County level data We derived the lists of Mississippi’s rural and HPSA counties from federal sources: the U.S. Bureau of the Census and the USDHHS Health Resources and Services Administration websites. We identified and coded Mississippi counties as rural/non-rural (we use the terms non-rural and urban interchangeably) and HPSA/non-HPSA (we use the terms HPSA and underserved interchangeably to denote a documented localized shortages of primary health care workers) in the physician data set. In the analyses presented later in this report, counties that met one of three rural Census definitional codes were designated rural (the remaining counties were coded as non-rural/urban). Counties that were federally designated as HPSAs, with documented shortages of primary medical care providers, were defined as HPSA (underserved) places (all other counties were defined by default as non-HPSA - areas with no documented primary care provider shortage).4 4

We do not mean to imply that HPSA-designated areas are the only places with primary care health provision shortages, only that the federal designation reflects documentation


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Sample Eight hundred and thirty four Mississippi physicians in active practice provided valid responses to the 2007/08 MSMD survey.5 Within that study sample, we were able to link cases to counties for 729 physicians. Physicians whose counties of practice could be identified were then coded as practicing in a rural or HPSA area based on where they said they had their primary practices. Physicians in rural and HPSA counties in Mississippi are the central focus of this research. Their experiences are compared in the analyses that follow to counterpart physicians whose primary practices are in non-rural locations and/or whose practices are in counties that conform to federal guidelines on the relationship between population size and adequacy of the primary health care provider workforce. Data from the 729 physicians with county matches for primary practice location represent the analytic sample reported in the following place-specific analyses.6 Among physicians in the analytic sample (those with county matches) who had primary practices in rural counties, 15.4 percent (N=328) responded to the 2007/08 MSMD survey, while 12.4 percent of non-rural physicians (N=401) responded. For physicians in the analytic sample (with county matches) who had primary practices in HPSA designated counties, 15.7 percent (N=126) responded to the survey compared to 13.3 percent (N=603) of physicians in communities with adequate primary health care provider supply. One purpose of this research project was to boost response rates among physicians practicing in rural and underserved areas of the state to better understand the circumstances of physicians who served especially vulnerable communities, and the higher response rates among rural and HPSA physicians indicates that we met that goal.

that shortages exist and the shortages are severe enough to meet federal definitions associated with medically underserved places. 5 Respondents to the 2007/08 MSMD who reported that they were retired, who did not have any active or direct patient contact with patients in the previous year, or who no longer practiced medicine in Mississippi were removed from the study sample. 6 In analyses not shown, the characteristics of the respondents with no county of primary practice match were compared to the characteristics of the entire sample of 2007/08 MSMD survey respondents. The demographic characteristics of the excluded physicians are broadly similar to those of the entire sample, so there is no apparent systematic bias introduced by using the smaller analytic sample restricted to 729 Mississippi physicians whose county of primary practice location could be determined.


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Analysis We conducted categorical and descriptive comparisons of rural versus nonrural physicians (Section 4) and physicians practicing in HPSA-designated counties versus non-HPSA counties (Section 5) on a series of themes relating to physicians’ workforce experiences, using data from the 2007/08 MSMD survey. We present findings from the analysis in a series of tables and figures in the following sections of the report. Individual respondent data from the 2007/08 MSMD survey, and the specialization and county of practice variables from the MSMLB were linked into a single analytic file. In the same linked file, the data for individual county of practice were coded to enable us to distinguish rural/non-rural places following Census conventions and HPSA/non-HPSA places following USDHHS conventions. The data were analyzed using the Statistical Program from the Social Sciences (SPSS ver.16). Tests of differences between means were used to establish levels of statistical significance in most of the analysis for the findings presented in the next sections. In some instances, the data required other statistical tests (e.g., Chi square). Regardless of the test statistic used, statistical significance is indicated by the Cronbach’s alpha, which indicates the percent chance the relationship is not random (e.g., alpha < .10 indicates a 90% chance that the relationship is real and a 10% chance that the relationship is a statistical artifact).


Page 15


SECTION 4

COMPARING MISSISSIPPI’S RURAL AND NON-RURAL PHYSICIANS This section of the report provides descriptive analyses in a series of tables and figures that compare the experiences of physicians who practice in rural areas of Mississippi to those who practice in non-rural areas. As the data show, there is little or no difference in experiences and perspectives between rural and urban doctors (recall that we use the terms non-rural and urban interchangeably in this report). However, for some, the distinctions between rural doctors and their non-rural counterparts are significant, with implications for physicians’ professional experiences, for the care delivered to the patient populations they serve, and for public policy makers and stakeholders to take into account. Comparing Rural and Non-Rural (Urban) Physicians As detailed in the previous section on data and methods, the results presented here are from an analytic sample of licensed physicians in active practice in rural and non-rural counties in Mississippi. Approximately 15.4 percent of rural Mississippi physicians and 12.5 percent of Mississippi’s urban physicians in active practice responded to the 2007/08 MSMD survey. There are many potential reasons for small differences in response rates. These include individual physician interest in the survey, tolerance for the survey process, competing time pressures, secular trends of declining survey participation, and individual perceptions of needs for data about the physician workforce to inform policy-making purposes, among others. One obvious reason that the response rate is higher for rural versus non-rural physicians was a deliberate outcome of this project: the focused effort researchers made to boost response rates for physicians serving vulnerable populations.


Page 16

Table 4.1 shows the descriptive demographic characteristics of the analytic sample (N=729) distinguished by rural/non-rural practice location. Note that non-US born individuals, men, whites, and married individuals are slightly overrepresented in rural practices. Table 4.1. Analytic Sample Descriptive Statistics by Rural/Urban Practice Location Rural (N=254)

Urban (N=283)

Place of birth Born in the U.S. Born elsewhere

90% 10%

92% 8%

Gender Men Women

85% 15%

74% 26%

Race White Non‐white

88% 12%

85% 15%

Marital Status Married Widowed, divorced, single

88% 12%

85% 15%

Medical school debt Under $20,000 $20,000 to 99,999 Over $100,000

40% 45% 16%

49% 37% 15%

HPSA/non‐HPSA location Practice located in HPSA Practice located in non‐HPSA

35% 65%

3% 97%

52 years

52 years

Average age

Percentages may not add to 100 due to rounding.

A larger percentage of physicians in non-rural practices finished medical training with less than $20,000 in student loan debt compared to their rural counterparts, and a greater percentage of rural physicians had debts ranging MIGMH Report #1 July 31, 2009

Page 17

from $20,000 to $100,000, but there are no significant differences by rural/non-rural practice location in terms of having student debts totaling over $100,000. Just over a third of rural physicians in the sample practice in underserved (HPSA) counties, while only 3 percent of non-rural physicians practice medicine in underserved counties. There are no differences in the average age of physicians associated with whether the physician practices in an urban or rural location. Patients of Rural/Non-rural Physicians One notable difference between rural and non-rural physicians is the amount of patient contact in a typical week. Rural physicians estimated that they saw, on average, approximately 110 patients in a typical week, while nonrural physicians estimated that they saw about 81 patients per week. This 35 percent difference between physicians practicing in different locations is statistically and substantively significant. Despite differences in volume, as Table 4.2 shows, the differences in the burden of different types of potentially challenging patients who rural and non-rural physicians treat are relatively minor. Rural physicians estimate treating slightly smaller percentages of patients with complex medical or substance abuse problems. These small differences may indicate that substance abuse is a thornier problem in more urban areas of Mississippi, and that despite the extent of co-morbidities among Mississippi’s rural residents, especially complex cases may (in the end) be referred to specializations located in more urban areas. Table 4.2. Patient Characteristics, by Rural/Urban Practice Location What percent of your patients… ...have complex or ...have complex or numerous medical numerous psycho‐ problems? social problems? Rural Urban

51% 53%

29% 35%

...have substance abuse problems?

…are generally frustrating to deal with?

13% 15%

14% 13%

Rows may not equal 100% due to rounding.

There was no significant difference in the percentage of patients who rural physicians characterized as frustrating to deal with compared to urban physicians. However, non-rural physicians were somewhat more likely than rural physicians to report having a greater percentage of patients who experience complex psycho-social problems. Whether this is a simple matter of population density, an expression of more complex experiences of daily life in more densely populated areas, or whether there is a selection MIGMH Report #1 July 31, 2009

Page 18

process by which individuals with complex psycho-social problems gravitate to non-rural areas where more services may be available is something we cannot determine. Table 4.3. Changes in Patient Access, by Rural/Urban Practice Location In the past 12 months, have any of the following conditions changed for patients in your community? Large Increase

Small Increase

No Change

Small Decrease

Large Decrease

Sig.

Rural

4%

18%

77%

1%

0%

0.00

Urban

8%

34%

56%

3%

0%

Rural

9%

25%

62%

4%

1%

Urban

17%

30%

51%

3%

0%

Rural

5%

20%

69%

5%

1%

Urban

13%

27%

58%

1%

0%

Rural

12%

30%

51%

8%

0%

Urban

16%

40%

39%

5%

0%

Rural

20%

27%

37%

13%

3%

Urban

27%

34%

32%

7%

0%

Rural

16%

37%

44%

3%

0%

Urban

24%

44%

29%

4%

0%

Rural

6%

32%

61%

1%

0%

Urban

15%

40%

45%

1%

0%

Rural

15%

48%

34%

3%

0%

23% Urban *Significant at the .10 level. Rows may not equal 100% due to rounding.

47%

28%

1%

1%

How far patients travel for primary care* How far patients travel for specialty care* How far patients travel for surgical procedures* Waiting times for patient appointments* Waiting times in the emergency room* Waiting times for specialist referrals* Interruptions in continuity of primary care* Loss of health insurance coverage*

0.01 0.00 0.01 0.00 0.00 0.00 0.08

Beyond variations in the characteristics physicians notice among their patients seen in rural versus urban practices, the patient bases of particular practices may also vary in terms of their experiences in accessing health care they need. A series of 2007/08 MSMD questions probed physicians about their recent observations related to their patients’ travel distances and waiting times associated with accessing health care. For every measure (except loss of health insurance coverage) there were significant differences in the proportion of rural versus urban physicians who reported increasing problems with the series of health access statements for their patients that we presented (see Table 4.3). Although it may seem counterintuitive, physicians in urban practices were significantly more likely to report increases in distances their patients had to travel and wait times for services than were their rural counterparts. More urban physicians also reported interruptions in service to patients than rural physicians. A plausible MIGMH Report #1 July 31, 2009

Page 19

explanation for this greater recent disruption in patients’ access to health care noted by physicians in urban practices may have at least two contributing components. First, the data likely reflect the fact that the rural patients’ travel distances and waiting times have always been different from urban patients. Most rural physicians estimated, for example, that travel times for their patients had not changed and that the continuity of primary care access and wait times was mainly stable. Rural physicians’ responses appear to reflect the rural status quo—their patients have always had to travel and wait, thus, not much recent change. The second point is that these data appear to capture a notable recent change in urban patients’ experiences of distance traveled and waits for different types of care, one potential signal of contemporary deterioration in routine health care access if this explanation holds. About the only bright spot in these data are improvements in wait times in emergency rooms for both rural and urban patients, although the improvements appear to be greatest for patients seen in rural practices.

Form of Payment

Figure 4.1 is a graphic depiction of variations in payment sources for patient care when provided in rural versus urban practices. As the pie charts indicate, urban physicians report having a greater proportion of patients with private health insurance, who pay cash for services, and whose care is paid through other sources. Rural physicians report that they have more patients depending on public sources for health insurance, whether Medicaid (health insurance for the poor) or Medicare Figure 4.1. Sources of Patient Payment, by Rural/Urban (health insurance Practice Location for individuals aged 65 and Other older). There are Uncompensated no significant Self-pay/cash Urban differences by Private health Insurance rural/urban Rural SCHIPs practice location Medicaid insofar as public insurance for Medicare children (SCHIPS) 0% 5% 10% 15% 20% 25% 30% 35% is concerned. Percent of Patients


Page 20

Physician’s Professional Experiences Our data for this research challenge one widely held popular assumption that rural and urban physicians always have widely different practice experiences. On many dimensions, the physician experience is the physician experience—experiences and perceptions are similar whether medicine is practiced in a rural or in a more urban setting. For such fundamental practice characteristics as number of hours devoted to professional activities during a typical week (around 47 hours) and percentages of physicians who report participating in on-call activities (about 72 percent) there are no significant differences related to rural/non-rural practice location. On another dimension of physician experience, 11 percent of both rural and urban physicians reported that receiving a high income was the main source of professional satisfaction, while about 40 percent of physicians in both types of places identified good patient relationships as their main source of satisfaction. A slightly higher proportion of urban physicians reported their main source of satisfaction was experiencing substantial intellectual challenge, while a slightly higher proportion of rural physicians reported that a congenial practice environment mattered most. Physicians likely gravitate to practice in the kinds of communities where they can be motivated by professional activities they value most. Urban physicians may work in towns and cities where availability of educational institutions interacts with their practice location to provide pools of intellectual and research opportunities. Rural physicians work in areas where the benefits of membership in tightknit communities are especially highly valued. However, even those differences in the main sources of physician satisfaction were quite small and did not reach statistical significance. Not every aspect of medical practice is satisfying, and Mississippi physicians (like physicians everywhere) have professional experiences ranging from enjoyable to incredibly stressful and alienating. About one in five Mississippi physicians report that they enjoy their work and feel no symptoms of professional burnout at all, regardless of their practice location and at the highest range of stress (high levels of frustration and burnout) location does not appear to matter much. Both rural and urban physicians in similar percentages report levels of severe stress, (only around 5 percent in both instances), reporting that they have symptoms of burnout that won’t go away, or that they are completely burnt out. To the extent that there are distinctions between rural and urban physicians’ stress and professional burnout experiences, it is in the middle ranges. Fifty-four percent of rural practitioners, compared to 59 percent of urban physicians reported that they were occasionally under stress but didn’t feel burned out. Twenty three MIGMH Report #1 July 31, 2009

Page 21

percent of rural physicians but only 17 percent of urban physicians reported that they had at least one or more symptoms of burnout, such as mental or physical exhaustion. To the extent that stress can lead to burnout and that burnout is a process that unfolds over time (Linzer et al. 2001), the data suggest that rural physicians are at slightly higher risk of burnout than their urban counterparts (given their higher levels of middle range stresses), although the differences in burnout experiences between rural and urban physicians are small. Another important aspect of physician experience is the balance between their own and third party control over routine medical practice conditions. Table 4.4 shows the responses of rural and non-rural physicians to a series of questions about that topic. Table 4.4. Control Over Practice Conditions, by Rural/Urban Practice Location How much control do you have over each of the following? None 8% The physicians to whom you refer Rural patients 13% Urban 7% Rural When to admit patients to the hospital* 8% Urban 27% Rural Length of patient hospital stays 26% Urban 4% Rural The specific medications patients receive 4% Urban 6% Details of your primary practice or clinic Rural schedule* 10% Urban 1% Rural Which diagnostic tests you order 2% Urban 41% Rural The volume of paperwork that you have to do 42% Urban 9% Rural The hours you work 12% Urban 22% Rural Volume of your patient load 21% Urban 51% Rural Pre‐authorization for patient services 55% Urban

Some 25% 26% 16% 19% 21% 28% 37% 38% 20% 28% 10% 13% 41% 45% 45% 51% 40% 42% 34% 35%

Much 32% 33% 32% 40% 35% 32% 49% 49% 42% 35% 53% 55% 14% 10% 33% 27% 30% 22% 11% 8%

Complete 36% 29% 44% 33% 18% 14% 10% 9% 32% 27% 36% 31% 4% 3% 14% 10% 9% 13% 4% 2%

Sig. 0.11 0.06 0.18 0.95 0.02 0.54 0.45 0.16 0.13 0.26

* Significant at the .10 level Rows may not add to 100% due to rounding.


Page 22

On most measures, there were no statistically significant differences associated with practice location. To the extent that there are significant differences, rural doctors report having more control over hospital admissions and the details of their primary practices compared to physicians practicing in non-rural settings. These differences may reflect systematic and long-standing differences in rural versus non-rural practices. Hospitalization rates in small communities and rural hospitals often surpass hospitalizations for similar conditions in more urban areas, in part because substitutable services are less readily available in rural places (Rosenthal and Fox 2000). Further, the nature of the communities where they work means that rural physicians are less likely to participate in large practices. Their concentration in small and solo practices would obviously give rural physicians more individualized control over the details of their clinic schedules and practices than, say, for urban physicians in larger practice settings. Our data show that Mississippi physicians, regardless of where they practice, would be likely or very likely to recommend pursuing careers paths very similar to their own to new medical graduates. More than 85 percent of Mississippi physicians, both in rural practices and non-rural ones, would offer such advice. This data suggests that there is a rather widespread and generalized career contentment held by the vast majority (more than 4 out of 5) of Mississippi physicians who participated in the 2007/08 MSMD survey. Table 4.5. Recommendations to Medical School Graduates, by Rural/Urban Practice Location How likely would you be to recommend to someone graduating from medical school to practice in… Somewhat Not Very I Would Not Very Likely Sig. Likely Likely Recommend Your specialty Your community Mississippi

Rural Urban Rural Urban Rural Urban

51% 60% 52% 56% 51% 55%

34% 28% 34% 32% 37% 33%

8% 6% 11% 9% 9% 7%

7% 6% 3% 3% 3% 5%

0.19 0.74 0.46

Rows may not add to 100% due to rounding.

Most are content enough with their specializations and practice location choices that they would recommend making similar career decisions when giving advice to newly minted colleagues. One interesting observation related to these data is the contention by many professionals and policyMIGMH Report #1 July 31, 2009

Page 23

makers that a stereotype of Mississippi as an unattractive or unappealing place to practice medicine works against recruiting and retaining physicians to the state, exacerbating physician undersupply. However, our data show that once physicians are in practice in Mississippi, they clearly do not experience the places they work as unappealing or unattractive. Only 3 percent said they would not recommend their communities or the state of Mississippi as the place to practice in advice to new medical graduates. Twice as many said they would not recommend their specialties as would not recommend their places of practice. So our data indicate that what physicians do (specialization) is a matter of less appeal to Mississippi physicians than where they do it, at least insofar as giving hypothetical advice to new medical graduates about to embark on their careers is concerned. Malpractice and Liability Experiences Mississippi was in the midst of a malpractice “crisis” in 2004. The media characterized the state as the site of “jackpot justice,” where runaway juries in small towns would award multi-million dollar awards against Mississippi physicians named in dubious lawsuits asserting medical injuries. The hyperbole surrounding the “crisis” has confounded accurate knowledge about the depth and precise contours of the crisis and the complex reasons for it. However, it is nonetheless true that by 2004, half of Mississippi physicians had been named in at least one liability lawsuit in the previous three years. Professional liability insurance was becoming prohibitively expensive in some areas of specialization and for generalist practitioners, and a number of insurance companies declined to write any policies in Mississippi. By 2004, policymakers were able to push through tort reform legislation that placed new limits on the regulatory framework associated with professional liability and in subsequent years, malpractice lawsuits dropped precipitously. Understanding physicians’ perspectives on the malpractice issue and their experiences and behavior associated with it was a core inquiry in the 2007/08 MSMD survey. In the aftermath of the state’s tort reform, we asked physicians to weigh in on their perspectives of the current malpractice and liability insurance climate. There were no statistically significant differences between physicians based on rural/non-rural practice location. More than three out of five physicians still characterized the malpractice climate in the state as only poor or fair, despite the reforms, and only 9 percent characterized it as good or excellent. However, problems associated with liability insurance have MIGMH Report #1 July 31, 2009

Page 24

clearly eased, with one in five Mississippi physicians (regardless of practice location) saying conditions were now good or excellent.

Percent

Despite rural and non-rural physicians having similar perspectives on current conditions surrounding medical malpractice and liability insurance, the role of place in physicians’ malpractice experiences in Mississippi is considerable. As Figure 4.2 shows, by 2004 nearly 1 in 5 rural physicians reported that they were named in a lawsuit during the previous year, as were nearly 18 percent of non-rural physicians. By 2005, the percentage of physicians who had been sued in the previous year dropped precipitously, likely a direct response to the 2004 tort reforms. Rural physicians named in a lawsuit the previous year Figure 4.2. Physicians Sued in the Previous Year, dropped to just by Rural/Urban Practice Location over ten percent, and urban 25 physicians reported nearly two thirds 20 fewer lawsuits 15 compared to the 10 previous year. By 5 2006, the last year 0 for which we have Rural Urban Rural Urban Rural Urban data, the 2004 2005 2006 percentage of rural physicians who had been sued was nearly two thirds lower than in 2004, at just over 7 percent. The percentage of non-urban physicians who reported being named in a lawsuit in the previous year declined even more to around 3 percent, one sixth of the level in 2004. Note that in every year, however, that a higher percentage of physicians in rural areas report being sued, with the gap between rural and urban physicians growing over the three years. In 2004, rates of lawsuits were very similar (about 20 and 18 percent for rural and non-rural respectively) but by 2006, rural physicians were sued at more than twice the rate of urban physicians. There are a number of strategies physicians can use to respond to perceived threats of malpractice suits. They can choose to limit their exposure, either by limiting the types and numbers of procedures they perform, or by limiting their hours of work (either by cutting back or retiring), or they can leave practice in Mississippi altogether (by moving their practice to another state, or leaving the profession). Another strategy is the practice of “defensive medicine” where physicians change their professional behavior in ways that MIGMH Report #1 July 31, 2009

Page 25

are more consistent with a calculated tactic to avoid potential lawsuits than to pursue routine best practices in treating patients. As Table 4.6 shows, there are stark and systematic differences in the reporting of defensive medicine practices when comparing rural and urban physicians. Table 4.6. Malpractice Concerns and Defensive Medicine, by Rural/Urban Practice Location How often do concerns about medical malpractice liability cause you to… Never, almost Sometimes Sometimes never, less than about once less than once in 6 a month once a months year Order more tests than you Rural 5% 15% 21% would based on your professional judgment of Urban 10% 23% 24% what is medically needed?* Prescribe more medications, such as antibiotics, than you would based only on your professional judgment of what is medically needed?* Refer patients to specialists more often than you would based only on your professional judgment?* Suggest invasive procedures, such as biopsies, to confirm diagnoses more often than you would based only on your professional judgment?* Avoid personally conducting certain procedures or interventions?*

Often, at least once per week

Regularly, daily or almost daily

Sig.

28%

30%

0.00

24%

20%

Rural

11%

24%

23%

24%

18%

Urban

17%

32%

21%

21%

10%

Rural

5%

24%

23%

29%

18%

Urban

14%

23%

25%

23%

15%

Rural

18%

30%

23%

19%

11%

Urban

26%

31%

21%

12%

11%

Rural

14%

20%

21%

22%

22%

Urban

23%

21%

26%

19%

12%

0.01

0.01

0.08

0.00

*Significant at the .10 level Rows may not add to 100% due to rounding.

For each of the items in the set of questions used to assess defensive medicine, higher percentages of rural physicians reported they used defensive medicine techniques due to their concerns about medical malpractice. Because rural physicians are more than twice as likely to be sued as their urban counterparts, one plausible interpretation of these MIGMH Report #1 July 31, 2009

Page 26

defensive medicine practices is that rural physicians regard them as a necessary safeguard, given their pragmatic concerns about the potential to be named in a lawsuit. Although that risk has dropped dramatically, the worst conditions occurred fairly recently (within the past five years) and the sheer numbers of lawsuits historically filed against rural physicians may be driving that behavior. Recruitment and Retention A perennial concern for Mississippi physicians and policymakers are the challenges of recruiting and retaining physicians to practice in the state. Recruiting and retention depends on a complex mix of personal preferences, place of training and internships, community characteristics, and reimbursement experiences. As Table 4.7 shows, there are both similarities and differences in issues related to the practice climate for Mississippi physicians that bear on recruitment and retention. The broad pattern of similarity that is not associated at all with place of practice is the general pessimism expressed by physicians (who report poor or fair) about the recruiting and retention prospects for physicians. Asked at the most abstract level (recruiting new physicians), four out of five physicians said conditions were poor or only fair. Asked at more specific levels—that is, prospects for recruiting minority or women physicians—and the level of concern that the climate was poor or fair dropped to around half of respondents. Another similarity was rating as poor or fair reimbursement prospects. More than 90 percent of respondents said that Medicaid reimbursement was poor or fair, 85 percent said that was the case for Medicare, and two thirds had the same impression of private insurance reimbursement rates. Four out of five physicians rated the manageability of uncompensated care as poor or fair. Clearly, Mississippi physicians are not optimistic about prospects for a favorable recruiting or reimbursement experience in the state. Where there were statistically significant differences associated with place, it was in the degree of pessimism, with rural physicians expressing more concern about recruiting physicians in general and minority physicians in particular, and retaining women physicians, than their urban counterparts. Rural physicians also seemed to have even less positive experiences with uncompensated care than non-rural physicians. When asked about whether problems of physician supply affected the practice where the respondent worked, identical percentages of both rural and urban practices, 58 percent, responded that yes, physician supply issues were a problem for their own practices. MIGMH Report #1 July 31, 2009

Page 27

Table 4.7. Assessment of Physician Practice Climate by Rural/Urban Practice Location Rate each of the following items relating to your practice climate in Mississippi Climate quality Recruiting new physicians* Retaining experienced physicians Recruiting minority physicians* Retaining experienced minority physicians Recruiting women physicians Retaining experienced women physicians* Medicaid reimbursement rates Medicare reimbursement rates Private insurance reimbursement rates Manageable amount of uncompensated care*

Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban

Poor 42% 45% 18% 22% 22% 23% 17% 20% 16% 18% 16% 15% 68% 70% 57% 54% 17% 17% 45% 50%

Fair 37% 33% 38% 38% 34% 31% 34% 30% 37% 33% 34% 30% 24% 19% 28% 31% 44% 42% 36% 26%

Average 19% 17% 30% 26% 33% 27% 37% 34% 37% 34% 40% 37% 8% 10% 15% 13% 33% 33% 16% 20%

Good 1% 5% 13% 13% 10% 17% 11% 15% 10% 12% 11% 14% 1% 1% 0% 1% 6% 8% 3% 5%

Excellent 0% 1% 1% 1% 1% 3% 1% 2% 1% 4% 0% 4% 0% 0% 0% 0% 0% 0% 0% 0%

Sig. 0.05 0.69 0.09 0.25 0.14 0.10 0.51 0.35 0.96 0.06

*Significant at the .10 level Rows may not add to 100% due to rounding.

Practice Relationships, Resources, and Autonomy Patients are the raison d’être for medical practice, and relationships with patients are a ubiquitous part of physicians’ daily experiences. As Table 4.8 shows, statistically significant differences in the quality of patient relationships associated with rural/non-rural practices are rare. The only significant difference in this set of items is that rural physicians were significantly less likely to strongly disagree with a statement that probed isolation from patients with cultural, gender, or ethnic differences. This may reflect the fact that in urban settings, patients have a wider selection of physicians to choose among, and they may more easily seek care from MIGMH Report #1 July 31, 2009

Page 28

physicians who have ethnic, cultural, or gender similarities if that is important for them. Rural physicians (and their patients) have a much more restricted capacity to do that. Table 4.8. Patient Relationships by Rural/Urban Practice Location

I feel a strong personal connection to my patients. Many patients demand potentially unnecessary treatments.† Time pressures keep me from developing good relationships with my patients.† I often feel like what I do for patients in my practice is just a drop in the bucket.† I am overwhelmed by the needs of my patients.† My relationship with patients is more adversarial than it used to be.† I am having a positive impact on a socio‐ economically disadvantaged population. I am isolated from my patients because of ethnic, cultural or gender differences.*†

Strongly Agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

Sig.

Rural

37%

50%

9%

5%

0%

0.18

Urban

42%

41%

11%

5%

1%

Rural

15%

43%

24%

17%

2%

Urban

12%

35%

27%

23%

3%

Rural

3%

20%

28%

42%

7%

Urban

3%

20%

24%

40%

13%

Rural

6%

29%

22%

35%

8%

Urban

7%

30%

21%

32%

10%

Rural

3%

18%

29%

42%

7%

Urban

4%

19%

32%

36%

10%

Rural

4%

19%

23%

39%

15%

Urban

3%

20%

18%

40%

19%

Rural

16%

55%

23%

6%

0%

Urban

19%

48%

23%

9%

1%

Rural

1%

3%

20%

45%

31%

Urban

0%

3%

16%

38%

43%

0.11 0.25 0.89 0.62 0.50 0.33 0.02

*Significant at the .10 level. † Question is reverse coded. Rows may not equal 100% due to rounding.

Another daily component of active medical practice are relationships with professional colleagues, whether other physicians, office staff, or ancillary health providers. Table 4.9 shows the different responses rural and nonrural physicians gave to a series of questions probing the quality of routine professional relationships. Unlike the broad similarities in response patterns associated with the quality of patient relationships, there are notable differences between rural and non-rural physicians in terms of their professional relationships.


Page 29

Table 4.9. Professional Relationships by Rural/Urban Practice Location

Non‐physicians in my practice support my professional judgment. My non‐physician colleagues are a major source of support.* Non‐physicians in my practice reliably carry out clinical instructions. My physician colleagues are a source of professional stimulation.* I get along well with my physician colleagues. I wish there were more doctors like me in my practice.† My physician colleagues value my unique perspective in practice.* My physician colleagues are an important source of personal support.* It is easy to communicate with physicians with whom I share patients. Many of my colleagues do not share my life experiences.† My colleagues support my efforts to balance family and career responsibilities.*

Strongly Agree

Agree


Disagree

Strongly Disagree

Sig.

Rural

47%

48%

5%

1%

0%

0.31

Urban

45%

48%

4%

3%

1%

Rural

19%

55%

22%

4%

0%

Urban

31%

42%

24%

2%

1%

Rural

26%

59%

12%

4%

0%

Urban

20%

63%

12%

3%

2%

Rural

13%

47%

30%

8%

3%

Urban

20%

56%

18%

5%

2%

Rural

33%

61%

5%

2%

0%

Urban

40%

55%

4%

1%

0%

Rural

22%

37%

38%

3%

0%

Urban

21%

41%

34%

3%

1%

Rural

13%

50%

30%

6%

1%

Urban

18%

59%

20%

2%

0%

Rural

6%

40%

34%

16%

5%

Urban

14%

41%

30%

12%

3%

Rural

18%

63%

13%

5%

1%

Urban

17%

64%

10%

9%

1%

Rural

13%

43%

29%

13%

2%

Urban

12%

35%

32%

19%

3%

Rural

7%

51%

32%

8%

2%

Urban

16%

47%

31%

5%

1%

0.00

0.11

0.00

0.40

0.81

0.01

0.01

0.51

0.16

0.01


For all the items that are significantly different, urban physicians have a more positive assessment of the quality of professional relationships than their rural counterparts. Although we cannot determine why this is the case, MIGMH Report #1 July 31, 2009

Page 30

certainly the professional networks of urban doctors may be more dense, which may mean that there are simply more relationships available, and that the increased availability of relationships also permits physicians to pursue relationships that are positive and supportive. The limited supply or number of professional colleagues in more rural settings could mean that there is either a professional relationships vacuum, or an unavoidable aspect of “settling” for what is available, even if not viewed as positively as in other, more relationship “rich” professional settings. Physicians practice in a universe of finite resources, and the resources and constraints in individual practice settings are an important component of overall physician experiences. Table 4.10 shows similarities and differences between rural and non-rural physicians’ available administrative and patient care resources. Table 4.10. Practice Patient and Administrative Resources, by Rural/Urban Practice Location

My practice has adequate resources for me to do my work.* Paperwork required by payers is a burden to me.† Medical supplies are not always available when I need them.† I have enough exam space to see my patients. My total compensation package is not adequate.† Competition with other physicians is a threat to my financial future.† There are too few support staff in my practice.*† In my opinion, I am expected to take too much call.*† My work in this practice has met my expectations. I am satisfied with the balance of time I spend on patient care vs. administrative tasks.

Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban

Strongly Agree

Agree

16% 21% 35% 37% 3% 5% 18% 20% 6% 10% 3% 2% 2% 5% 5% 8% 13% 13% 12%

64% 55% 46% 41% 24% 22% 68% 59% 24% 27% 13% 16% 22% 27% 21% 15% 62% 67% 49%

Neither Agree nor Disagree 11% 8% 11% 12% 20% 18% 5% 6% 31% 27% 17% 17% 23% 15% 30% 19% 16% 10% 17%

9%

55%

14%

Disagree

Strongly Disagree

8% 14% 6% 9% 47% 47% 7% 12% 34% 32% 54% 54% 48% 45% 40% 47% 8% 9% 18%

1% 2% 2% 1% 7% 9% 2% 4% 5% 3% 14% 12% 5% 7% 5% 11% 0% 0% 4%

17%

5%

Sig. 0.04 0.43 0.63 0.20 0.28 0.77 0.03 0.00 0.33 0.49

* Significant at the .10 level. † Question is reverse coded. Rows may not equal 100% due to rounding.


Page 31

Mostly, response patterns are similar, and the statistically significant differences reflect more differences in the emphasis placed on responses rather than major differences in rates of response. Rural physicians were significantly more likely to regard the amount of resources and support staff they had as adequate, compared to physicians in non-rural practices. This may seem counterintuitive, given the reality that practice in rural locations is typically characterized as a less complex health care environment with fewer and a smaller variety of resources. A plausible explanation is that these perceptions of adequacy (of what is needed to accomplish patient care, or in terms of necessary support from staff) are conditioned by expectations, and that expectations map in predictable ways to place. In the complex and varied environment of more urban settings, physicians expect more. In the simpler rural settings with less variety in the health care supply, physicians tailor their expectations to work with what is available, given the realities of place. Physicians in rural areas were somewhat more likely to agree that they took too much call; this finding coincides with fewer people on the ground available to take call. The last sets of items related to the quality of physician practices explore physician experiences of professional autonomy, prestige (See Table 4.11) and satisfaction in current practice circumstances (see Table 4.12). In terms of professional autonomy, rural and urban physicians have similar opinions, except that rural physicians are significantly more likely to express concern that formularies restrict their capacity to use their professional judgment in treating their patients. This may be a direct result of the larger percentage of patients in rural practices who depend on Medicaid and Medicare, which are more highly regulated in terms of what medical items and services are eligible for reimbursement than private pay arrangements. Mississippi Medicaid has tightly restricted prescription benefits in recent years (Crowley, Ashner and Elam 2005). On measures associated with prestige, urban doctors were significantly more likely to respond that they needed to work where there were research opportunities, and to say that recognition for their work was important than were rural physicians. Rural physicians were significantly more accepting than non-rural physicians of their position as role models in their communities. Having made the decision to practice in small places, often hometowns or nearby communities, a plausible explanation is that rural physicians embrace the role model expectations because of feelings of social connectedness to their communities.


Page 32

Table 4.11. Autonomy, Prestige, and Career Satisfaction, by Rural/Urban Practice Location Neither Agree Strongly nor Strongly Agree Agree Disagree Disagree Disagree Rural 12% 49% 11% 23% 6% I am able to set the pace of my own work. Urban 17% 42% 13% 23% 5% In my practice, it often feels like bureaucrats are second‐guessing me.† Clinical guidelines restrict my freedom to practice.† I can keep patients in the hospital as long as is medically necessary. Formularies or prescription limits restrict the quality of care I can provide.*† Outside reviewers rarely question my professional judgments. Career advancement opportunities are available to me in the same ways as they are available to my colleagues. I am well‐compensated compared to physicians in other specialties. I need to work in an area where I have research opportunities.* I find my present clinical work personally rewarding. Recognition of the importance of my work and my profession is critical.* I am isolated from my colleagues because of ethnic, cultural and gender differences.† The responsibility of being a role model for others is a burden.*†

Rural

21%

39%

24%

14%

3%

Urban

19%

38%

22%

18%

3%

Rural

3%

21%

29%

40%

7%

Urban

5%

15%

31%

43%

6%

Rural

8%

47%

17%

19%

9%

Urban

11%

39%

23%

19%

9%

Rural

19%

43%

15%

21%

2%

Urban

15%

35%

19%

26%

4%

Rural

10%

53%

23%

12%

2%

Urban

9%

50%

23%

15%

4%

Rural

10%

48%

26%

14%

3%

Urban

9%

48%

23%

16%

4%

Rural

7%

23%

23%

33%

14%

Urban

5%

25%

21%

35%

14%

Rural

1%

7%

15%

51%

26%

Urban

6%

14%

20%

43%

18%

Rural

23%

64%

10%

3%

0%

Urban

24%

64%

8%

4%

0%

Rural

8%

36%

36%

18%

3%

Urban

12%

45%

28%

14%

2%

Rural

1%

6%

13%

49%

31%

Urban

2%

3%

10%

47%

38%

Rural

0%

8%

27%

54%

10%

Urban

1%

9%

21%

53%

16%

Sig. 0.46

0.78

0.27

0.35

0.10

0.58

0.77

0.87 0.00 0.85 0.05

0.26

0.10

* Significant at the .10 level. † Question is reverse coded. Row may not equal 100% due to rounding.


Page 33

In terms of specialization and career satisfaction, a greater percentage of urban physicians expressed concern that the specialization they had chosen did not offer the same level of security now as in the past. In general, however, the majority of physicians, regardless of practice location, were satisfied with their careers, to say that their careers met expectations, and that given the choice they would choose medicine again. Table 4.12. Specialty and Career Satisfaction, by Rural/Urban Practice Location Strongly Agree

Agree

Rural

4%

21%

Neither Agree nor Disagree 20%

Urban

5%

21%

My specialty does not provide the security that it once did.*

Rural*

10%

Urban

I am not well‐compensated, given my training and experience.† In general, practice in my specialty has met my expectations. If I were to choose over again, I would not become a physician.† All things considered, I am satisfied with my career as a physician.

My specialty no longer has the appeal to me it used to have.†

I would recommend medicine to others as a career.

Disagree

Strongly Disagree

Sig.

37%

19%

0.89

17%

37%

21%

40%

21%

24%

6%

14%

36%

15%

23%

12%

Rural

11%

21%

29%

29%

10%

Urban

12%

26%

26%

32%

5%

Rural

11%

56%

21%

10%

2%

Urban

14%

61%

15%

9%

2%

Rural

4%

11%

19%

33%

33%

Urban

7%

14%

13%

35%

31%

Rural

24%

60%

9%

6%

1%

Urban

29%

54%

11%

7%

0%

Rural

15%

43%

20%

16%

5%

17%

40%

21%

16%

7%

Urban * Significant at the .10 level. † Question is reverse coded. Rows may not equal 100% due to rounding.

0.03 0.14

0.29

0.15

0.20

0.91

Family and Community Experiences The final look at similarities and differences steps back from an exclusive focus on practice related experiences and perceptions and incorporates a broader perspective. Physicians are little different from anyone else in terms of the importance of family and community factors in their lives, so the small


Page 34

differences between physicians in rural and urban practice locations on such perspectives is not surprising. Table 4.13 shows the patterns of response to a series of items about physicians’ family and personal lives. Urban physicians appear to feel more time pressures that interfere with their family lives than their rural counterparts, suggesting that striking the right work/family balance is less challenging in rural practices. Although there is a statistically significant difference in the importance of living close to extended family, this is an instance where the substantive differences are small, although the emphasis is somewhat different for rural versus non-rural physicians. Table 4.13. Perspectives on Family and Personal Life, by Rural/Urban Practice Location

My family and I are strongly connected to the community where I work. My work schedule leaves me enough time for my family.*

Strongly Agree

Agree

Rural

25%

44%

Neither Agree nor Disagree 20%

Urban

23%

49%

Rural Urban

Rural

4% 8% 5% 6% 11%

Urban Rural Urban

Disagree

Strongly Disagree

Sig.

10%

2%

0.73

17%

10%

1%

41% 34% 32% 36% 51%

18% 15% 31% 23% 21%

29% 36% 29% 31% 14%

8% 7% 4% 5% 3%

19%

46%

18%

13%

5%

Rural

44% 46% 2% 3% 24%

48% 47% 17% 19% 51%

4% 5% 18% 17% 16%

2% 2% 48% 41% 7%

1% 1% 16% 20% 2%

Urban

33%

47%

14%

5%

2%

The interruption of my personal life by work is a problem.† Living in close proximity to parents and/or extended family is important to me.* My spouse (or partner) supports my career.

Rural Urban

Work rarely encroaches on my personal time. High quality schools are important in deciding where I want to work and live.

Rural Urban

0.03 0.33 0.09

0.92 0.39 0.24


Table 4.14 shows responses to a series of items that assess community aspects of physicians’ lives. It is not surprising that urban physicians are significantly more likely to emphasize the importance of local amenities than rural physicians. Individuals for whom a wide array of local cultural amenities is very important would be unlikely to locate to rural practices if there were acceptable alternatives. Rural physicians may feel that the MIGMH Report #1 July 31, 2009

Page 35

distance they have to travel to access such amenities, and a slower pace of life, are simply part of the package of choosing to practice in rural locations. Rural physicians are slightly more likely to be ambivalent or to disagree that they “fit” in their communities than their rural counterparts. While we cannot determine the precise reason for a larger percentage of rural physicians reporting some fit problems with their practice locations, it could be that the data capture some of the experiences of recent influxes of international medical graduate to rural areas of Mississippi, where becoming embedded in the community is a process that unfolds only over time. Table 4.14. Community Perspectives, by Rural/Urban Practice Location

Cost of living in a community is an important consideration for where I want to work. Mississippi taxes are a burden.† People from elsewhere don't realize Mississippi is a great place to live. I feel a sense of belonging to the community where I practice. Local amenities, like parks, shopping, and cultural events, are important in deciding where I want to work and live.* I do not feel at home in the community where I practice.*† Practicing medicine in Mississippi is not much different from practicing in other states. I feel respected by the community where I practice I am proud to practice medicine in Mississippi.

Strongly Agree

Agree


Disagree

Strongly Disagree

Rural

9%

57%

21%

12%

2%

Urban

12%

55%

17%

14%

2%

Rural Urban Rural

7% 10% 29%

30% 28% 55%

35% 33% 14%

25% 24% 2%

4% 5% 1%

Urban

28%

59%

11%

2%

0%

Rural Urban Rural

27% 23% 8%

52% 56% 54%

11% 14% 23%

9% 6% 13%

1% 1% 2%

Urban

18%

57%

16%

8%

1%

Rural Urban Rural

1% 2% 4%

11% 8% 37%

13% 11% 26%

45% 55% 27%

31% 24% 6%

Urban

4%

34%

24%

28%

9%

Rural Urban

26% 20% 31% 31%

59% 66% 51% 49%

12% 10% 17% 17%

3% 3% 2% 2%

0% 1% 0% 1%

Rural Urban

Sig. 0.56

0.65 0.54

0.41 0.00

0.10 0.73

0.17 0.92

* Significant at the .10 level. † Question is reverse coded. Row does not equal 100% due to rounding error.


Page 36

Summary To some extent, the experience of practicing professional medicine is a shared experience, with many similarities regardless of the precise location of a Mississippi physician’s primary practice. But there are some real and important differences in the experiences and perceptions of physicians in rural practices compared to physicians who practice in non-rural settings. Rural practices ARE different from non-rural ones in some characteristics of practice experiences and patient characteristics. They are certainly different in terms of malpractice experiences and the practice of defensive medicine, and on several measures related to professional relationships and work/life balance. However, rural and non-rural practice locations are not the only relevant place related differences that are expressed in the Mississippi health care landscape. Recall that rural and HPSA counties are not as tightly linked spatially as might be assumed (see Figure 2.3). Consequently, the next section of the report compares the experiences of Mississippi physicians in HPSA and non-HPSA counties.


Page 37

SECTION 5

PHYSICIANS PRACTICING IN UNDERSERVED (HPSA) AREAS This section of the report provides a series of tables and figures that compare the experiences of physicians who practice in Mississippi’s underserved communities (with federal HPSA designation) to those who practice in adequately served areas. As the data show, for some experiences there is little or no difference between physicians practicing under HPSA and non-HPSA designations. However, for other experiences, the distinctions between HPSA doctors and their non-HPSA counterparts are significant. These differences have implications for physicians’ professional experiences, for the care delivered to the patient populations they serve, and for public policy makers and stakeholders to take into account. Comparing Physicians in HPSA versus non-HPSA Places Similar to the patterns observed in responses of physicians in rural and urban practices, there are small differences in response rates between HPSA (15.7%) and non-HPSA physicians (13.3%). The potential reasons for differences in response rates across groups are essentially similar: differences in individual interest in the survey, patience with the survey process, and individual perceptions about the need for or value of the collection of data about Mississippi’s physician workforce for traded off against competing demands on time. The higher response rate among HPSA providers is also a result of the researchers’ explicit strategy to increase response rates for physicians in underserved areas of Mississippi. Another intuitively appealing explanation for HPSA physicians’ higher rate of response is that physicians in officially designated underserved areas may be more acutely aware of the specialized needs of their communities and see extra value in providing data for research. If that is the case, physicians practicing in HPSA areas may perceive their participation in a survey about physician issues as having the potential for greater import or impact, and thus may be more willing to respond than physicians who practice in adequately resourced areas.


Page 38

There were fewer HPSA respondents to the 2007/08 MSMD than non-HPSA respondents. This is at the core of one of the problematic phenomenon driving this research: there are places in Mississippi in dire need of health care services, yet which remain sorely understaffed by health care professionals. Table 5.1 shows the demographic characteristics of physicians who practice in areas of provider shortage (HPSA counties) compared to physicians who practice in non-HPSA areas of Mississippi. Table 5.1. Analytic Sample Descriptive Statistics by HPSA/non‐HPSA Practice Location HPSA (N=97)

Non‐HPSA (N=440)

Place of birth Born in the U.S. Born elsewhere

81% 19%

93% 7%

Gender Men Women

85% 15%

78% 22%

Race White Non‐white

82% 18%

87% 13%

Marital Status Married Widowed, divorced, single

87% 13%

86% 14%

Medical school debt Under $20,000 $20,000 to 99,999 Over $100,000

44% 41% 15%

45% 40% 15%

Practice Location Urban Rural

10% 90%

65% 35%

53 years

52 years

Average age

Percentages may not add to 100 due to rounding.


Page 39

Note that a smaller proportion of providers in HPSAs report being born in the United States than non-HPSA providers. This reflects incentives offered by programs that encourage international medical school graduates (IMGs) to serve a specified period of practice in underserved communities in return for gaining legal immigrant status and the right to practice in the U.S. Eighty-seven percent of HPSA respondents are men, compared to seventy-eight percent of non-HPSA respondents. Levels of medical school debt are nearly identical for HPSA versus non-HPSA physicians. Rural physicians make up 90 percent of the physicians who work in medically underserved places and only about one third of the physician workforce in places having adequate primary health care providers. Patients of HPSA/non-HPSA Physicians A striking difference between HPSA and non-HPSA physicians is the amount of patient contact in a typical week. HPSA practitioners see an average of 121 patients per week, while non-HPSA practitioners saw about 89 patients per week. In areas where the supply of physicians is limited, our data show that health professionals have weekly patient workloads that exceed nonHPSA physicians by about a third, suggesting that the average HPSA provider is overburdened by patient contact during a typical week. Table 5.2. Patient Characteristics, by HPSA/non‐HPSA Practice Location What percent of your patients… ...have complex or ...have complex or numerous medical numerous psycho‐ problems? social problems? HPSA non‐HPSA

52% 53%

28% 33%

...have substance abuse problems?

…are generally frustrating to deal with?

13% 14%

13% 14%


Except for one measure associated with patient characteristics, our data show little difference between HPSA and non-HPSA physicians concerning the relative complexity of challenges in their patient population mix. The burden of psycho-social problems among patients is more prevalent for nonHPSA providers than for HPSA providers. This is interesting when considered in context with the rural/urban analysis on the same measure (see Section 4) in which urban physicians reported they had greater percentages of patients with psycho-social problems than rural physicians. This finding on rural/urban differences, combined with the concentration of non-HPSA providers in urban areas, suggests that patients living in non-rural MIGMH Report #1 July 31, 2009

Page 40

areas of Mississippi are especially vulnerable to experiencing psycho-social problems, and/or that they may locate in areas where services for addressing psycho-social problems are most available, with non-rural areas the likeliest place to find needed services. While our study does not directly address the situation of mental health care provision, the spillover of psycho-social problems into the primary care arena is an indication that meeting mental health care needs should also be a prevalent concern for future research and policy making. Table 5.3. Changes in Patient Access, by HPSA/non‐HPSA Practice Location In the past 12 months, have any of the following conditions changed for patients in your community?

How far patients travel for primary care How far patients travel for specialty care How far patients travel for surgical procedures Waiting times for patient appointments* Waiting times in the emergency room Waiting times for specialist referrals Interruptions in continuity of primary care* Loss of health insurance coverage

Large Increase

Small Increase

No Change

Small Decrease

Large Decrease

HPSA

6%

27%

66%

1%

0%

non‐HPSA

6%

26%

66%

2%

0%

HPSA

15%

26%

55%

4%

0%

non‐HPSA

12%

28%

56%

4%

1%

HPSA

12%

27%

56%

5%

1%

non‐HPSA

9%

23%

65%

3%

0%

HPSA

19%

26%

51%

4%

0%

non‐HPSA

13%

37%

43%

7%

0%

HPSA

24%

27%

38%

12%

0%

non‐HPSA

23%

32%

33%

10%

2%

HPSA

23%

35%

41%

1%

0%

non‐HPSA

19%

42%

35%

4%

0%

HPSA

8%

44%

47%

1%

1%

non‐HPSA

11%

34%

54%

1%

0%

HPSA

25%

46%

25%

4%

1%

non‐HPSA

18%

47%

33%

2%

1%

Sig. 0.80 0.82 0.26 0.07 0.57 0.26 0.08 0.21

*Significant at the .10 level. Rows may not equal 100% due to rounding.

Beyond differences in patients’ complex needs, practice location also influences some differences in their patients’ experiences as they relate to access to health care. On a series of questions probing physicians’ perceptions of their patients’ experiences with health care-related travel and wait times, only two measures differed significantly between HPSA and nonHPSA providers. Six percent more HPSA than non-HPSA physicians reported a large increase in waiting times for patient appointments, although nine percent more non-HPSA physicians reported a small increase and eight MIGMH Report #1 July 31, 2009

Page 41

percent more non-HPSA physicians reported no change at all. This pattern of variation suggests that underserved areas may have experienced more dramatic recent changes in wait times, while adequately served communities are seeing more gradual increases in time-related barriers to access. It is plausible that the inherent vulnerability of HPSAs, coupled with the already heightened workload of providers in these areas, makes them especially sensitive to small increases in caseload, contributing to a backlog in waiting rooms. The second differences were associated with interruptions in care. Ten percent more HPSA than non-HPSA physicians report a small increase in interruptions to continuity of primary care, while seven percent more non-HPSA physicians report no change. The chart that follows (Figure 5.1) shows that Other dependence by patients on public Charity /uncompensated programs to pay Self-pay/cash for health care is non-HPSA Private health Insurance higher for HPSA physicians in SCHIPs underserved areas. Medicaid A greater Medicare proportion of patients payments 0% 10% 20% 30% 40% come from Medicare and Medicaid in underserved areas than in practices in non-HPSA locations. The role of private health insurance for patient care is much greater in non-HPSA practices, and other sources of payment are more usual in such practices, too. There were no significant differences in children’s public health insurance coverage under SCHIP or in the proportion of patients who depended on self-payment or charity care by HPSA/non-HPSA designation. Figure 5.1. Sources of Patient Payment, by HPSA/nonHPSA Practice Location

Physicians’ Professional Experiences Where our data challenged some broadly held lay assumptions of fundamentally different rural/non-rural practices and found little difference between rural and urban physician practice experiences on several dimensions, conventional wisdom and findings from our data are more consistent in terms of expected relationships associated with HPSA/nonMIGMH Report #1 July 31, 2009

Page 42

HPSA comparisons. For instance, HPSA practitioners spend somewhat more time on professional activities than those working in nonHPSA communities. Excluding call, HPSA physicians spend an average of 49 hours per week on work, approximately two hours more than their nonHPSA counterparts. Physicians in both practice locations work long hours, but HPSA physicians (at that estimated rate) work an extra hundred hours or so per year compared to non-HPSA physicians. A statistically significant smaller percentage of HPSA physicians (70%) report participation in on-call activities than their non-HPSA counterparts (74%), although we cannot determine the reason for this small difference in on-call activities, it may reflect the rising trend of hiring hospitalists in take call in rural areas. Moving from rates of professional activities to other considerations, a set of 2007/08 MSMD survey items assessed the most important source of professional satisfaction for Mississippi physicians. Sixteen percent of HPSA physicians identified high income as the most important source of professional satisfaction for them, compared to 10 percent of non-HPSA physicians who identified high income as the most important component of professional satisfaction. Recall from Section 2 that, in HPSA areas, there are enhanced payments or top-ups for medical services covered under public insurance programs like Medicare. Such financial feature of public programs that provides bonuses to physicians for delivering services to rural patients affects physician incomes differently, depending on where they deliver particular types of services to patients. That financing difference may contribute to the perception by a larger percentage of HPSA physicians that high income as the most important factor in professional satisfaction. There were no meaningful differences between HPSA and non-HPSA physicians in whether they identified substantial intellectual challenges, congenial practice environments or the quality of patient relationships as most important factors contributing to their professional satisfaction. The most frequently cited source of satisfaction, no matter whether a physician practiced in an underserved area or not, was having high quality patient relationships. Similar to the distinctions noted when comparing rural and non-rural physicians, approximately 1 in 5 physicians in both the HPSA and non-HPSA area subsets reported that they enjoy their work and feel no burnout whatsoever. The proportions of physicians reporting complete burnout and the highest levels of stress are also similar regardless of whether a physician worked in an underserved community or not. Differences in the stressrelated experiences of Mississippi physicians associated with whether or not they worked in an underserved area occurred in the middle of the stress/burnout distribution. Seven percent more HPSA providers reported that they were beginning to notice symptoms of professional burnout, that MIGMH Report #1 July 31, 2009

Page 43

they are definitely starting to burnout and experience one or more symptoms, such as mental or physical exhaustion. Although this heightened reporting of stressful symptoms for HPSA physicians does not reach statistical significance, these results can be considered in light of their higher weekly professional hours worked and greater patient workloads for physicians working in underserved areas, which could certainly contribute to stress. Comparisons between physicians serving in underserved areas (HPSAs) and non-HPSA physicians’ perceptions of control over their work did not reach statistical significance. There are small non-significant differences by practice location in perceived control over length of patient hospital stay, prescriptions for specific medications, and patient load. Table 5.4. Control over Practice Conditions, by HPSA/non‐HPSA Practice Location How much control do you have over each of the following: None 9% The physicians to whom HPSA you refer patients 11% Non‐HPSA 7% When to admit patients to HPSA the hospital 8% Non‐HPSA 30% Length of patient hospital HPSA stays 26% Non‐HPSA 5% The specific medications HPSA patients receive 4% Non‐HPSA 8% Details of your primary HPSA practice or clinic schedule 8% Non‐HPSA 1% Which diagnostic tests you HPSA order 2% Non‐HPSA 41% The volume of paperwork HPSA that you have to do 41% Non‐HPSA 7% HPSA The hours you work 11% Non‐HPSA 24% Volume of your patient HPSA load 21% Non‐HPSA 52% Pre‐authorization for HPSA patient services 53% Non‐HPSA

Some 29% 25% 18% 18% 28% 24% 45% 36% 16% 26% 14% 11% 40% 44% 46% 49% 34% 44% 33% 35%

Much 27% 34% 36% 37% 28% 35% 42% 51% 43% 37% 56% 53% 15% 11% 31% 29% 32% 24% 11% 10%

Complete 35% 31% 39% 38% 15% 16% 9% 9% 34% 29% 29% 34% 4% 4% 16% 11% 10% 11% 4% 3%

Sig. 0.43 0.99 0.54 0.33 0.19 0.68 0.72 0.35 0.20 0.82


For example, 58 percent of HPSA practitioners report having quite limited or no control over length of hospital stays compared to only 50 percent of nonMIGMH Report #1 July 31, 2009

Page 44

HPSA providers. Nine percent more HPSA physicians report only some control over specific medications received by patients, while 9 percent more non-HPSA physicians report having much control over this dimension of practice. Non-HPSA physicians tend to report more limited control over patient load than HPSA physicians. This is interesting in light of the findings that HPSA physicians’ weekly patient load is approximately 26 percent greater than non-HPSA. An opposite trend appears on other measures of control. Seventy-seven percent of HPSA providers have either much or complete control over the details of their primary practice or clinic schedule, compared to 66 percent of non-HPSA physicians. Five percent more HPSA physicians feel they have complete control over the hours she/he works, while 5 percent more non-HPSA physicians report having no control over this element of their work. HPSA physicians also report more control over details such as volume of paperwork he/she has to do. This suggests that while HPSA providers perceive less control over treatment related practices, they experience greater control over contextually related dimensions of their practice. Figure 5.2. Advice to Medical Graduates about Specialization and Practice Location, by HPSA/non-HPSA Practice Location

You r Communi ty*

HPSA Non‐

I Would Not Recommend

HPSA

Not Very Likely

You r Sp e ci a l ty*

Somewhat Likely

Non‐

Very Likely

HPSA MS* Non‐

0%

10%

20%

30%

40%

50%

60%

70%

Recall that there were no significant differences in the advice relating to place of practice or specialization that distinguished between rural and urban physicians likely advice to new medical graduates. In contrast, whether or not a physician practices in a HPSA or non-HPSA county is associated with statistically significant differences across all three measures of place and specialization (See Figure 5.2). Thirteen percent more non-HPSA physicians would recommend their specialty to medical school graduates, and 13 percent more non-HPSA providers would recommend Mississippi to med school graduates. The most telling difference is that 24 percent more nonHPSA providers compared to physicians who practice in underserved areas would recommend their community to future physicians. Of the three items MIGMH Report #1 July 31, 2009

Page 45

we asked about in the 2007/08 MSMD, this measure seems to most closely reflect the impact of working in a HPSA, as the term community captures the essence of place more specifically than whether or not practice in the state is good advice. Malpractice and Liability Experiences Malpractice matters, in different ways, to physicians practicing in HPSA versus non-HPSA communities. Differences in four of the five items measuring concerns about malpractice issues are statistically significant and there are noticeable differences between HPSA and non-HPSA practitioners in the frequencies of taking precautionary, defensive medicine actions with certain procedures or treatment approaches. In 2004 HPSA providers reported disproportionately more lawsuits (three or more) than physicians practicing in non-HPSA areas. For the entire three year period, the number of HPSA providers reporting three or more lawsuits represents 8.4 percent of all the reported lawsuits, compared to 6 percent for non-HPSA providers. While this gap may initially appear small, when considered in light of the fact that HPSA providers represent fewer than twenty percent of all respondents on this survey item, their reports of more lawsuits is amplified to overrepresentation: a minority of Mississippi physicians is carrying a greater share of the burden of medical malpractice litigation.

Figure 5.3. Percentage of Physicians Named in a Lawsuit in the Previous Year, by HPSA/non-HPSA Practice Location 14.00 12.00 10.00 8.00 6.00 4.00 2.00 0.00 HPSA

NonHPSA

2004


HPSA

NonHPSA

2005

HPSA

NonHPSA

1 2 3 4 5 6 or more

2006

Page 46

Figure 5.3 shows percentages of physicians who were sued within the previous year in 2004, 2005, 2006. The general level of lawsuits during 2004, the last year of the malpractice crisis, was much higher than the two following years, trending lower for physicians in both HPSA and nonHPSA practices in 2005 and 2006. Physicians practicing in underserved areas were sued at much higher rates in all three years. Table 5.5 shows one way that being at higher risk for being sued may be expressed behaviorally. Table 5.5. Malpractice Concerns and Defensive Medicine, by HPSA/non‐HPSA Practice Location How often do concerns about medical malpractice liability cause you to…

Order more tests than you would based on your professional judgment of what is medically needed?* Prescribe more medications, such as antibiotics, than you would based only on your professional judgment of what is medically needed?* Refer patients to specialists more often than you would based only on your professional judgment?* Suggest invasive procedures, such as biopsies, to confirm diagnoses more often than you would based only on your professional judgments? Avoid personally conducting certain procedures or interventions?*

Never, almost never, less than once a year

Sometimes, less than once in 6 months

Sometimes, about once a month

Often, at least once per week


Sig.

HPSA

5%

17%

17%

25%

35%

0.08

Non‐ HPSA

9%

19%

24%

26%

23%

HPSA

10%

22%

22%

25%

21%

Non‐ HPSA

15%

30%

21%

22%

12%

HPSA

5%

21%

17%

33%

24%

Non‐ HPSA

11%

24%

26%

24%

15%

HPSA

16%

31%

23%

18%

13%

Non‐ HPSA

23%

30%

21%

15%

10%

HPSA

18%

16%

13%

24%

29%

Non‐ HPSA

19%

22%

26%

20%

14%

0.09

0.02

0.52

0.00



Page 47

Twelve percent more HPSA providers order more tests on a daily basis than they would based solely on their professional medical judgment. On a regular basis, 9 percent more HPSA providers prescribe more medications out of concern about medical malpractice liability. Nine percent more HPSA practitioners refer patients to more specialists, and 15 percent more avoid conducting certain procedures or interventions (again, these practices occur on a daily or almost daily basis), compared to their counterparts who practice in areas of the state that are adequately served by primary care health professionals. In the case of each of the practice choices associated with defensive medicine, a greater percentage of non-HPSA providers report being motivated by concerns over medical malpractice liability than HPSA providers. On a scale ranging from never/less than once a year to daily/almost daily, over half of the non-HPSA respondents reported having these concerns when ordering tests between never and once a month, while 60 percent of HPSA respondents reported having these concerns at least once per week to daily. This same trend occurs with prescriptions, with referrals to specialists and with the avoidance of treatments. The only defensive medicine measure with no meaningful difference in responses associated with practice in a HPSA place was in responses about invasive procedures. It appears that this dimension is not as sensitive to spatiallyrelated concerns over litigation. Despite their very different experiences with lawsuits and the practice of defensive medicine, there were no significant differences in the impressions of the current malpractice climate or availability of liability insurance associated with whether or not a physician practiced in an underserved area. Nearly two thirds of physicians characterized the malpractice climate as poor or fair, and about half of physicians characterized the availability of liability insurance as poor or fair…despite recent tort reforms. Recruitment and Retention When asked to rate the practice climate for recruiting and retaining experienced physicians in Mississippi, the only significant differences between HPSA and non-HPSA providers relate to one aspect of retention and one aspect of reimbursement. As Table 5.6 shows HPSA providers expressed considerably more concern about the capacity for retaining experienced physicians. The second difference is in the perceptions HPSA providers versus non-HPSA providers hold about the adequacy of Medicaid MIGMH Report #1 July 31, 2009

Page 48

reimbursement rates. Physicians practicing in HPSA counties have a significantly higher percentage of patients whose care is reimbursed under the state Medicaid program than physicians who practice in more adequately served communities throughout the state, yet HPSA providers are significantly less likely that providers in other areas to regard Medicaid reimbursement as poor. This may reflect different expectations about reimbursement levels in underserved versus more adequately served communities, or the occasional supplements to public reimbursement rates that some services provided in HPSA (but not non-HPSA) areas receive. Table 5.6. Assessment of Physician Practice Climate by HPSA/non‐HPSA Practice Location Rate each of the following items relating to your practice climate in Mississippi Poor Fair Average Good 41% 35% 24% 1% Recruiting new HPSA physicians 44% 35% 17% 4% Non‐HPSA 25% 46% 25% 5% Retaining experienced HPSA physicians* 19% 36% 28% 15% Non‐HPSA 20% 32% 37% 11% Recruiting minority HPSA physicians 23% 32% 28% 14% Non‐HPSA 19% 36% 34% 11% Retaining experienced HPSA minority physicians 18% 31% 36% 14% Non‐HPSA 16% 38% 38% 7% Recruiting women HPSA physicians 17% 34% 34% 12% Non‐HPSA 17% 37% 35% 11% Retaining experienced HPSA women physicians 15% 31% 39% 13% Non‐HPSA 58% 31% 10% 1% Medicaid reimbursement HPSA rates* 72% 19% 8% 1% Non‐HPSA 52% 32% 17% 0% Medicare reimbursement HPSA rates 57% 29% 13% 1% Non‐HPSA 25% 40% 32% 4% Private insurance HPSA reimbursement rates 16% 44% 33% 8% Non‐HPSA 46% 32% 22% 0% Manageable amount of HPSA uncompensated care 48% 30% 17% 5% Non‐HPSA

Excellent 0% 1% 0% 1% 0% 3% 0% 2% 1% 3% 0% 3% 0% 0% 0% 0% 0% 0% 0% 0%

Sig. 0.37 0.03 0.26 0.57 0.56 0.40 0.05 0.73 0.14 0.11


On a survey measure that assesses whether or not physician supply problems adversely affect the particular practices where physicians are working, 59 percent of non-HPSA physicians reported that they were, compared to just 54 percent of HPSA providers. Obviously, a majority of Mississippi physicians, regardless of practice location, work in practices MIGMH Report #1 July 31, 2009

Page 49

impacted by physician shortages—but non-HPSA physicians appear to feel that shortage somewhat more acutely. This may be because deliberate policy initiatives to beef up supply in underserved areas either ameliorate some of the undersupply, or at least create the perception of that. Practice Relationships, Resources, and Autonomy Considering the most central relationship associated with medical practices, there were few differences, and only one statistically significant one, in terms of patient relationships associated with practicing in underserved areas (see Table 5.7). Table 5.7. Patient Relationships by HPSA/non‐HPSA Practice Location

I feel a strong personal connection to my patients. Many patients demand potentially unnecessary treatments.† Time pressures keep me from developing good relationships with my patients.† I often feel like what I do for patients in my practice is just a drop in the bucket.† I am overwhelmed by the needs of my patients.† My relationship with patients is more adversarial than it used to be.† I am having a positive impact on a socio‐economically disadvantaged population. I am isolated from my patients because of ethnic, cultural or gender differences.*†

Strongly Agree

Agree


Disagree

Strongly Disagree

Sig.

HPSA

36%

50%

11%

4%

0%

0.74

Non‐HPSA

41%

44%

10%

5%

0%

HPSA

15%

42%

24%

18%

1%

Non‐HPSA

13%

38%

26%

20%

3%

HPSA

6%

21%

28%

41%

5%

Non‐HPSA

2%

20%

25%

41%

11%

HPSA

7%

26%

26%

36%

6%

Non‐HPSA

7%

30%

21%

33%

10%

HPSA

2%

25%

32%

34%

8%

Non‐HPSA

4%

17%

30%

40%

9%

HPSA

5%

15%

24%

45%

11%

Non‐HPSA

3%

21%

19%

38%

19%

HPSA

25%

49%

22%

5%

0%

Non‐HPSA

17%

51%

23%

8%

1%

HPSA

3%

4%

28%

42%

23%

0%

3%

16%

41%

41%

Non‐HPSA

0.78

0.14

0.49

0.29 0.13

0.29

0.00



Page 50

A larger proportion of physicians who practiced in counties designated as underserved (HPSA) reported that they experienced cultural, ethnic, or gender isolation from their patients. This may be related to the requirement that physicians from other countries who want to practice in the U.S. serve for a specified period in an area of the United States that is designated as underserved in order to qualify for a permanent visa. It is impossible to tell from this analysis whether that is the reason for the difference between HPSA and non-HPSA physicians, but it is the likeliest explanation. Although there are no significant differences in professional relationships with non-physician colleagues, our data indicate that non-HPSA providers have better quality relationships with other physicians across a range of professional relationships dimensions compared to physicians working in underserved areas. Although the survey does not measure for negative effect of relationships on physician experiences, the relatively small numbers of extreme responses (strongly agree or strongly disagree) suggest that relationships are not conflictual. However, the data do suggest at least some isolation or alienation from other physicians experienced by physicians working in HPSAs. It is unclear whether the issue is mainly one of depressed sociability (liking) or professional experiences (supportive or collaborative peer relationships) or a combination of both. Non-HPSA physicians appear to experience their relationships with other physicians as a more essential component of their professional experiences than physicians in underserved areas. Seventy-three percent of non-HPSA respondents regard physician colleagues as a source of professional stimulation, but less than 50 percent of HPSA respondents share that perspective. However, relationships are not necessarily conflictual or noncollegial. Fewer than 10 percent of respondents, regardless of practice locale, were ambivalent or negative about getting along well with their colleagues. HPSA providers appear to have a different impression of their own worth viewed through the eyes of their peers than non-HPSA providers. Just 51 percent of HPSA practitioners agreed with the statement “My physician colleagues value my unique perspective in practice,” compared to three quarters of non-HPSA respondents. This may reflect a lower sense of self-worth where professional identity is concerned, a sense of difference that cannot be bridged, or an impression that other physicians do not (whether justifiably or not) hold the individual in very high regard. We cannot determine the reason for these response patterns from survey data. However, professional and personal relationships often overlap and this appears more the case among non-HPSA providers than among HPSA providers. Twelve percent of non-HPSA respondents strongly agree that their physician colleagues are important sources of personal support, MIGMH Report #1 July 31, 2009

Page 51

compared to only 2 percent of HPSA providers. In fact, 62 percent of HPSA providers are either ambivalent, disagree or disagree strongly that their professional peers are important sources of personal support. Compared to physicians in underserved areas, a greater proportion of non-HPSA physicians report positive levels of support for achieving work family balance from their colleagues, although this item reflects a broaderbased sense of “colleague” versus the more specific “other physician”. Table 5.8. Professional Relationships by HPSA/non‐HPSA Practice Location Neither Strongly Agree Strongly Agree Disagree Agree nor Disagree Disagree Non‐physicians in my 43% 46% 8% 2% 1% HPSA practice support my 46% 48% 3% 2% 1% Non‐HPSA professional judgment. My non‐physician colleagues 17% 56% 25% 2% 1% HPSA are a major source of 27% 47% 22% 3% 1% support. Non‐HPSA Non‐physicians in my 23% 60% 13% 4% 0% HPSA practice reliably carry out 23% 61% 12% 3% 1% clinical instructions. Non‐HPSA My physician colleagues are 6% 42% 39% 10% 3% HPSA a source of professional 19% 54% 20% 5% 2% stimulation.* Non‐HPSA 26% 67% 4% 3% 1% I get along well with my HPSA physician colleagues.* 39% 56% 4% 1% 0% Non‐HPSA I wish there were more 23% 41% 32% 4% 0% HPSA doctors like me in my 21% 39% 37% 3% 1% practice.† Non‐HPSA My physician colleagues 10% 41% 43% 6% 0% HPSA value my unique perspective 17% 58% 21% 3% 1% in practice.* Non‐HPSA My physician colleagues are 2% 37% 43% 16% 3% HPSA an important source of 12% 41% 30% 13% 4% personal support.* Non‐HPSA It is easy to communicate 12% 62% 16% 9% 1% HPSA with physicians with whom I 18% 64% 11% 7% 1% share patients. Non‐HPSA Many of my colleagues do 12% 42% 34% 10% 1% HPSA not share my life 12% 38% 30% 17% 3% experiences.† Non‐HPSA My colleagues support my 3% 55% 32% 8% 2% HPSA efforts to balance family and 14% 48% 31% 6% 1% Non‐HPSA career responsibilities.* * Significant at the .10 level. † Question is reverse coded. Rows may not equal 100% due to rounding.


Sig. 0.32

0.21

0.80

0.00

0.02 0.74

0.00

0.01

0.33

0.29

0.04

Page 52

On measures of practice resources (Table 5.9), only two items reach statistical significance: “my practice has adequate resources for me to do my work,” and “there are too few support staff in my practice.” For these two items, the most meaningful difference between HPSA and nonHPSA practitioners lies in the strength of agreement (or disagreement) that their practice is adequately resourced. Only 9 percent of HPSA practitioners strongly agreed with this statement, compared to 21 percent of non-HPSA physicians. As for differences in the perspectives on the adequacy of support staff, the differences between HPSA and non-HPSA physicians likely reflect the reality of fewer health care delivery resources generally in medically underserved areas. Table 5.9. Practice Patient and Administrative Resources, by HPSA/non‐HPSA Practice Location

My practice has adequate resources for me to do my work.* Paperwork required by payers is a burden to me.† Medical supplies are not always available when I need them.† I have enough exam space to see my patients.

Strongly Agree

Agree


Disagree

Strongly Disagree

Sig.

HPSA

9%

65%

13%

13%

1%

0.05

Non‐HPSA

21%

58%

8%

11%

2%

HPSA Non‐HPSA HPSA

43% 35% 5%

43% 44% 27%

8% 12% 21%

5% 8% 39%

2% 2% 9%

Non‐HPSA

4%

22%

18%

49%

8%

HPSA Non‐HPSA

HPSA

17% 20% 10% 8% 3%

69% 62% 29% 25% 14%

2% 6% 30% 29% 15%

11% 9% 30% 34% 54%

1% 4% 2% 4% 13%

Non‐HPSA

2%

14%

17%

54%

13%

HPSA Non‐HPSA

4% 4% 6% 6% 9% 14% 10%

22% 26% 27% 16% 63% 65% 43%

29% 16% 26% 24% 18% 12% 22%

40% 48% 37% 45% 10% 8% 21%

5% 7% 5% 9% 0% 0% 4%

11%

54%

14%

17%

4%

My total compensation package is not adequate.† Competition with other physicians is a threat to my financial future.† There are too few support staff in my practice.*†

HPSA Non‐HPSA

In my opinion, I am expected to take too much call.†

HPSA Non‐HPSA

My work in this practice has HPSA met my expectations. Non‐HPSA I am satisfied with the balance HPSA of time I spend on patient care versus administrative tasks. Non‐HPSA *Significant at the .10 level. † Question is reverse coded. Row may not equal 100% due to rounding .


0.43 0.55

0.24 0.64 0.99

0.06 0.13 0.25 0.18

Page 53

Table 5.10. Professional Autonomy and Prestige, by HPSA/non‐HPSA Practice Location Neither Strongly Strongly Agree Agree nor Disagree Agree Disagree Disagree 10% 57% 8% 20% 5% HPSA I am able to set the pace of Non‐ my own work.* 16% 42% 13% 24% 5% HPSA 27% 32% 22% 15% 3% In my practice, it often feels HPSA like bureaucrats are second‐ Non‐ 18% 39% 23% 17% 3% guessing me.† HPSA 9% 25% 24% 39% 4% HPSA Clinical guidelines restrict my Non‐ freedom to practice.*† 3% 16% 31% 43% 7% HPSA 10% 43% 21% 17% 9% I can keep patients in the HPSA hospital as long as is medically Non‐ 9% 43% 20% 20% 9% necessary. HPSA 2% 7% 16% 54% 21% I need to work in an area HPSA where I have research Non‐ 3% 11% 18% 46% 22% opportunities. HPSA 17% 63% 14% 7% 0% HPSA I find my present clinical work Non‐ personally rewarding.* 25% 64% 8% 3% 0% HPSA 10% 32% 36% 20% 2% Recognition of the importance HPSA of my work and my profession Non‐ 10% 42% 31% 15% 2% is critical. HPSA I am isolated from my 1% 6% 17% 50% 27% HPSA colleagues because of ethnic, cultural and gender Non‐ 2% 5% 10% 47% 37% differences.† HPSA 17% 22% 31% 22% 8% I am not well‐compensated, HPSA given my training and Non‐ 11% 24% 27% 32% 7% experience.† HPSA 24% 46% 11% 17% 3% Formularies or prescription HPSA limits restrict the quality of Non‐ 16% 37% 19% 25% 4% care I can provide.*† HPSA Career advancement 8% 44% 26% 17% 5% HPSA opportunities are available to me in the same ways as they 10% 49% 24% 14% 3% Non‐ are available to my colleagues. HPSA 6% 44% 26% 21% 3% Outside reviewers rarely HPSA question my professional Non‐ 10% 53% 22% 12% 3% judgments.* HPSA *Significant at the .10 level. † Question is reverse coded. Row may not equal 100% due to rounding.


Sig. 0.07

0.31

0.01

0.98

0.56

0.03

0.34

0.19

0.20

0.03

0.73

0.09

Page 54

The accumulation of professional experiences shape respondents’ perspectives on issues related to professional autonomy and prestige (See Table 5.10). The 2007/08 MSMD also included measures of physician perceptions of autonomy and prestige. There are several significantly different perspectives on issues bearing on physician autonomy and prestige when comparing HPSA and non-HPSA physicians. For example, higher percentages of physicians working in underserved areas (despite demonstrably high levels of patient need) reported that they had control over the pace of their work, but feel less in control of the constraints that affect their practices. On three measures of autonomy (feeling second guessed by bureaucrats, being restricted by formularies, and being subject to outside reviewers), physicians working underserved areas felt more beleaguered than non-HPSA physicians. HPSA physicians treat more Medicaid patients and may also have to conform to additional bureaucratic expectations associated either with regularlizing visa statuses or conforming to the strictures of specialized programs designed to address needs in underserved communities. Whatever the explanation (it is likely a complex interaction between these and many other factors) physicians in underserved areas feel more constraints on their clinical autonomy than do physicians working elsewhere. It may be that the autonomy constraints that HPSA physicians experience are part of the explanation why a lower percentage report finding their current clinical work rewarding, since autonomy is a consistent predictor of physician satisfaction. There were no statistically significant differences in HPSA versus non-HPSA physicians’ reports of satisfaction with their specialties in particular and their careers in general (see Table 5.11). There are, however, several distinctive patterns in the emphasis placed on different aspects of satisfaction associated with specialization. A larger percentage of physicians who work in locations where there is a sufficient supply of primary health care providers were more about their specialties becoming less secure than in the past, but were simultaneously more enthusiastic in their responses that their specialty practices had met their expectations than their HPSA counterparts. Regardless of practice location, most physicians seemed satisfied with the overall experiences of their professional careers.


Page 55

Table 5.11. Specialization and Career Satisfaction, by HPSA/non‐HPSA Practice Location

Agree


Disagree

Strongly Disagree

HPSA

6% 4% 9% 13% 4%

21% 21% 43% 37% 23%

23% 17% 22% 17% 17%

34% 37% 23% 24% 37%

16% 21% 3% 10% 20%

Non‐HPSA

6%

25%

23%

34%

13%

HPSA

8%

55%

25%

12%

1%

Non‐HPSA

14%

60%

16%

9%

2%

HPSA

6%

12%

19%

35%

29%

Non‐HPSA

6%

13%

15%

34%

32%

HPSA

23%

61%

10%

5%

2%

Non‐HPSA

27%

56%

10%

7%

0%

HPSA Non‐HPSA

14% 17%

40% 42%

23% 20%

17% 16%

7% 6%

My specialty no longer has the appeal to me it used to have.†

HPSA Non‐HPSA

My specialty does not provide the security that it once did. I am well‐compensated compared to physicians in other specialties. In general, practice in my specialty has met my expectations. If I were to choose over again, I would not become a physician.† All things considered, I am satisfied with my career as a physician. I would recommend medicine to others as a career.

HPSA Non‐HPSA

Strongly Agree

Sig. 0.50 0.14 0.27

0.11

0.88

0.17

0.84

Significant at the .10 level. † Question is reverse coded. Rows may not equal 100% due to rounding.

Family and Community Experiences Although statistically significant differences are few, physicians working in underserved areas compared to non-HPSA providers are more likely to say they lack enough family time and that work often encroaches on personal time. The one significant difference was in terms of reports on the importance of school quality for practice location, where non-HPSA physicians were significantly likelier to agree that this was an important consideration about where to locate their practices (and their families). One possible explanation for this is that physicians who agree to work in underserved areas in return for relief of student debt, or to gain a permanent visa to work in the United States may have traded off (or have no expectation in the first place) about quality of schools in the areas where they must practice to meet obligations. This does not mean that their families are not important to them, or that school quality is a trivial concern, MIGMH Report #1 July 31, 2009

Page 56

only that school quality is but one aspect of family life that has bearing on its quality. Table 5.12. Perspectives on Family and Personal Life, by HPSA/non‐HPSA Practice Location

My family and I are strongly connected to the community where I work. My work schedule leaves me enough time for my family. The interruption of my personal life by work is a problem.† Living in close proximity to parents and/or extended family is important to me. My spouse (or partner) supports my career. Work rarely encroaches on my personal time. High quality schools are important in deciding where I want to work and live.*

Strongly Agree

Agree


Disagree

Strongly Disagree

Sig.

HPSA

23%

41%

21%

13%

3%

0.41

Non‐HPSA

24%

48%

18%

10%

1%

HPSA

6%

32%

18%

35%

10%

Non‐HPSA

6%

38%

16%

32%

7%

HPSA

6%

38%

28%

28%

1%

Non‐HPSA

5%

33%

27%

31%

5%

HPSA

13%

56%

14%

12%

4%

Non‐HPSA

15%

47%

20%

14%

4%

HPSA

39%

52%

6%

2%

1%

Non‐HPSA

47%

46%

4%

2%

1%

HPSA

0%

15%

19%

49%

18%

Non‐HPSA

3%

19%

17%

43%

18%

HPSA

20%

45%

26%

9%

1%

Non‐HPSA

30%

50%

13%

5%

2%

0.73 0.37

0.49

0.67 0.35 0.01


In terms of community experiences, three items stand out as significant differences between physicians who practice in underserved communities and those who do not. Non-HPSA physicians placed significantly more emphasis on the importance of community amenities available and higher percentages also regarded the state as a great place to practice. These are two attributes of community life that could look very different, depending on how much choice a physician felt she or he had in picking where to practice. In some instances, the array of choices for physicians who want to participate in special programs linked to areas of medical underservice would preclude many community amenities. Further, choices about which state to practice in is driven, for HPSA-related programs, to areas of most need, and not necessarily the first choice states of physicians who have no constraints whatsoever. Still, physicians in HPSA areas still regard Mississippi a great place to practice, just not at the same rate as their non-HPSA counterparts. A greater percentage of HPSA physicians were ambivalent or disagreed with MIGMH Report #1 July 31, 2009

Page 57

the statement that they were respected by their communities. Survey data do not permit determination of why this pattern of difference occurs, but it may be related to feeling like outsiders in places that are dissimilar to the original background of the physician. Since many providers in HPSA areas are “outsiders” (individuals from other states or countries) at least for their first years of practice, this may contribute to feelings that they are not as respected as they could be in their practice communities. Table 5.13. Community Perspectives, by HPSA/non‐HPSA Practice Location

Cost of living in a community is an important consideration for where I want to work. Mississippi taxes are a burden.†

HPSA Non‐ HPSA HPSA Non‐ HPSA

Strongly Agree

Agree


Disagree

Strongly Disagree

Sig.

7%

56%

23%

15%

0%

0.26

11%

56%

18%

13%

3%

12%

27%

36%

21%

5%

8%

29%

33%

25%

5%

People from elsewhere don't realize Mississippi is a great place to live.*

HPSA Non‐ HPSA

20%

60%

15%

4%

2%

30%

57%

12%

2%

0%

I feel a sense of belonging to the community where I practice.

HPSA Non‐ HPSA

25%

57%

8%

11%

0%

25%

53%

14%

7%

1%

HPSA

9%

45%

21%

23%

3%

Non‐ HPSA

14%

58%

19%

7%

2%

I do not feel at home in the community where I practice.†

HPSA Non‐ HPSA

1%

11%

9%

53%

26%

2%

9%

13%

50%

28%

Practicing medicine in Mississippi is not much different from practicing in other states.

HPSA Non‐ HPSA

2%

32%

29%

29%

8%

5%

36%

24%

27%

8%

I feel respected by the community where I practice.*

HPSA Non‐ HPSA

24%

59%

9%

8%

0%

23%

64%

12%

2%

1%

I am proud to practice medicine in Mississippi.

HPSA Non‐ HPSA

22%

58%

17%

2%

1%

33%

48%

17%

2%

1%

Local amenities, like parks, shopping, and cultural events, are important in deciding where I want to work and live.*

0.60

0.03

0.21

0.00

0.77

0.70

0.01

0.29



Page 58

Summary As was the case for the rural/urban physician comparison, comparing physicians who work in underserved areas with those who do not shows that there is a large “common denominator” of shared physician experiences, independent of the influences of place. However, there are important distinctions between physicians in underserved locations and their counterparts who serve in more generously resourced areas. These differences include differences in hours of work and number of patients seen (not surprising given the underserved character of HPSA locales), sources of patient insurance, rates of malpractice suits brought against them, differences in their relationships with other physicians, and a varying sense of embeddedness within their communities of practice. Some of these differences are likely rooted in differences associated with place—that is, the way the character of the communities they serve shape physicians practice experiences. However, others of these differences may be associated with characteristics of physicians themselves, the focus of the second report in this series.


Page 59

SECTION 6

CONCLUSION AND IMPLICATIONS Using a combination of survey data, census data and Mississippi State Board of Medical Licensure data, we analyzed physicians’ perceptions concerning patient characteristics, practice characteristics, concerns about malpractice, relationships with both patients and physician colleagues, and measures of autonomy, satisfaction and work-life balance, including connections to the community. These items were compared for physicians in urban practices to those working in rural practices and also for those in Health Professional Shortage Areas (HPSAs) and those practicing in areas that are not official health shortage areas. Comparing rural and urban physicians, we find that rural doctors are more likely to report being sued recently (even after tort reform) and (likely related to being sued more frequently) also report more frequently practicing defensive medicine. Although rural physicians are unique from their urban counterparts in terms of some measures of work-life balance and quality of professional relationships, urban and rural physicians in Mississippi have similar perceptions about patient relationships, concerns about recruiting physicians, resource availability and autonomy. Rural physicians do have a larger Medicare and Medicaid patient base compared to urban physicians, with rural physicians serving a greater proportion of elderly and poor patients. And, perhaps as obviously, urban physicians are more likely to value research opportunities while rural physicians are more likely to value their position as community role models. For comparisons between physicians working in a HPSA-designated county compared to those who do not, a different set of divergences emerge (compared to the differences the analysis demonstrated between urban and rural physicians). HPSA physicians treat an average of 121 patients per week, while non-HPSA practitioners treat about 89 patients per week. Further, HPSA physicians treat more publicly insured patients (Medicare and Medicaid) than physicians who practice in areas that are not officially labeled as shortage areas. Non-HPSA providers are more likely than providers in underserved areas to recommend their community to future physicians. MIGMH Report #1 July 31, 2009

Page 60

Non-HPSA providers also report having better professional relationships with other physicians compared to physicians in HPSAs. However, the most frequently cited source of physician satisfaction, no matter whether a physician practiced in an underserved area or a community with more resources, was having high quality patient relationships. The findings in this report lay the groundwork to better understand physicians’ experiences when they are practicing in rural areas and in health professional shortage areas. In these instances, physicians can be more removed from their colleagues, which have some consequences for career satisfaction. As health care demands continue to rise, especially with the possible advent of a health insurance mandate, pressures on rural physicians and those providing care in HPSA, identified in this research, might increase. Patterns of difference and similarity identified in this research may apply to other rural and underserved areas throughout the US. In conjunction with the two forthcoming reports (analyses of (1) physician characteristics, including race, as they relate to health care provider experiences and (2) interactions between race and place experienced by Mississippi physicians) the findings presented here have implications for stakeholders in Mississippi health care and beyond. At the very least, the findings we document provide fodder for a serious conversation about how to address some of the problem areas of health care delivery for physicians who serve vulnerable populations in Mississippi. Obvious implications include the possibility of more appropriately tailored policy and program measures to enhance the health care experiences of physicians practicing in rural and underserved areas.


Page 61


SECTION 7

REFERENCES Auchincloss, A.H. and W. Hadden. 2002. “The health effects of rural urban residence and concentrated poverty.” Journal of Rural Health 18:319-336. Agency for Healthcare Research and Quality (AHRQ). 2004. AHRQ Annual Report on Research and Financial Management. Rockville, MD: USDHHS. Association of American Medical Colleges (AAMC). 2007. 2007 State Physician Workforce Data Book. Baer, L.D., T.C. Ricketts, T.R. Konrad, and S.S. Mick. 1998. “Do International Medical Graduates Reduce Rural Physician Shortages?” Medical Care 36(11):1534-1544. Bennett, Kevin J., Bankole Olatosi, and Janice C. Probst. 2008. Health Disparities: A Rural-Urban Chartbook. Columbia, SC: South Carolina Rural Health Research Center. Butts, C.C. and J.S. Cossman. 2008. Where’s the Primary Care for Children? A Spatial Analysis of Mississippi Pediatricians. http://nemsahec.msstate.edu/publications/healthmaps/peds.pdf Butts, C.C., J.S. Cossman and E. Welford. 2008. Where’s the Primary Care? A Spatial Analysis of Mississippi Generalists. http://nemsahec.msstate.edu/publications/healthmaps/generalist.pdf Centers for Disease Control and Prevention. 2005. “Health disparities experienced by black or African Americans-United States.” Morbidity and Mortality Weekly Review 54(01):1-3.


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Cossman, J.S. 2003. Mississippi’s Physician Labor Force: Current Status and Future Concerns. http://www.healthpolicy.msstate.edu/publications/laborforcereport.pdf Cooper, J. 2008. Towards Better Behavioral Health for Children, Youth and their Families: Financing that Supports Knowledge. New York City, NY: Columbia University, Mailman School of Public Health, National Center for Children in Poverty. Downloaded July 31, 2009 http://www.nccp.org/publications/pdf/text_804.pdf Crowley, J.S., D. Ashner and L. Elam. 2005. State Medicaid Outpatient Prescription Drug Policies: Findings from a National Survey, 2005 Update. Kaiser Commission on Medicaid and the Uninsured. Available at http://www.kff.org/medicaid/upload/State-Medicaid-Outpatient-PrescriptionDrug-Policies-Findings-from-a-National-Survey-2005-Update-report.pdf Families USA. 2000. Seniors’ Prescription Drug Bills Projected to More Than Double in the Next 10 Years. Washington, D.C. Downloaded July 31, 2009 http://www.familiesusa.org/resources/ newsroom/press-releases/2000press-releases/press-release-seniors-prescription-drug-bills-projected-tomore-than-double-in-the-next-1o-year.html Institute of Medicine [IOM] Smedley, B. D., A. Y. Stith, A. R. Nelson, and eds. 2003. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, D.C.: National Academy of Press. Jones, C. A., W. Kandel and T. Parker. 2007. “Population Dynamics are Changing the Profile of Rural America.” Amber Waves 5(2). Washington, D.C.: U.S. Department of Agriculture, Economic Research Service. Link, B.J. and J. Phelan. 2005. “Fundamental Sources of Health Disparities.” pp.71-84 in Policy Challenges in Modern Health Care, edited by D. Mechanic. Rutgers University Press. -----. 1995. “Social Conditions as Fundamental Causes of Disease.” Journal of Health and Social Behavior 36(extra issue):80-94. Linzer, M., M.R. Visser, F.J. Oort, E.M. Smets, J.E. McMurray, and H.C. de Haes. 2001. “Predicting and preventing physician burnout: results from the United States and the Netherlands.” American Journal of Medicine 111(2):170-175.


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National Advisory Committee on Rural Health and Human Services [NACRHHS]. 2009. The 2009 Report to the Secretary: Rural Health and Human Services Issues. Rockville, MD: USDHHS, Office of Rural Health Policy, HRSA. -----. 2008. Report to the DHHS Secretary. Rockville, MD: USDHHS, Office of Rural Health Policy, HRSA. Rabinowitz, H. K., J. J. Diamond, F. W. Markham and J.R. Wortman. 2008. “Medical School Programs to Increase the Rural Physician Supply: A Systematic Review and Projected Impact of Widespread Replication.” Academic Medicine 83(3):235-243. Washington, D.C.: American Association of Medical Colleges. Rosenthal, T.C. and C. Fox. 2000. “Access to Health Care for the Rural Elderly.” JAMA 284:2034-2036. Shi, L., M.E. Samuels, T.C. Ricketts and T.R. Konrad. 1994. “A Rural-Urban Comparative Study of Nonphysician Providers in Community and Migrant Health Centers.” Public Health Reports 109(6):809-815. Slama, K. 2004. “Rural Culture is a Diversity Issue.” Minnesota Psychologist January:9-13. United Health Foundation. 2008. America’s Health Rankings. Downloaded July 15, 2009 http://www.americashealthrankings.org/2008/getreport.html U.S. Census Bureau. 2008. Mississippi Quick Facts. Washington, D.C.: U.S. Census Bureau. Retrieved July 27, 2009 (http://quickfacts.census.gov/qfd/states/28000.html) Williams, D.R. and C. Collins. 1999. “U.S. Socioeconomic and Racial Differences in Health: Patterns and Explanations.” Pp. 349-377 in Health, Illness and Healing: Society, Social Context and Self, An Anthology eds. Kathy Charmaz and Debora A. Paterniti. Los Angeles, CA: Roxbury Publishing. Williams, D.R. and P.B. Jackson. 2005. “Social sources of racial disparities in health.” Health Affairs 24(2):325-34.


Page 64

Appendix A. Mississippi Counties, by Rural and HPSA designation County Adams County Alcorn County Amite County Attala County Benton County Bolivar County Calhoun County Carroll County Chickasaw County Choctaw County Claiborne County Clarke County Clay County Coahoma County Copiah County Covington County DeSoto County Forrest County Franklin County George County Greene County Grenada County Hancock County Harrison County Hinds County Holmes County Humphreys County Issaquena County Itawamba County Jackson County Jasper County Jefferson County Jefferson Davis County Jones County Kemper County Lafayette County Lamar County Lauderdale County Lawrence County Leake County Lee County


Rural

HPSA

X X X X X X X X X X X X X X

X X

X X X

X

X X X

X X X X X X X

X X X X X X X X X X X X X X

X X

X X X

X

County Leflore County Lincoln County Lowndes County Madison County Marion County Marshall County Monroe County Montgomery County Neshoba County Newton County Noxubee County Oktibbeha County Panola County Pearl River County Perry County Pike County Pontotoc County Prentiss County Quitman County Rankin County Scott County Sharkey County Simpson County Smith County Stone County Sunflower County Tallahatchie County Tate County Tippah County Tishomingo County Tunica County Union County Walthall County Warren County Washington County Wayne County Webster County Wilkinson County Winston County Yalobusha County Yazoo County

Rural X X X

HPSA X X X

X X X X X X X X X

X

X X X X

X X

X

X X X X X X X X X X X X X X X X X X X X

X X

Page 65

Appendix B 2007/08 MSMD Survey


Page 66

The 2007 MSMD Survey A survey on physician workforce, worklife, recruitment & retention.

To complete the survey on-line, you may proceed to www.ssrc.msstate.edu/2007MSMD, which has a link to the survey or go directly to https://snaponline.snapsurveys.com/siam/surveylanding/surveylogin.asp?k=116923170264. This survey was funded by the Mississippi Physician Care Network, the Mississippi and American Academies of Family Physicians and the Social Science Research Center at Mississippi State University.

1

Welcome to the 2007 MSMD. Please write your User ID (Mississippi physician license number) to begin the survey. 1.

Mississippi Physician License Number This number is critical to track of response rates

All information you provide for the 2007 MSMD survey is strictly confidential and will be used only for research purposes. Your responses will only be released as aggregated data for the purpose of analysis and reporting. No data will be released that will permit the identification of any individual or individual characteristics. Once your data is entered in the 2007 MSMD database, the license number used to track responses is removed and replaced by an anonymous case ID number, de-identifying data received from study participants. We understand how important your privacy is and we safeguard it carefully. Your participation is important for the quality of the study. If you have questions about the 2007 MSMD study, you can contact Dr. Jeralynn Cossman at Mississippi State University (662-325-3791, [email protected]). The Institutional Review Board at Mississippi State University reviewed this study protocol. If you have any questions about your rights as a participant in a research project, you should contact the MSU Institutional Review Board at 662-325-3294. We know how valuable your time is and we appreciate your participation in this important research. Your participation is entirely voluntary and you may stop answering questions or withdraw from the survey at any time. There are no known risks for participating in this study. Completing the 2007 MSMD survey indicates that you understand the information you just read about the study and have consented to participate. We have adapted this paper survey from an internet version, consequently some questions are skipped in this version of the survey. Throughout the survey, we use terms like “community” and “primary practice.” Please consider your “community” to be the area from which you draw your practice base. If you practice in a larger city, you might even consider your specific part of town. For your “primary practice” location or setting, please consider that as the place where you spend the most time and/or see the most patients. For some questions, we are asking your best estimate for the state as a whole; for others, thinking more specifically about your community is what we want to know. For some of the items in the survey, you may not know the answer (DK) or the item may not be applicable (NA) to your circumstances. In those instances, please check the NA/DK box. And remember, if there are items that you prefer not to answer at all, you can skip those items entirely-although we hope you will agree to answer most of the questions. 2

DIRECT PATIENT CARE Not all physicians licensed in Mississippi are currently providing direct patient care. In this first series of questions, we would like to find out whether you currently provide direct patient care in Mississippi or have done so in the past. 2.

Do you currently provide direct patient care in Mississippi? ‰ Yes, full-time (31 hours or more per week) (Please skip to Question 10 on page 4) ‰ Yes, part-time (at least 1 hour but no more than 30 hours per week) (Please skip to Question 10 on page 4) ‰ No (Not at all, or less than 1 hour per week)

3.

Do you currently practice medicine in Mississippi, but not direct patient care? ‰ Yes ‰ No (Please skip to Question 5 below)

4.

Please describe the nature of your practice.

5.

Did you ever provide direct patient care on a regular basis in Mississippi, excluding occasional emergencies? ‰ Yes ‰ No, never (Please skip to Question 148 on Page 33)

6.

When did you last provide direct patient care in Mississippi on a regular basis?

7.

Why did you stop providing direct patient care in Mississippi?

8.

Would you ever consider providing direct patient care in Mississippi again? ‰ Yes ‰ No

9.

Please briefly explain why or why not.

[four digit year]

3

EFFECTS OF HURRICANE KATRINA ON PHYSICIAN PRACTICES When Hurricane Katrina hit the Gulf Coast, many individuals and businesses were displaced by the storm. We are interested in knowing about experiences in your primary practice in the aftermath of the storm. There are no right or wrong answers to these questions. Your responses will likely be influenced by where in the state you were practicing medicine when Katrina hit. 10.

How was your practice affected by Hurricane Katrina? (NA/DK=not applicable, don't know) Yes No NA/DK Did your practice have an influx of patients displaced by Katrina? ‰ ‰ ‰ ‰ ‰ ‰ Did your practice lose existing patients due to Katrina? ‰ ‰ ‰ Did your practice provide more uncompensated care post-Katrina? ‰ ‰ ‰ Did your practice temporarily add a displaced physician? ‰ ‰ ‰ Did you temporarily work in another practice, hospital or clinic? ‰ ‰ ‰ Did your patients lose private health insurance due to the storm? ‰ ‰ ‰ Were patient medical records destroyed? ‰ ‰ ‰ Were patient prescription records destroyed?

11.

Were you considered a first responder when Katrina hit in 2005? (check one) ‰ Yes ‰ No ‰ NA/DK

12.

Was your primary practice located in a county that was designated a FEMA disaster area after Katrina? (check one) ‰ Yes ‰ No (Please skip to Question 20 on page 5) ‰ NA/DK (Please skip to Question 21 on page 5)

13.

Which of the following describes what you did regarding your primary practice in the immediate aftermath of the storm? (check one) ‰ I never left. ‰ I left and have now returned to permanent practice in the area. ‰ I left and plan to return to practice in the area in the future. (Please skip to Question 16 on page 5) ‰ I left and I have no plans to return to practice in the area. (Please skip to Question 19 on page 5)

14. What percent of your patient base was in the area: One month post-Katrina? % One year post-Katrina? % 4

15.

Please describe the immediate unmet needs for health care providers in the area where you were in primary practice.

Please skip to Question 21 on page 6. 16.

What have you done in the meantime since being displayed by Katrina?

17.

If you have not yet done so, when do you plan to return permanently to that area?

18.

What remains to be done before your permanent return?

19.

If you have not returned, what have you done instead of practicing in your original pre-hurricane community?

Please skip to Question 21 on page 6.

20.

In the immediate aftermath of Katrina (within one month) did you leave your usual primary practice location to provide short term help in Katrina-affected areas? (check one) ‰ Yes ‰ No ‰ NA/DK 5

PRACTICE AND PATIENT ISSUES We’re shifting gears a bit now, away from the focus on last year’s disaster to more general information about Mississippi’s health care environment for physicians. 21.

In what year did you begin practicing medicine in Mississippi?

[four digit year]

22.

Excluding problems related to Hurricane Katrina, what would you say are the biggest challenges or most important issues that Mississippi physicians face right now? 1.

2.

3.

We are also interested in how your own medical practice is organized. 23. Please fill in the number for each type of health care provider in your primary practice setting, including yourself. Primary Care Physicians Specialist Physicians Nurse practitioners Registered nurses Other nurses (LPNs, RLPNs) Dieticians/Nutritionists Psychologists Occupational therapists Other (please specify"other")

6

24.

Which of the following best describes your primary practice’s use of electronic medical records for at least some patient record keeping? (check only one) ‰ I (we) already use electronic medical records. ‰ Plans are well along for implementation of electronic medical records. ‰ I (we) have no plans to use electronic medical records at this time. ‰ I (we) would like to use electronic medical records if resources were available. ‰ I (we) need more information to decide if electronic medical records are right for the practice.

25.

Do you, personally, use a computer or computer-like device for… Yes Receiving lab results, x-rays, hospital records ‰ ‰ Updating electronic medical records ‰ Looking up information about treatment alternatives ‰ Sending prescriptions to pharmacies ‰ Communication with patients ‰ Taking courses for CME credits ‰ Providing care via telemedicine ‰ Other (please specify "other")

No ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

NA/DK ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

For the following items, please select the answer that best reflects your own experiences with patients in your primary practice setting. 26.

Please estimate the number of patients you personally see in your primary practice setting in an average week, excluding patients seen while on call. Approximately: patients per week

27.

Please describe the dominant patient population you served in your primary practice setting. (check all that apply) ‰ Inner city ‰ Urban/suburban ‰ Small town ‰ Rural ‰ Geographically isolated/remote ‰ Other (please specify "other")

7

28.

Thinking about the patients you see in your primary practice, please indicate the best response for each of the following statements. (NA/DK=not applicable, don’t know) I have enough time to spend with patients during a typical office visit. I have the freedom to make clinical decisions that meet my patients’ needs. It is possible to provide high quality care to all of my patients. I can make clinical decisions in my patients’ best interests without reducing my income. The level of communication I have with specialists about the patients I refer to them is sufficient to ensure the delivery of high quality care. The level of communication I have with primary care physicians about the patients they refer to me is sufficient to ensure the delivery of high quality care. It is possible to maintain the kind of continuing relationships with patients over time that promote the delivery of high quality care.

Strongly Agree

Agree


Disagree

Strongly Disagree

NA/DK

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰ ‰

‰ ‰

‰ ‰

‰ ‰

‰ ‰

‰ ‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

‰

29.

What percent of your patients…..(note: these do not need to sum to 100%) have complex or numerous medical problems? % % have complex or numerous psycho-social problems? % have substance abuse problems? % are generally frustrating to deal with?

30.

In your own capacity to accept new patients (not including your partners or other physicians in your practice), do you accept ANY new patients at all? ‰ Yes ‰ No (Please skip to Question 32 on page 9) ‰ NA/DK (Please skip to Question 32 on page 9)

8

31.

In your own capacity to accept new patients, do you accept: New patients with specific medical problems New patients with limited medical problems New referrals from other physicians Family members of current patients Friends of current patients New Medicaid patients New Medicare patients Patients from other public programs (like SCHIP or VA) New uninsured patients

32.

Yes ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

No ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

NA/DK ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

How would you assess the general availability of health care services in Mississippi, other than the services you provide? Is your opinion that the quantity and quality of services and professionals listed below are sufficient or insufficient at the state level for Mississippi residents? (Check the best answer for each) Sufficient Insufficient NA/DK Primary care physicians ‰ ‰ ‰ ‰ ‰ ‰ Specialist physicians ‰ ‰ ‰ Psychiatrists ‰ ‰ ‰ OB/GYNs ‰ ‰ ‰ Orthopedic surgeons ‰ ‰ ‰ Women physicians for patients who prefer them ‰ ‰ ‰ Minority physicians for patients who prefer them ‰ ‰ ‰ Family physicians accepting new patients ‰ ‰ ‰ Anesthesia services ‰ ‰ ‰ Emergency room services ‰ ‰ ‰ Non-emergency hospital admissions ‰ ‰ ‰ Hospital bed availability ‰ ‰ ‰ Diagnostic services ‰ ‰ ‰ Physiotherapy services ‰ ‰ ‰ Occupational therapy services ‰ ‰ ‰ Long-term care bed availability ‰ ‰ ‰ Community nursing services ‰ ‰ ‰ In-patient mental health care ‰ ‰ ‰ Out-patient mental health services ‰ ‰ ‰ Health care in patient’s language 9

33.

In the last 12 months, have any of the following conditions changed for patients in your community? How far patients travel for primary care How far patients travel for specialty care How far patients travel for surgical procedures Waiting times for patient appointments Waiting times in the emergency room Waiting times for specialist referrals Interruptions in continuity of primary care Loss of health insurance coverage

Large Increase

Small Increase

No Change

Small Decrease

Large Decrease

NA/DK

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

For each item above that you indicated changed in Question 33, please indicate the main reason for the change. 34. If you indicated there had been a change in how far patients travel for primary care in your community over the past 12 months, what was the primary reason for this change? ‰ Hurricane aftermath ‰ Physician supply ‰ Malpractice issues ‰ Other (Please specify): 35. If you indicated there had been a change in how far patients travel for specialty care in your community over the past 12 months, what was the primary reason for this change? ‰ Hurricane aftermath ‰ Physician supply ‰ Malpractice issues ‰ Other (Please specify): 36. If you indicated there had been a change in how far patients travel for surgical procedures in your community over the past 12 months, what was the primary reason for this change? ‰ Hurricane aftermath ‰ Physician supply ‰ Malpractice issues ‰ Other (Please specify): 37. If you indicated there had been a change in waiting times for patient appointments in your community over the past 12 months, what was the primary reason for this change? ‰ Hurricane aftermath ‰ Physician supply ‰ Malpractice issues ‰ Other (Please specify): 10

38.

If you indicated there had been a change in waiting times in the emergency room in your community over the past 12 months, what was the primary reason for this change? ‰ Hurricane aftermath ‰ Physician supply ‰ Malpractice issues ‰ Other (Please specify):

39.

If you indicated there had been a change in waiting times for specialist referrals in your community over the past 12 months, what was the primary reason for this change? ‰ Hurricane aftermath ‰ Physician supply ‰ Malpractice issues ‰ Other (Please specify):

40.

If you indicated there had been interruptions in continuity of primary care in your community over the past 12 months, what was the primary reason for this change? ‰ Hurricane aftermath ‰ Physician supply ‰ Malpractice issues ‰ Other (Please specify):

41.

If you indicated there had been loss of health insurance coverage in your community over the past 12 months, what was the primary reason for this change? ‰ Hurricane aftermath ‰ Physician supply ‰ Malpractice issues ‰ Other (Please specify):

11

For the next questions, we are not asking about your own practice, but rather about your opinion of patients’ experiences with the Mississippi health care system in general. Based on your own impressions, please indicate whether it is harder for some Mississippians to get health care than others. 42.

How often would you say a patient’s ability to get routine medical care when needed is limited when the patient is: Often Sometimes Rarely/Never NA/DK ...a man? ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ...a woman? ‰ ‰ ‰ ‰ ...a race/ethnic minority individual? ‰ ‰ ‰ ‰ ...a poor person? ‰ ‰ ‰ ‰ ...a low income person (but not "poor")?

43.

How often would you say that a patient’s ability to get specialized treatment or services is limited when the patient is: Often Sometimes Rarely/Never NA/DK ...a man? ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ...a woman? ‰ ‰ ‰ ‰ ...a race/ethnic minority individual? ‰ ‰ ‰ ‰ ...a poor person? ‰ ‰ ‰ ‰ ...a low income person (but not "poor")?

44.

How often would you say that a patient lacks any kind of health insurance to pay for medical care if the patient is: Often Sometimes Rarely/Never NA/DK ‰ ‰ ‰ ‰ ...a man? ‰ ‰ ‰ ‰ ...a woman? ‰ ‰ ‰ ‰ ...a race/ethnic minority individual? ‰ ‰ ‰ ‰ ...a poor person? ‰ ‰ ‰ ‰ ...a low income person (but not "poor")?

45.

Please do your best to estimate what percentage of patients in your own primary practice use each of the following forms of payment for health care you provide (estimate should total 100%) Medicare % Medicaid % Child Health Insurance (SCHIP) % Private health insurance % Self-pay/Cash % Charity/uncompensated care % Other (please specify ) % Total 100 % 12

47.

Do you have any special concerns regarding accepting or treating patients whose care is paid by Medicare?

48.

Do you have any special concerns regarding accepting or treating patients whose care is paid by Mississippi Medicaid?

CHANGES IN PRACTICE Conditions for physicians practicing in Mississippi can sometimes change very quickly. The next series of questions seeks information on how your primary practice setting may have changed in recent years. 49.

How long have you been providing care in your current primary practice setting?

years

50.

During the past two years, have you made any major changes to your practice, such as moving your practice location, changing specialty, changing the scope of your practice, changing your work hours, or retiring? ‰ Yes ‰ No (Please skip to Question 65 on page 15) ‰ DK/NA (Please skip to Question 65 on page 15)

13

51.

During the past two years, have you made any of the following major changes to your practice? Yes No I moved to the US from another country. ‰ ‰ ‰ ‰ I moved to MS from another state. ‰ ‰ I relocated within MS. ‰ ‰ I changed specialty. ‰ ‰ I narrowed work within my specialty. ‰ ‰ I reduced my scope of practice (e.g. stopped OB or surgical procedures). ‰ ‰ I expanded my scope of practice (e.g. added OB or surgical procedures). ‰ ‰ I reduced my work hours. ‰ ‰ I increased my work hours. ‰ ‰ I changed discipline or retrained. ‰ ‰ I changed practice settings. ‰ ‰ I retired. ‰ ‰ I made another major change in my practice.

52.

If during the past two years, you made at least one of the major changes listed in the question you just answered, what was the most important reason for the change? ‰ Better practice environment ‰ More professional opportunities ‰ Opportunities for higher income ‰ Lower professional liability insurance rates ‰ Better medical malpractice climate ‰ Minimize malpractice risk ‰ Losses associated with hurricane ‰ Mid-career adjustment ‰ Personal/family issues ‰ Other (please specify) ‰ DK/NA

14

65.

During the next two years, do you plan to make any major changes to your practice, such as moving your practice location, changing specialty, changing the scope of your practice, changing your work hours, or retiring? ‰ Yes ‰ No (Please skip to Question 80 on Page 16) ‰ DK/NA (Please skip to Question 80 on Page 16)

66.

For each of the items listed below, please indicate whether you plan to make such a change in the next two years. Yes No ‰ ‰ I plan to relocate from the US to another country. ‰ ‰ I plan to relocate from MS to another state. ‰ ‰ I plan to relocate my practice within MS. ‰ ‰ I plan to change my specialty. ‰ ‰ I plan to narrow work within my specialty. ‰ ‰ I plan to reduce my scope of practice (e.g. stop OB or surgical procedures). ‰ ‰ I plan to expand my scope of practice (e.g. add OB or surgical procedures). ‰ ‰ I plan to reduce my work hours. ‰ ‰ I plan to increase my work hours. ‰ ‰ I plan to change disciplines or retrain. ‰ ‰ I plan to change practice settings. ‰ ‰ I plan to retire. ‰ ‰ I plan to make another major change.

67.

During the next two years, if you plan to make a major change to your practice, what would be the most important reason for this planned change? ‰ Better practice environment ‰ More professional opportunities ‰ Opportunities for higher income ‰ Lower professional liability insurance rates ‰ Better medical malpractice climate ‰ Minimize malpractice risk ‰ Losses associated with hurricane ‰ Mid-career adjustment ‰ Personal/family issues ‰ Other (please specify) ‰ DK/NA 15

TIME ALLOCATION/SCOPE OF WORK For the following items, please give your best estimate about how you spend practice time and tasks you perform in the course of your professional duties. When we refer to on-call, we mean time outside of regularly scheduled clinical activity during which you are available to patients.

80.

In a typical year, how many weeks do you spend on each of the following: Providing clinical services Away from practice for CME purposes On vacation Other (please specify ) Total

52

weeks weeks weeks weeks weeks

82.

In a typical week, about how many hours do you spend on professional activities, not including on-call time?

83.

In a typical week, excluding call, about what percentage of your work time is spend on each of the following?

hrs/wk

Providing primary care to patients Providing specialty care to patients Management of practice Utilization review Legal consultation Other (please specify ) 85.

Do you participate in on-call activities? ‰ Yes ‰ No (Skip to Question 89 on Page 17)

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86.

Do your on-call activities involve the following: obstetrical call? Surgical call? neurosurgery call? on-call for hospital patients? on-call for non-hospitalized patients, phone only? on-call for non-hospitalized patients, phone and in person? emergency room call? other? (please specify )

Yes ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

87.

Estimate your average number of on-call hours in a typical month.

88.

Average on-call hours in a typical month requiring direct patient care.

No ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ hours/month hours/month

PERSONAL/FAMILY LIFE The research literature on the professions shows that most physicians work hard to maintain a work/life balance that feels right for them. The items in this section of the survey ask for your impressions relating to work/life balance. There are no right or wrong answers; please select the most appropriate answer for you. 89.

Please choose the single item that most closely represents how you feel. (check one) ‰ I enjoy my work. I do not feel burned out. ‰ Occasionally I am under stress, and I don’t always have as much energy as I once did. But, I don’t feel burned out. ‰ I am definitely burning out and have one or more symptoms of burnout, such as physical or emotional exhaustion. ‰ The symptoms of burnout that I’m experiencing won’t go away. I think about frustrations at work a lot. ‰ I feel completely burned out and often wonder if I can go on. I am at the point where I may need to make some changes or may need to seek some sort of help.

90.

Do you have any minor dependents or children for whom you provide direct personal care or supervision? (check one) ‰ Yes ‰ No (Skip to Question 92 on Page 18) ‰ NA/DK (Skip to Question 92 on Page 18)

91.

To how many minor dependents or children do you provide care?

children under 18 years of age. 17

92.

Do you provide direct personal care or supervision for any adults, such as adult disabled children or elderly parents? (check one) ‰ Yes ‰ No (Skip to Question 94 below) ‰ NA/DK (Skip to Question 94 below)

93.

To how many adults do you provide care?

94.

If you had one choice, what would you say about the balance of your personal and professional commitments? Would you say the balance is… (check one) ‰ About right ‰ Need more time for family ‰ Need more time for career ‰ Need more time for self

adults who need care.

PROFESSIONAL SATISFACTION AND PERCEPTIONS 95.

Please rank these sources of professional satisfaction, from 1 (most important) to 4 (least important). Please use each rank only once. High income Substantial intellectual challenge Good patient relationships Congenial practice environment

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96. PRACTICE RELATIONSHIPS Professionals like you have a wide range of experiences relating to practice, professional satisfaction and community relationships. There are no right or wrong responses. Simply select the responses ranging from strongly agree to strongly disagree that are most appropriate for you and your unique experiences. (NA/DK=not applicable, don’t know) Strongly Agree Neither Agree Disagree Strongly NA/DK Agree or Disagree Disagree I feel a strong personal connection to my patients. ‰ ‰ ‰ ‰ ‰ ‰ Non-physicians in my practice support my professional judgment. ‰ ‰ ‰ ‰ ‰ ‰ I often feel like what I do for my patients is just a drop in the bucket. ‰ ‰ ‰ ‰ ‰ ‰ My physician colleagues are a source of professional stimulation. ‰ ‰ ‰ ‰ ‰ ‰ Many patients demand potentially unnecessary treatments. ‰ ‰ ‰ ‰ ‰ ‰ I get along well with my physician colleagues. ‰ ‰ ‰ ‰ ‰ ‰ My non-physician colleagues are a major source of support. ‰ ‰ ‰ ‰ ‰ ‰ Time pressures keep me from developing good patient relationships. ‰ ‰ ‰ ‰ ‰ ‰ My physician colleagues value my unique perspective in practice. ‰ ‰ ‰ ‰ ‰ ‰ I am overwhelmed by the needs of my patients. ‰ ‰ ‰ ‰ ‰ ‰ My physician colleagues are an important source of personal support. ‰ ‰ ‰ ‰ ‰ ‰ My relationship with patients is more adversarial than it used to be. ‰ ‰ ‰ ‰ ‰ ‰ It is easy to communicate with physicians with whom I share patients. ‰ ‰ ‰ ‰ ‰ ‰ Many of my colleagues do not share my life experiences. ‰ ‰ ‰ ‰ ‰ ‰ I am having a positive impact on a socio-economically disadvantaged population. ‰ ‰ ‰ ‰ ‰ ‰ I wish there were more doctors like me in my practice. ‰ ‰ ‰ ‰ ‰ ‰ My colleagues support my efforts to balance family and career responsibilities. ‰ ‰ ‰ ‰ ‰ ‰ Non-physicians in my practice reliably carry out clinical instructions. ‰ ‰ ‰ ‰ ‰ ‰ I am isolated from my patients because of ethnic, cultural or gender differences. ‰ ‰ ‰ ‰ ‰ ‰

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97. AUTONOMY AND PRESTIGE

I am able to set the pace of my own work. I need to work in an area where I have research opportunities. I find my present clinical work personally rewarding. In my practice, it often feels like bureaucrats are second-guessing me. The responsibility of being a role model for others is a burden. Clinical guidelines restrict my freedom to practice. Recognition of the importance of my work and my profession is critical. I am isolated from my colleagues because of ethnic, cultural or gender differences. I can keep patients in the hospital as long as is medically necessary. I am not well-compensated, given my training and experience. Formularies or prescription limits restrict the quality of care I can provide. Career advancement opportunities are available to me in the same ways as they are available to colleagues. I am well-compensated compared to physicians in other specialties. Outside reviewers rarely question my professional judgments. All things considered, I am satisfied with my career as a physician. I would recommend medicine to others as a career. My specialty no longer has the appeal to me it used to have. If I were to choose over again, I would not become a physician. My specialty does not provide the security it once did. In general, practice in my specialty has met my expectations.

Strongly Agree ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

Agree

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Neither Agree Disagree Strongly NA/DK or Disagree Disagree ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

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98.

FAMILY AND COMMUNITY

Cost of living in a community is an important consideration for where I want to work. My family and I are strongly connected to the community where I work. Mississippi taxes are a burden. People from elsewhere don’t realize Mississippi is a great place to live. I feel a sense of belonging to the community where I practice. My work schedule leaves me enough time for my family. Local amenities, like parks, shopping, and cultural events, are important in deciding where I want to work and live. The interruption of my personal life by work is a problem. I do not feel at home in the community where I practice. Living in close proximity to parents and/or extended family is important to me. Practicing medicine in Mississippi is not much different from practicing in other states. I feel respected by the community where I practice. My spouse (or partner) supports my career. Work rarely encroaches on my personal time. High quality schools are important in deciding where I want to work and live. I am proud to practice medicine in Mississippi.

Strongly Agree ‰

Agree

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99.

PRACTICE CONDITIONS

My practice has adequate resources for me to do my work. Paperwork required by payers is a burden to me. Medical supplies are not always available when I need them. I have enough exam space to see my patients. My total compensation package is not adequate. Competition with other physicians is a threat to my financial future. There are too few support staff in my practice. In my opinion, I am expected to take too much call. My work in this practice has met my expectations. I am satisfied with the balance of time I spend on patient care versus administrative tasks.

Strongly Agree ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

Agree ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

Neither Agree Disagree Strongly NA/DK or Disagree Disagree ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

100.

Practicing physicians commonly face pressures related to their medical practices. Please indicate whether or not you have experienced these pressures and whether they have affected your practice. I do not feel pressure I feel pressure, does not I feel pressure, it affect care affects care I feel pressure to see more patients per day. ‰ ‰ ‰ I feel pressure to limit the number of tests I order. ‰ ‰ ‰ I feel pressure to limit referrals to specialists. ‰ ‰ ‰ I feel pressure to limit what I tell patients about treatment options. ‰ ‰ ‰

101.

How much control do you have over each of the following? The physicians to whom you refer patients. When to admit patients to the hospital. Length of patient hospital stays. The specific medications patients receive. Details of your primary practice or clinic schedule. Which diagnostic tests you order. The volume of paperwork you have to do. The hours you work. Volume of your patient load. Pre-authorization for patient services.

None ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

Some ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

Much ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

Complete ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ 22

102.

How likely would you be to recommend to someone graduating from medical school that they practice in... Very Likely Somewhat Likely Not Very Likely I would not recommend ‰ ‰ ‰ ‰ your specialty? ‰ ‰ ‰ ‰ ‰ your community? ‰ Mississippi?

103.

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What is your opinion on giving the general public a performance measure (i.e., a report card) on each of the following elements of the Mississippi health care system? Favor Neutral Oppose Health plans ‰ ‰ ‰ ‰ ‰ ‰ Medical groups/practices ‰ ‰ ‰ Hospitals ‰ ‰ ‰ Individual physicians ‰ ‰ ‰ Other Please specify

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MALPRACTICE ISSUES Medical malpractice is an issue of nearly constant interest for physicians in Mississippi. Until the 2004 professional liability reforms, state and national physician organizations characterized Mississippi as a “crisis state” with respect to medical malpractice litigation and professional liability insurance. Reforms enacted in 2004 were intended to address the Mississippi "medical malpractice crisis." We’re interested in your perceptions about issues related to medical malpractice and professional liability insurance both before and after Mississippi professional liability reform. 104.

First, we have some general questions regarding malpractice concerns. How often (never, seldom, sometimes, often, regularly/daily) do concerns about malpractice liability cause you to… Never, almost Seldom, less than Sometimes, about once a month never, less than once in 6 months once a year

Order more tests than you would based on your professional judgment of what is medically needed? Prescribe more medications, such as antibiotics, than you would based only on your professional judgment of what is medically needed? Refer patients to specialists more often than you would based only on your professional judgment? Suggest invasive procedures, such as biopsies, to confirm diagnoses more often than you would based only on professional judgment? Avoid personally conducting certain procedures or interventions?

Often, at least once a week


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POST-REFORM QUESTIONS 105.

After state professional liability reform to improve the malpractice climate in Mississippi in 2004, did the way you get your primary layer liability insurance change? Remember, this pertains only to the post-reform period. ‰ No it has not changed. (Please skip to Question 107 on page 25) ‰ Yes, my insurance coverage changed. Number times changed since 2004:

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106.

For each change in professional liability insurance carrier or coverage source since 2004, please give a brief description of the change (e.g., "My insurance company stopped writing policies so I found another," "I switched from the state insurance pool to hospital coverage," "I initially self-insured but switched to an insurance carrier," etc.)

107.

The Mississippi legislature reformed professional liability laws in the fall of 2004. Since that time, what typical annual premium changes have you experienced for your professional liability insurance? ‰ Rates decreased ‰ Rates remained about the same ‰ Rates increased less than 25% annually ‰ Rates increased 25% - 50% annually ‰ Rates increased 51% - 100% annually ‰ Rates increased more than 100% annually ‰ NA/DK

108.

In your opinion, did recent reforms addressing medical malpractice and professional liability solve the problems Mississippi physicians had faced during the medical malpractice crisis? ‰ Almost all of them ‰ Some ‰ A few ‰ None ‰ NA/DK

109.

In your opinion, what is the best way to address malpractice issues? Please check the single answer that best reflects your perspective. ‰ Uniform practices across the country, regulated by the federal government ‰ State level regulation ‰ Self-regulation through physicians’ professional associations ‰ System is fine as it is ‰ Other (Please specify )

25

110.

Are you currently covered by professional medical liability insurance? ‰ Yes ‰ No (Please skip to Question 113 below) ‰ NA/DK (Please skip to Question 114 below)

111.

How do you get your primary layer professional liability insurance (first $500,000 of coverage)? ‰ Through a hospital that you are employed by ‰ Through a hospital that you are affiliated with ‰ Directly from an insurance carrier, either individually or though your practice/group ‰ State pool ‰ Self-insured ‰ Other (please specify )

112.

How much of a financial burden is your current professional liability insurance premium? ‰ Not a burden at all (Please skip to Question 114 below) ‰ Minor burden (Please skip to Question 114 below) ‰ Major burden (Please skip to Question 114 below) ‰ Extreme burden (Please skip to Question 114 below)

113.

Why are you not currently covered?

114.

We recognize that being named in a lawsuit does not reflect on the excellence of a physician’s practice. For each year please estimate how many medical/professional lawsuits you were named in relating to your medical practice in Mississippi. (If you practiced in Mississippi and were not named in a lawsuit, enter '0'; if you did not practice in Mississippi, leave blank.) 2004 2005 2006

115.

What was your most recent annual malpractice premium, in dollars?

$

/year

116.

What do you expect to pay for your next annual malpractice premium, in dollars? $

/year 26

117.

Are you a neurosurgeon practicing in Mississippi? ‰ Yes ‰ No (Please skip to Question 119 below).

118.

As a neurosurgeon practicing in Mississippi: Did you ever stop performing brain surgery? Did you ever stop performing spinal surgery? Did you ever stop taking call? Do you currently perform brain surgery? Do you currently perform spinal surgery? Do you currently take call?

119.

Have you ever provided maternity and newborn care? Yes No (Please skip to Question 133 Page 29)

120.

As a provider of maternity/newborn care: Did you ever stop providing maternity care? Did you ever stop providing newborn care? Do you currently provide maternity care? Do you currently provide newborn care?

Yes ‰ ‰ ‰ ‰ ‰ ‰

No ‰ ‰ ‰ ‰ ‰ ‰

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No ‰ ‰ ‰ ‰

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121.

When did you stop delivering babies?

[four digit year]

122.

Please rate the importance of each of the following factors in your decision to stop delivering babies. Not Important Somewhat Important Very Important Lack of backup coverage for C-sections ‰ ‰ ‰ ‰ ‰ ‰ Time demands/personal life ‰ ‰ ‰ Medical liability premiums ‰ ‰ ‰ Experience with lawsuit(s) ‰ ‰ ‰ Lack of demand ‰ ‰ ‰ Low level of reimbursement ‰ ‰ ‰ Lack of interest in continuing this type of care ‰ ‰ ‰ Other (please specify ) 27

123.

Please estimate the number of deliveries in the past 12 months.

124.

Please describe your involvement in maternity and newborn care. Do you provide: Yes No ‰ ‰ Shared care: Provide antenatal care, then make referrals? ‰ ‰ Intrapartum care in addition to prenatal care?

125.

If no, please skip Question 133 on page 29.

Which of the following do you provide? Vacuum extractions Mid-forceps and rotations Low forceps Cesarean section, primary surgeon Cesarean section, assists High-risk pregnancies or deliveries Deliveries to Medicaid beneficiaries

126. 127. 128. 129. 130. 131. 132.

births.

Yes ‰ ‰ ‰ ‰ ‰ ‰ ‰

In the coming 12 months, do you plan to continue providing…… Yes Vacuum extractions ‰ ‰ Mid-forceps and rotations ‰ Low forceps ‰ Cesarean section, primary surgeon ‰ Cesarean section, assists ‰ High-risk pregnancies or deliveries ‰ Deliveries to Medicaid beneficiaries

No ‰ ‰ ‰ ‰ ‰ ‰ ‰

If yes, please answer Question 126 below. If yes, please answer Question 127 below. If yes, please answer Question 128 below. If yes, please answer Question 129 below. If yes, please answer Question 130 below. If yes, please answer Question 131 below. If yes, please answer Question 132 below.

No ‰ ‰ ‰ ‰ ‰ ‰ ‰

NA/DK ‰ ‰ ‰ ‰ ‰ ‰ ‰

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WORKFORCE ISSUES: SUPPLY, RECRUITMENT, RETIREMENT, RETENTION This section is concerned with identifying key issues related to physician workforce recruitment and retention in Mississippi. 133.

The following items concern your perceptions of the practice climate in Mississippi. Please rate, from poor to excellent, each of the items relating to the practice climate in Mississippi. Recruiting new physicians. Retaining experienced physicians. Recruiting minority physicians. Retaining experienced minority physicians. Recruiting women physicians. Retaining experienced women physicians. Medicaid reimbursement rates. Medicare reimbursement rates. Private insurance reimbursement rates. Manageable amount of uncompensated care. Medical malpractice conditions. Availability of liability insurance.

Poor

Fair

Average

Good

Excellent

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134.

How difficult would you say it is to recruit physicians to work in Mississippi? ‰ Easy to recruit ‰ Moderate ‰ Difficult to recruit ‰ NA/DK

135.

In your opinion, what is the single most effective means of recruiting new physicians? ‰ Recruiter ‰ Internet job advertisement/on-line job board ‰ Journal or print ad ‰ Networking/word of mouth ‰ Residency program participants ‰ Other (please specify

)

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136.

Since tort reform in 2004 addressed medical liability, how has the supply of physicians been in your community (too few, just right, too many)? Practicing physicians overall Minority physicians Women physicians Family practitioners Primary care providers General surgeons Neurosurgeons Obstetricians Emergency room doctors Other specialists International medical graduates

137.

Too Few

Just Right

Too Many

NA/DK

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Since tort reform in 2004 addressed medical liability, would you way the supply has increased, stayed about the same, or decreased? inreased

Practicing physicians overall Minority physicians Women physicians Family practitioners Primary care providers General surgeons Neurosurgeons Obstetricians Emergency room doctors Other specialists International medical graduates 138.

139.

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Stayed about the same

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decreased

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On average, about how many months would you estimate it takes to Recruit a physician to your type of practice in your area of the state? About

NA/DK

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ months.

Are physician supply issues a problem for you/your practice? ‰ Yes ‰ No ‰ NA/DK 30

140.

Have you attempted to recruit any new physicians to your practice in the last three years? ‰ Yes ‰ No ‰ NA/DK

141.

Please write your concerns about issues surrounding the recruitment or retention of physicians in general, or any specific types of physicians, including family physicians, specialists, minority physicians, women physicians, and/or foreign-trained physicians.

142.

How difficult would you say it is to recruit the types of non-physician health professionals listed below to work in Mississippi? Easy to recruit Moderate Difficult to Recruit NA/DK ‰ ‰ ‰ ‰ Nurses ‰ ‰ ‰ ‰ Nurse practitioners ‰ ‰ ‰ ‰ Physician assistants ‰ ‰ ‰ ‰ Other health professionals

143.

Since tort reform in 2004 addressed medical liability, how has the supply of non-physician health professionals been in your community (too few, just right, too many)? Certified nurse midwives Chiropractors Nurse Practitioners Physician Assistants

Too Few

Just Right

Too Many

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NA/DK

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144.

Please indicate the extent to which you agree or disagree with each of the following items concerning nurse practitioners. Employing a nurse practitioner to provide primary care increases a physician’s chance of being sued for malpractice more than hiring a staff nurse. Nurse practitioners should be allowed to practice independently in underserved areas. Nurse practitioners provide lower-quality primary care than physicians. Hiring a nurse practitioner can attract new patients to a practice. Use of a lower-cost nurse practitioner is unfair to other physicians in the area. Nurse practitioners can provide 80 percent or more of the primary care services of a physician. Nurse practitioners should be allowed to prescribe commonly used drugs. Patients are willing to see a nurse practitioner for some of their primary care. Nurse practitioners bring a different yet positive dimension of care to a physician’s practice. Employing a nurse practitioner would increase a physician’s time for activities other than patient care. Nurse practitioners are not needed to improve access to primary care services in rural areas. Nurse practitioners are practical as physician extenders when immediate supervision is provided by a physician.

Strongly Agree

Agree

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Disagree

Strongly Disagree

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145.

To what extent do you think the supply of non-physician health professionals (thinking mainly of nurse practitioners, certified nurse midwives, chiropractors, and physician assistants) in your community affects your professional security? ‰ Enhances security ‰ Threatens security ‰ Has no effect on my security ‰ NA/DK

146.

To what extent do you think the expanded scopes of practice for non-physician health professionals affects your professional security? ‰ Enhances security ‰ Threatens security ‰ Has no effect on my security ‰ NA/DK

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147.

Have you attempted to recruit any new non-physician health professionals to your practice in the last three years? ‰ Yes ‰ No ‰ NA/DK

DEMOGRAPHICS, EDUCATION AND COMPENSATION 148.

What is your sex? ‰ Male ‰ Female

149.

Are you of Hispanic origin or descent? ‰ Yes ‰ No ‰ NA/DK

150.

What do you consider to be your race? ‰ White/Caucasian ‰ African-American/Black ‰ Asian ‰ American Indian/Native American ‰ Other (please specify)

151.

What is your marital status? ‰ Single, never married ‰ Married ‰ Divorced or separated ‰ Widowed ‰ Other (please specify)

152.

In what year were you born?

[four digit year]

33

153.

Which of the following items best describe your history in Mississippi? (check all that apply) ‰ Graduated from high school in Mississippi ‰ Graduated from college in Mississippi ‰ Attended medical school in Mississippi ‰ Completed internship, residency, or fellowship training in Mississippi ‰ Began practice in Mississippi immediately after training in another state ‰ Moved to Mississippi from practice in another state ‰ Other (please specify)

154.

When did you begin medical practice (after completing medical training, including residencies and fellowships, and licensing)?

[four digit year]

155.

How many offices have you held and committees have you served on in Mississippi state professional associations over the past five years? Your best estimate is fine. offices/committees

156.

Were you born in the United States? ‰ Yes ‰ No (Please skip to Question 158)

157.

What was your state of birth?

158.

In what country were you born?

159.

What was your student loan debt load when you completed your medical training? ‰ None ‰ $19,999 or less ‰ $20,000-39,999 ‰ $40,000-59,999 ‰ $60,000-79,999 ‰ $80,000-99,999 ‰ $100,000-119,999 ‰ $120,000-139,999 ‰ $140,000-159,999 ‰ $160,000-179,999 ‰ $180,000-199,999 ‰ $200,000 or more

(Please skip to Question 159)

34

160.

Did you participate in any incentive programs related to your medical education, licensure, or practice that encouraged you or required you to practice in Mississippi? ‰ Yes ‰ No (Please skip to Question 162 below) ‰ NA/DK (Please skip to Question 162 below)

161.

In which incentive programs that encouraged or required you to practice in Mississippi did you participate?"

PAYMENT / COMPENSATION / PROFESSIONAL INCOME 162. In your current position, are you salaried or are you the solo or part-owner of the practice where you work? (check single answer) ‰ Salaried ‰ Self-employed (solo or part owner of practice) ‰ Other (please specify) 163.

Please look at the categories below and select the best category for your total annual income from your medical activities in 2006. [We are interested in your own net income from the practice of medicine, after expenses but before taxes. Please include contributions to retirement plans made for you by the practice and any bonuses as well as fees, salaries and retainers. Exclude investment income. Also, please include earnings from ALL practices, not just your primary practice. This information will be reported only in aggregate form to ensure confidentiality.] ‰ $59,999 or less ‰ $60,000-79,999 ‰ $80,000-99,999 ‰ $100,000-119,999 ‰ $120,000-139,999 ‰ $140,000-159,999 ‰ $160,000-179,999 ‰ $180,000-199,999 ‰ $200,000-249,999 ‰ $250,000-299,999 ‰ $300,000-349,999 ‰ $350,000-399,999 ‰ $400,000-449,000 ‰ $450,000-499,999 ‰ $500,000 or more 35

Thank you for taking the time to complete our survey. Please return this survey to: Lynne Cossman Mississippi State University SSRC PO Box 5287 Mississippi State, MS 39762 Your responses are extremely valuable to us. We will be combining your responses with those of other Mississippi physicians, analyzing the results, and producing a report that will be made available to the public. If you would like to receive this report or if you have comments or questions about the survey, please contact Dr. Cossman by e-mail at [email protected] or by telephone at 662-325-3791.

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