Ronald E. Cossman. Ph.D.

Presented to: Applied Demography ConferenceJanuary 10, 2014

Mississippi Center for Health WorkforceSocial Science Research Center

Mississippi State University

Rurality Not the Determinant of Access to

Primary Health Care in Mississippi

Three ways to measure health care workforce

1. Supply2. Demand3. Access

Supply

Simple: Physician-to-population ratio

Complex: Health Professional Shortage Areas (HPSAs) (ratio of physicians-to-population) and other factors such as:

1) Poverty rate (all categories)2) Travel distance/time (all categories)

3) Infant mortality/low birth weight (primary care)3) Fluoridated water (dental)

3) Pop under 18, over 65, alcohol or substance abuse (mental health)

Note: This “assumes” total access to care for patients.

Demand

Via the National Health Interview Survey. “Were you unable to obtain health care in the last

12 months?”

Note: The question is relative, does not ask the reasons, and is not available below the state level.

Access

1. Physician Reimbursement Records (who accepted what kind of patient)Note: This is a retrospective measure.

2. Telephone survey of Primary Care offices (by type of health care insurance)

Assumption/Hypothesis:

Health insurance equates to access to primary care.

and….access is worse in rural places

Methodology

Telephone each primary care physician practice office using G-mail voice-over-internet-protocol (VOIP) to mask calling identity and location.Poise as a new patient to the area asking for a visit to establish a relationship with the physicianVolunteer health insurance status:1. Blue Cross & Blue Shield (the 800-lb gorilla)2. Medicare (automatic insurance for the elderly)3. Medicaid (means-based insurance)

There were 5,098 “licensed” physicians in the state of Mississippi There are 2,138 active “primary care” physicians in the state There are 678 primary care facilities that were used in our study

Local government clinics, hospitals and E.R.s were excluded 88 facilities were excluded because they were walk-in facilities 580 offices were successfully contacted

“Core” Primary Care is comprised of: general practitioner, family practice, and internal medicine. The other two categories are pediatrics and OB/GYN. (Note: HPSA definition of primary care)

Descriptives

FINDINGS:

Private (Blue Cross and Blue Shield of Mississippi)

Core Primary Care**

OB/GYN Pediatrics Total0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AcceptDeclineOther

Note the “Other” category. We may

be significantly understating the

denial rate.

Type of Insurance/Specialty Private (Blue Cross and Blue Shield of Mississippi)

Accept Decline Other*Core Primary Care** 75% 8% 17%OB/GYN 91% 0% 9%Pediatrics 83% 5% 12%Total*** 78% 7% 16%

* Did not resolve an appointment, required call-back, additional information, valid insurance number

** General practitioner, family practice, internal medicine*** May not add to 100% due to rounding

Medicare (elderly)

Core Primary Care** OB/GYN Total0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AcceptDeclineOther

Types of Insurance/SpecialtyMedicare (elderly)

Accept Decline Other*Core Primary Care** 63% 16% 21%OB/GYN 76% 8% 16%Pediatrics N/A N/A N/ATotal 64% 15% 21%

* Did not resolve an appointment, required call-back, additional information, valid insurance number

** General practitioner, family practice, internal medicine

Medicaid (means-based)

Core Primary Care** OB/GYN Pediatrics Total0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AcceptDeclineOther

Decline may range from

43% to 50%

Type of Insurance/SpecialtyMedicaid (means-based)

Accept Decline Other*Core Primary Care** 47% 43% 10%OB/GYN 59% 28% 13%Pediatrics 61% 21% 17%Total 50% 38% 12%

* Did not resolve an appointment, required call-back, additional information, valid insurance number

** General practitioner, family practice, internal medicine

Number of Residents that Practices Serve in Selected* Cities

Amory

Bay Sa

int Louis

Brandon

Carthag

e

Clinto

n

Columbus

Flowood

Greenvil

le

Grenad

a

Hernan

do

Jackso

nLa

urel

Louisv

ille

Mccomb

Moss Point

New Alban

y

Olive B

ranch

Pascag

oulaPeta

l

Picayu

ne

Richlan

dRipley

South

aven

Tupelo

Way

nesboro

Yazo

o City -

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

*Randomly selected cities

Beale Code Frequencies in MS

B1: Metr

o 1 milli

on +

B2: Metr

o area

250k-1 m

illion

B3: Metr

o area

fewer

than

250k

B4: Nonmetr

o urban

20k+ ad

jacen

t to a m

etro

B5: Nonmetr

o urban

20k+ not a

djacen

t to a m

etro

B6: Nonmetr

o urban

2,000-19,999 adjac

ent t

o a metr

o

B7:Nonmetr

o urban

2,500-19,999 not adjac

ent t

o a metr

o

B8: Nonmetr

o rural

or less

than

2,500 adjac

ent t

o a metr

o

B9: Nonmetr

o rural

or less

than

2,500 not adjac

ent t

o a metr

o0

2

4

6

8

10

12

14

16

18

20

Primary Care and Counties by Beale Code

B1: Metro

1 millio

n +

B2: Metro

area 250k-1 millio

n

B3: Metro

area fewer th

an 250k

B4: Nonmetro

urban 20k+ adjacent to

a metro

B5: Nonmetro

urban 20k+ not adjace

nt to a m

etro

B6: Nonmetro

urban 2,500-19,999 adjacent to

a metro

B7: Nonmetro

urban 2,500-19,999 not adjace

nt to a m

etro

B8:Nonmetro

rural o

r less

than 2,500 adjacent to

a metro

B9: Nonmetro

rural o

r less

than 2,500 not adjace

nt to a m

etro

0%

5%

10%

15%

20%

25%

30%

35%

40%

% of primary care offices per Beale code% of counties per Beale code

0%

5%

10%

15%

20%

25%

30%

35%

Metro - 1 million +

Metro - 250 K - 1 million

Metro - <250,000

Nonmetro - >20,000, adjacent

Nonmetro - >20,000, not adjacent

Nonmetro - 2,500-19,999, adjacent

Nonmetro - 2,500-19,999, not adjacent

Nonmetro - <2,500, adjacent

Nonmetro - <2,500, not adjacent

Percent Population by Rural-Urban Continuum Code

Pop 2010

Primary Care

Percent Not Currently Accepting New Patients

B1: Metr

o 1 milli

on +

B2: Metr

o area

250k-1 m

illion

B3: Metr

o area

fewer

than 250k

B4: Nonmetr

o urban

20k+ ad

jacen

t to a

metro

B5: Nonmetr

o urban

20k+ not a

djacen

t to a

metro

B6: Nonmetr

o urban

2,500-19,999 adjac

ent to

a metr

o

B7: Nonmetr

o urban

2,500-19,999 not adjac

ent to

a metr

o

B8:Nonmetro ru

ral or le

ss than

2,500 adjac

ent to

a metr

o

B9: Nonmetr

o rural

or less

than 2,500 not a

djacen

t to a

metro

0%10%20%30%40%50%60%70%80%90%

100%

Decline Rate by County Population and Type Insurance

BC & BSMedicareMedicaid

Perc

ent D

eclin

e

The 2 counties in white (DeSoto &

Lowndes) are not HPSA physician

shortage areas in Mississippi

Primary care offices in only 1 county (Copiah) did

not accept private (BC&BS) insurance. More

than three quarters of MS counties (primary care offices) (77%) had zero decline rates of BCBS.

In one county (Copiah) there was zero

acceptance of new Medicare patients.

There are 5 counties that were not currently

accepting new Medicaid patients.

They are (NE to SW) Itawamba, Tallahatchie,

Attala, Copiah and Lincoln.

Additional Finding:Our results my underestimate the percentage of declines. When the

unresolved calls are factored in, decline of service could be as high as 57%.

Implications of the findings

Health insurance does NOT equate to access to primary care

Implication #1

A Medicaid expansion will not necessarily provide access to primary care to all.Thus, the impact of expansion will be less.

Thus, the non-critical emergency room load will not drop as expected

Implication #2

Since physician offices are a business, a substantial portion have chosen not to accept certain kinds of insurance.

Thus, we need to revisit the payment/reimbursement system

Implication #3

Using physicians ratios treats all physicians as independent. However, if

there are five physicians in a county and they all practice together, a decline of

service from one is a decline from all 5 health care providers.

Thank you for your attention

Ronald E. Cossman, Ph.D.Research Professor

Mississippi Center for Health WorkforceSocial Science Research Center

P.O. Box 5287 Mississippi State University

Mississippi State, MS. 39762 Office: (662) 325-4801

E-mail: rcossman@ssrc.msstate.edu Web: http://www.ssrc.msstate.edu