Barriers to prenatal care for low-income women.

Inadequate prenatal care is associated with poor birth outcomes. Recognizing barriers to care is necessary to improve results. Postpartum in-hospital interviews were conducted with women admitted through emergency departments with no physician of record (n = 69) in 8 Sacramento hospitals during April and May 1991. A focus group of local obstetrician-gynecologists was used to determine physicians'' attitudes about caring for low-income women. We undertook the study in response to an increased number of "no doc" births. The inability to find a physician willing to accept them was reported by the women as the single largest barrier to obtaining care, cited by 64% of women overall and 96% of those who tried but were unable to obtain care. Transportation difficulties were a problem regardless of women''s success in obtaining care and were ranked as the top barrier by women who never tried to obtain care. Physicians cited administrative difficulties and reimbursement levels of Medi-Cal plus extra care requirements and resource dependency of low-income patients as barriers to caring for this population. The value ascribed to prenatal care by women and physicians'' perceptions of women''s attitudes about care contrasted sharply. The link between poor women and physicians providing obstetric services can be fragile. The difficulty finding physicians willing to take them indicates that these women need special support services to ensure adequate care during pregnancy.     

Participation of Colorado pediatricians and family physicians in the Medicaid program.

The Pediatric Health Policy Group of the University of Colorado Health Sciences Center (Denver) surveyed 650 family physicians and 296 pediatricians in 1988, with 50% of family physicians and 48% of pediatricians responding. Half of the pediatricians in private practice and 35% of family physicians in private practice accepted all children who were Medicaid beneficiaries into their practice; 42% of pediatricians and 50% of family physicians accepted all non-Medicaid patients but only some new Medicaid patients; and 8% of pediatricians and 15% of family physicians accepted new non-Medicaid patients but no Medicaid patients. Practice location was associated with the level of Medicaid participation for these primary care physicians: Significantly more rural pediatricians and family physicians than those with urban practices accepted Medicaid patients. The average reimbursement level for these physicians was shown to be an important determinant of whether physicians would accept Medicaid patients. Nonparticipatory physicians were more concerned about excessive paperwork compared with physicians with limited participation. Among physicians with limited participation, family physicians and pediatricians both cited problems of excessive paperwork, reimbursement delays, and retroactive denials of payment as important deterrents to accepting Medicaid patients.     

Obstetric care,Medicaid, and family physicians. How policy changes affect physicians' attitudes.

Recent expansion of Medicaid eligibility for pregnant women and increased reimbursement to physicians who provide perinatal services were designed to improve access to care. Family physicians provide a relatively high proportion of care to pregnant women on Medicaid, especially in rural areas. We surveyed all family physicians who provide obstetric services in 26 northern California counties regarding these changes and perceived barriers to providing obstetric care to women on Medicaid. Of surveyed physicians who limited the number of their Medicaid obstetric patients, 58% stated that recent Medicaid policy changes had increased their willingness to accept new Medicaid obstetric patients. Despite these policy changes, administrative issues and poor reimbursement were cited as the two most notable barriers to providing obstetric care to women on Medicaid. Fear of being sued by Medicaid patients is still seen as a barrier by physicians who have recently discontinued practicing obstetrics and by those who continue to care for a large number of Medicaid obstetric patients.     

Taking care of patients--does it matter whether the physician is a woman?

Researchers have recently begun to compare male and female physicians'' attitudes toward patients, medical knowledge, and practice styles. Although women start medical school with more "humanistic views," the conservative effect of medical socialization on both male and female students attenuates these differences. While some studies suggested that men are more scientifically knowledgeable, recent studies showed no significant differences in physicians'' medical knowledge. Male and female physicians also had comparable diagnostic and therapeutic behavior. In the intimate world of physicians and patients, however, there were notable differences. Women physicians seemed better able to communicate sensitivity and caring to patients, which may account for the common perception that women are more caring and empathic physicians. Medical educators may wish to study more closely female physicians'' communication styles to identify these behaviors and inculcate them into all physicians.     

Uncompensated and undercompensated care provided by San Francisco Medical Society physicians.

Practicing physician members of the San Francisco Medical Society were surveyed regarding reimbursement rates for medical care provided to underinsured and uninsured patients. Of 394 respondents, about $51,000 per physician practice was written off as uncompensated care or services not billed for in 1985. An average of 7% of each physician''s patients was estimated to be "no-pay" or charity patients, accounting for $19,000 of this total. Almost $32,000 was reported as being uncompensated care, or that which is billed but not paid. In addition to these amounts, an average of $32,000 was reported as being discounted from the usual fee levels by government insurance programs. Extrapolating these results to the physician membership of the local medical society indicates that physicians in San Francisco may be providing as much as $81 million in uncompensated or charity care annually. These results emphasize that private practitioners are providing a significant amount of medical care at reduced or charity rates, an amount that can be expected to increase given present trends. Substantial changes are needed if the burden of providing medical care to poor and uninsured Americans is not to fall disproportionately on private providers.     

The Physician and Workmen's Compensation—A New Paramedic to Help with Compensation Cases

The first social, no-fault, insurance legislation in California was the Workmen''s Compensation Act of 1911. It has been changed and modified in the years since, and is having an increasing impact on the practice of most California physicians. Many physicians consider caring for the occupationally ill or injured time-consuming and difficult. A newly emerging kind of paramedic, the workmen''s compensation benefit administrator, is available to assist the physician in overcoming difficulties encountered. A cooperative effort between the physician and the benefit administrator will expedite management of industrial patients.     

Managed-care plans. Their future under national health insurance.

The nation''s health maintenance organizations, preferred-provider organizations, independent practice associations, and similar managed-care efforts are not well positioned to take a leadership role in a nationwide universal access or national health insurance plan. They--with the possible exception of some large staff and group health maintenance organizations--have been unable to show uniformly that they can contain costs, provide better access or higher quality of care, and achieve greater patient satisfaction than fee-for-service endeavors. As the United States pursues universal access as a step toward national health insurance, the managed-care plans will continue to increase their numbers of subscribers. They will not, however, be able to enroll large numbers of the young, low-income employees and their dependents who account for most of the 63 million people uninsured sometime during each year. Under national health insurance, there might be an option for some health maintenance organizations to negotiate capitated payments. The vast majority of the nation''s physicians, however, will reluctantly embrace a centrally managed fee-for-service approach rather than a salary or capitated reimbursement method, leaving only a trace of the competitive managed-care plan theme in a future, primarily monolithic, national health care system.     

Effect of medicolegal liability on patterns of general and family practice in Canada.

As part of the Federal/Provincial/Territorial Review on Liability and Compensation Issues in Health Care, in 1988 we surveyed Canadian general practitioners and family physicians to determine the effect of liability concerns on their practices in the previous 5 years. Questionnaires were sent to a random, stratified national sample of 1295 physicians, with a response rate of 64.6%. However, a high proportion of the returned questionnaires were ineligible because the physicians were not in general or family practice, were not involved in direct patient care, or had died or moved; thus, the corrected response rate was 50.8%. The newsletter of the Canadian Medical Protective Association was the source of information on liability most frequently cited (by 88.1% of the physicians) and most influential (to 62.4%). Only 15.5% of the physicians cited personal involvement with medicolegal issues as a source of information; the rate was higher for Ontario physicians and those in urban areas generally. A total of 74.6% of the respondents had altered their style of practice in the previous 5 years, and 56.3% reported changes in the scope of their practice. Concern about litigation was the most important reason for changing style of practice and reducing or eliminating administration of anesthesia, whereas lifestyle and other issues along with liability concerns most influenced decisions to reduce obstetric care and emergency department work. Our findings suggest that physicians'' perceptions of liability issues have had a profound influence on primary care practice in Canada in the past several years.     

What factors influence primary care physicians' charges for their services? An exploratory study using standardized patients

OBJECTIVE: To determine the extent of variation in physicians'' charges for health care encounters with unannounced standardized patients and factors associated with the variation. DESIGN: Cross-sectional study. SETTING: Family practices open to new patients within 1 hour''s drive of Hamilton, Ont. PARTICIPANTS: A stratified random sample of 125 physicians who had responded to an earlier survey regarding preventive care were invited to participate. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew because they closed their practices to new patients. Sixty-two physicians thus participated in the study. INTERVENTION: Unannounced standardized patients posing as new patients to the practice visited study physicians'' practices between September 1994 and August 1995, portraying 4 scenarios: 28-year-old woman, 52-year-old woman, 48-year-old man and 70-year-old man. OUTCOME MEASURES: Physician characteristics, encounter characteristics and charges made for services. RESULTS: The 62 physicians had 246 encounters with the standardized patients. Charges were made to the health insurance plan for services by 59 physicians for up to 4 encounters (215 encounters in all). Charges varied considerably both within and across patient scenarios. Time spent with the patient was an important factor predicting charges made (p < 0.01), although the effect of time spent on charges varied across scenarios (p < 0.01). Fee-for-service physicians charged more for their services than physicians who usually had alternative billing arrangements (p < 0.01). Female physicians charged more for their services than their male colleagues (p = 0.03). No relation was found between quality of preventive care and charges made (p = 0.15). CONCLUSIONS: Physician-related factors are better able to account for the variability in charges for their services than patient-related factors. Physicians seeing comparable patients may earn much more or less than their colleagues because of differences in the services they provide and the way they apply the fee schedule. Quality-assurance techniques are likely needed to reduce the variability in charges seen and increase value for money spent in health care.     

TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

Fatal hyperthermia associated with cocaine use.

Health insurance in the United States is failing patients and physicians alike. In this country 37 million uninsured face economic barriers to care, and the health of many suffers as a result. The "corporatization" of medical care threatens professional values with an unprecedented administrative and commercial intrusion into the daily practice of medicine. Competitive strategies have also failed their most ostensible goal--cost control. In contrast, Canada offers a model of a national health insurance plan that provides universal and comprehensive coverage, succeeds at restraining health care inflation, and does little to abrogate the clinical autonomy of physicians in private practice. I propose that American physicians relent in their historical opposition to national health insurance and participate in the development of a universal, public insurance plan responsive to the needs of both patients and physicians.     

Primary care physicians' refusal to care for patients infected with the human immunodeficiency virus.

We conducted a telephone survey of a random sample of office-based primary care physicians in Los Angeles County to determine their practice experiences with patients infected with the human immunodeficiency virus (HIV). Telephone interviews included questions related to the physicians'' experiences evaluating patients for HIV infection during the past 6 months and the presence of HIV-infected patients in their practices. Those without HIV-infected patients were asked if this was because they had not encountered such patients, because those patients had died, or because the physicians had chosen to refer these patients elsewhere or the patients had gone elsewhere for care. Of physicians who participated in the survey, 78% had evaluated a patient for HIV infection in the past 6 months; 34% were currently providing primary care for infected patients; and 36% had elected to refer HIV-infected patients elsewhere, or their patients had elected to find other physicians. In all, 48% of physicians in the sample had elected not to care for, or said they would not provide care for, patients with HIV infection. Among Los Angeles County primary care physicians, 36% have refused to provide continuing care for HIV-infected patients and another 12% indicated their unwillingness to do so should such patients present themselves for care. As of 1991, the reservoir of primary care physicians in Los Angeles not yet involved with but willing to care for HIV-infected patients is relatively small (15%).     

Do physicians have an ethical obligation to care for patients with AIDS?

This paper responds to the question: Do physicians have an ethical obligation to care for patients with acquired immunodeficiency syndrome (AIDS)? First, the social and political milieu in which this question arises is sampled. Here physicians as well as other members of the community are found declaring an unwillingness to be exposed to people with AIDS. Next, laws, regulations, ethical codes and principles, and the history of the practice of medicine are examined, and the literature as it pertains to these areas is reviewed. The obligation to care for patients with AIDS, however, cannot be located in an orientation to morality defined in rules and codes and an appeal to legalistic fairness. By turning to the orientation to morality that emerges naturally from connection and is defined in caring, the physicians'' ethical obligation to care for patients with AIDS is found. Through an exploration of the writings of modern medical ethicists, it is clear that the purpose of the practice of medicine is healing, which can only be accomplished in relationship to the patient. It is in relationship to patients that the physician has the opportunity for self-realization. In fact, the physician is physician in relationship to patients and only to the extent that he or she acts virtuously by being morally responsible for and to those patients. Not to do so diminishes the physician''s ethical ideal, a vision of the physician as good physician, which has consequences for the physician''s capacity to care and for the practice of medicine.     

Physician Fee Indices in California and the U.S. Through June 1971 Socio-Economic Report of the Bureau of Research and Planning

California physicians'' fees increased 2.2 percent in the first half of 1971, according to figures compiled by the Bureau of Research and Planning. Nationally, physicians'' fees increased at a faster rate of 3.4 percent during the same period.This was the slowest semi-annual increase in the California Index since the final six months of 1968 when fees increased only 2.0 percent. A decline was also recorded in the rate of price increase for other goods and services in the first half of 1971. Nationally, the “all items” increase amounted to 2.0 percent, and the service component rose 2.1 percent.Also included in this Report is special information on the charging patterns of physicians for office and hospital visits and data on physicians'' fees in the Los Angeles and San Francisco Metropolitan Areas.The California Physician Fee Index is a continuing survey conducted by the CMA Bureau of Research and Planning since 1962. The survey questionnaire which lists 26 medical, surgical, radiological, and laboratory procedures, elicits fee information from approximately 1,000 randomly selected physicians. Since June 1970, the procedures on the questionnaire have been listed according to the coding nomenclature used in the 1969 edition of the Relative Value Studies, published by the California Medical Association. Prior to that, the 1964 edition was used to delineate the procedure being surveyed.     

Tort reform and the obstetric access crisis. The case of the WAMI states.

The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetric services during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians'' obstetric practices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion.     

Which physicians make home visits and why? A survey

BACKGROUND: Recent changes in the North American health care system and certain demographic factors have led to increases in home care services. Little information is available to identify the strategies that could facilitate this transformation in medical practice and ensure that such changes respond adequately to patients'' needs. As a first step, the authors attempted to identify the major factors influencing physicians'' home care practices in the Quebec City area. METHODS: A self-administered questionnaire was sent by mail to all 696 general practitioners working in the Quebec City area. The questionnaire was intended to gather information on physicians'' personal and professional characteristics, as well as their home care practice (practice volume, characteristics of both clients and home visits, and methods of patient assessment and follow-up). RESULTS: A total of 487 physicians (70.0%) responded to the questionnaire, 283 (58.1%) of whom reported making home visits. Of these, 119 (42.0%) made fewer than 5 home visits per week, and 88 (31.1%) dedicated 3 hours or less each week to this activity. Physicians in private practice made more home visits than their counterparts in family medicine units and CLSCs (centres locaux des services communautaires [community centres for social and health services]) (mean 11.5 v. 5.8 visits per week), although the 2 groups reported spending about the same amount of time on this type of work (mean 5.6 v. 5.0 hours per week). The proportion of visits to patients in residential facilities or other private residences was greater for private practitioners than for physicians from family medicine units and CLSCs (29.7% v. 18.9% of visits), as were the proportions of visits made at the patient''s request (28.0% v. 14.2% of visits) and resulting from an acute condition (21.4% v. 16.0% of visits). The proportion of physicians making home visits at the request of a CLSC was greater for those in family medicine units and CLSCs than for those in private practice (44.0% v. 11.3% of physicians), as was the proportion of physicians making home visits at the request of a colleague (18.0% v. 4.5%) or at the request of hospitals (30.0% v. 6.8%). Physicians in family medicine units and CLSCs did more follow-ups at a frequency of less than once per month than private practitioners (50.9% v. 37.1% of patients), and they treated a greater proportion of patients with cognitive disorders (17.2% v. 12.6% of patients) and palliative care needs (13.7% v. 8.6% of patients). Private practitioners made less use of CLSC resources to assess home patients or follow them. Male private practitioners made more home visits than their female counterparts (mean 12.8 v. 8.3 per week), although they spent an almost equal amount of time on this activity (mean 5.7 v. 5.2 hours per week). INTERPRETATION: These results suggest that practice patterns for home care vary according to the physician''s practice setting and sex. Because of foreseeable increases in the numbers of patients needing home care, further research is required to evaluate how physicians'' practices can be adapted to patients'' needs in this area.     

Impact of patient care appraisal on physician behaviour in the office setting

The effect of patient care appraisal on physicians'' management of patients'' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians'' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians'' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients'' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care.     

Hormone replacement therapy: a survey of Ontario physicians' prescribing practices

BACKGROUND: Although much has been written about hormone replacement therapy (HRT), there are few clearcut recommendations on its use. The purpose of this study was to determine Ontario physicians'' patterns of and reasons for prescribing HRT, their use of pretreatment investigations and their surveillance of HRT users, and to determine whether physicians'' reported practice is consistent with existing recommendations. METHODS: A self-administered questionnaire was mailed to a nonproportional stratified sample of 327 Ontario physicians (23.9% gynecologists, 76.1% general practitioners/family physicians [GP/FPs]). Outcome measures were ranking of reasons for prescribing HRT, nature of preliminary testing, regimens prescribed, duration of HRT and frequency of follow-up. RESULTS: The response rate was 60.9% overall (70.9% of the gynecologists, 58.3% of the GP/FPs). Prevention of osteoporosis was reported by 97.4% as an important or very important reason for prescribing HRT; prevention of coronary artery disease was important or very important for 89.3%. When considering whether or not to prescribe HRT, 97.3% stated that breast cancer was an important or very important factor. When presented with hypothetical cases, 97.0% stated that they would prescribe combined estrogen-progestin for a symptomatic woman with an intact uterus; 13.6% stated that they would do so for a woman with no uterus. Most reported that they would prescribe HRT for 12 or more years (73.3%) and would follow up patients every 1 to 2 years (70.6%). INTERPRETATION: Despite controversy about HRT in the published literature, the Ontario physicians surveyed reported similar reasons and patterns of prescribing, pretreatment investigations, and surveillance of postmenopausal women using HRT. These results suggest that Ontario physicians'' knowledge about HRT is consistent with recommendations in the published literature.     

Radioallergosorbent testing for penicillin allergy in family practice.

OBJECTIVES: To determine (a) the prevalence of patients supposedly allergic to penicillin who have a positive radioallergosorbent test (RAST) result for penicillin G or V and (b) the predictive power of family physicians'' clinical judgement that a patient who is supposedly allergic to penicillin will have a positive RAST result. DESIGN: Prospective multicentre cross-sectional observational study. SETTING: Eleven primary care practices in Newfoundland; 10 were in a rural setting. PATIENTS: Of 110 consecutive adult patients with a supposed allergy to penicillin 97 agreed to participate in the study; 92 underwent RAST. INTERVENTIONS: Patients helped physicians complete a questionnaire and had a venous blood sample taken for the RAST. Physicians examined the clinical history and judged whether the patient was likely to have a positive RAST result. MEAN OUTCOME MEASURES: Rates of positive and negative RAST results for penicillin V and G. RESULTS: Of the 92 patients 8 had a positive RAST result and 84 a negative one. The positive predictive power of a "good" clinical history (e.g., urticaria, swollen eyes, tongue or lips, or an anaphylactic reaction witnessed by a physician) was low (10%); the negative predictive power of a "poor" clinical history (e.g., nausea, vomiting, diarrhea, fever, nonspecific rash or fainting) was 92%. CONCLUSIONS: Less than 10% of primary care patients with a supposed allergy to penicillin will have a positive RAST result. In addition, physicians'' predictions of allergy in such patients are imprecise.     

The Health Policy Attitudes of American Medical Students: A Pilot Survey

Background

Relatively little is known about American medical student’s attitudes toward caring for the uninsured, limiting physician reimbursement and the role of cost-effectiveness data in medical decision-making. We assessed American medical student’s attitudes regarding these topics as well as demographic predictors of those attitudes, and compared them to practicing physicians.

Methods and Findings

A survey instrument was explicitly designed to compare medical student attitudes with those previously reported by physicians. Between December 1st 2010 and March 27th 2011 survey responses were collected from more than 2% of the total estimated 2010–2011 US medical student population enrolled at 111 of 159 accredited US medical schools within the 50 United States (n = 2414 of possible 98197). Medical students were more likely to object to reimbursement cuts, and more likely to object to the use of cost effectiveness data in medical decision making than current physicians according to the literature. Specialty preference, political persuasion, and medical student debt were significant predictors of health policy attitudes. Medical students with anticipated debt in excess of $200,000 were significantly less willing to favor limiting reimbursement to improve patient access (OR: 0.73 [95% confidence interval (CI): 0.59–0.89]), and significantly more likely to object to using cost effectiveness data to limit treatments (OR 1.30, 95% CI 1.05–1.60) when compared to respondents with anticipated debt less than $200,000.

Conclusions

When compared to physicians in the literature, future physicians may be less willing to favor cuts to physician reimbursements and may be more likely to object to the use of cost effectiveness data. Political orientation, specialty preference and anticipated debt may be important predictors of health policy attitudes among medical students. Early career medical providers with primary care ambitions and those who anticipate less debt may be more likely to support healthcare cost containment.