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Biomedical subjects

P R Kletke

Publications and source records attributed to P R Kletke.

At least 19 recordsLinked to original sources
PubMed2000

HMO penetration and the geographic mobility of practicing physicians.

In this study, we assessed the influence of changes in health maintenance organization (HMO) penetration on the probability that established patient care physicians relocated their practices or left patient care altogether. For physicians who relocated their practices, we also assessed the impact of HMO penetration on their destination choices. We found that larger increases in HMO penetration decreased the probability that medical/surgical specialists in early career stayed in patient care in the same market, but had no impact on generalists, hospital-based specialists, or mid career medical/surgical specialists. We also found that physicians who relocated their practices were much more likely to choose destination markets with the same level of HMO penetration or lower HMO penetration compared with their origin markets than they were to choose destination markets with higher HMO penetration. The largely negligible impact of changes in HMO penetration on established physicians' decisions to relocate their practices or leave patient care is consistent with high relocation and switching costs. Relocating physicians' attraction to destination markets with the same level of HMO penetration as their origin markets suggests that, while physicians' styles of medical practice may adapt to changes in market conditions, learning new practice styles is costly.

Career Mobility↗
PubMed2000

HMO growth and the geographical redistribution of generalist and specialist physicians, 1987-1997.

OBJECTIVE: To assess the impact of the growth in HMO penetration in different metropolitan areas on the change in the number of generalists, specialists, and total physicians, and on the change in the proportion of physicians who are generalists. DATA SOURCES/STUDY SETTING: The American Medical Association Physician Masterfile, to obtain the number of patient care generalists and specialists in 1987 and in 1997 who were practicing in each of 316 metropolitan areas in the United States. Additional data for each metropolitan area were obtained from a variety of sources, and included HMO penetration in 1986 and 1996. STUDY DESIGN: We estimated multivariate regression models in which the change in the number of physicians between 1987 and 1997 was a function of HMO penetration in 1986, the change in HMO penetration between 1986 and 1996, population characteristics and physician fees in 1986, and the change in population characteristics and fees between 1986 and 1996. Each model was estimated using ordinary least squares (OLS) and two-stage least squares (TSLS). PRINCIPAL FINDINGS: HMO penetration did not affect the number of generalist physicians or hospital-based specialists, but faster HMO growth led to smaller increases in the numbers of medical/surgical specialists and total physicians. Faster HMO growth also led to larger increases in the proportion of physicians who were generalists. Our best estimate is that an increase in HMO penetration of .10 between 1986 and 1996 reduced the rate of increase in medical/surgical specialists by 10.3 percent and reduced the rate of increase in total physicians by 7.2 percent. CONCLUSIONS: The findings of this study support the notion that HMOs reduce the demand for physician services, particularly for specialists' services. The findings also imply that, during the past decade, there has been a redistribution of physicians-especially medical/surgical specialists-from metropolitan areas with high HMO penetration to low-penetration areas.

Catchment Area, Health↗
PubMed1999

Self-reported physician specialties and the primary care content of medical practice: a study of the AMA physician masterfile. American Medical Association.

BACKGROUND: Many internal medicine physicians report both primary and secondary specialties in the American Medical Association (AMA) Physician Masterfile. Usually, those represent combinations of general internal medicine and medical subspecialty practice. Whether reported specialty combinations can be used to assess the contribution of specialists to primary care is unknown. OBJECTIVES: To examine whether internists' primary and secondary specialties reported in the Masterfile reflect the amount of primary care that they provide, and whether changes over time in internists' reported specialties reflect changes in primary care provision. DESIGN: The Masterfile was used to identify internists' reported specialties in 1992 and in 1996. A mail questionnaire was used to assess the primary care content of physicians' practices. The association between reported specialties and the amount of primary care provided was evaluated using analysis of variance. SUBJECTS: A stratified random sample of internists in active clinical practice. MEASURES: The percentage of visits which were for the general medical care of patients for whom the physicians maintained ongoing responsibility. In addition, how often the physicians initiated the provision of preventive care for their regular patients, provided general medical care to these patients, and organized and coordinated the care received by these patients from other providers. RESULTS: There was a strong association between the internists' primary and secondary specialties reported in the Masterfile and measures of the primary care content of physicians' practices (P < 0.0001). In contrast, changes over time in internists' reported specialties were not associated with physicians' assessments of changes in the primary care content of their practices. CONCLUSIONS: Aggregate estimates of the availability of primary care in the US could be adjusted by taking into account the primary and secondary specialties reported by internal medicine physicians in the AMA Physician Masterfile.

American Medical Association↗
PubMed1998

Health maintenance organization penetration and the practice location choices of new physicians: a study of large metropolitan areas in the United States.

OBJECTIVES: The rapid growth of health maintenance organizations is reshaping the practice opportunities available to physicians. The practice location decisions of new physicians provide a sensitive bellwether of these changes. This study assessed the effect of health maintenance organization penetration on practice location for physicians completing graduate medical education (GME). METHODS: Conditional logit regression analysis was used to determine the effect of health maintenance organization penetration on practice location, controlling for other market characteristics. Subjects were physicians who finished GME between 1989 and 1994 and who located in one of the 98 US metropolitan areas with more than 500,000 population. The outcome measure was the particular metropolitan area chosen by each new physician. RESULTS: Early in the study period, new generalists were significantly more likely to locate in metropolitan areas with high health maintenance organization penetration than in low penetration areas, whereas new specialists' practice location choices were not associated with health maintenance organization penetration. The likelihood of choosing a high penetration relative to a low penetration area declined with time, however, for both generalists and specialists. Consequently, by the end of the study period, health maintenance organization penetration had a weak but significant negative effect on practice location for generalists and a strong negative influence on practice location for specialists. CONCLUSIONS: New generalists who completed graduate medical education between 1989 and 1994 were more likely than new specialists to locate in market areas with high health maintenance organization penetration; however, the proportions of both generalists and specialists who chose high penetration areas decreased during the study period. This finding may reflect reduced practice opportunities in high penetration areas relative to low penetration areas as health maintenance organizations' systems for controlling utilization began to yield results. Alternatively, new physicians may have become more hesitant to accept available positions in high penetration areas.

Adult↗
PubMed1997

The changing supply of renal physicians.

In 1993, there were 4,355 active, postresident physicians in the United States who, according to the American Medical Association (AMA) Physician Masterfile, had their primary specialty in either adult nephrology or pediatric nephrology. These renal physicians constituted 0.8% of the active postresident physician population, and there were 1.67 renal physicians for every 100,000 people in the United States. The population of renal physicians has grown at a significantly greater rate than the physician population as a whole. The number of renal physicians increased more than 10-fold between 1970 and 1993, and it increased by 19% between 1990 and 1993. In recent years, the growth of the renal physician population has been bolstered by the large number of new international medical graduates (IMGs) entering the United States, who have entered nephrology at a much higher rate than entering US medical graduates (USMGs). The future growth of the renal physician population will be determined by a wide variety of factors, including future trends in specialty selection and whether policies are implemented to reshape the physician workforce. The projection analysis of the future supply of adult nephrologists considers three different scenarios. First, if the production of new nephrologists remains at status quo, the supply of adult nephrologists will increase 101% between 1993 and 2010. However, it is possible that the number of entrants into the adult nephrologist population will increase because of the large influx of IMGs in US residency programs in recent years. If new IMGs continue to enter adult nephrology at their current rates and if this heightened level of entry is sustained, the supply of adult nephrologists will increase 134% between 1993 and 2010. Finally, if proposals are implemented to reduce the number of first-year residency positions to 110% of the number of new graduates of US medical schools and to raise the proportion of new physicians entering primary care to 50%, the supply of adult nephrologists will increase 62% between 1993 and 2010. The demand for nephrologists' services is likely to grow in the near future. The prevalence rate of end-stage renal disease (ESRD) more than doubled between 1984 and 1993, and a continuation of this trend will expand the need for more nephrologists. The long-term growth of the ESRD population will also be sustained, to some extent, by the aging of the US population, because the prevalence of ESRD is relatively high in the older age categories. However, long-term increases in the demand for nephrologists may be restricted by the growth of managed care, the use of nonphysician providers, and the implementation of other cost-cutting measures that impact the delivery of services to the ESRD population.

Adult↗
PubMed1997

Medicaid participation among urban primary care physicians.

OBJECTIVES: This article describes Medicaid participation among office-based primary care physicians in cities and examines its determinants. METHODS: Data used in this study were collected through the 1993 and 1994 American Medical Association Socioeconomic Monitoring System telephone surveys. The sample includes 1,300 primary care physicians. Our multivariate model includes a variety of personal, practice, community, and policy factors thought to influence participation. Logistic regression was used to examine determinants of accepting any Medicaid patients and ordinary least square regression was used to examine determinants of the extent of participation among participants. RESULTS: The authors found that 19% of respondents did not participate in Medicaid and 62% had practices with 9% or fewer Medicaid patients. Multivariate analyses indicated that Medicaid payment levels were not associated with observed patterns of Medicaid participation. Community sociodemographic characteristics and demand from Medicaid-eligibles, by contrast, play a significant role in influencing observed levels of participation. CONCLUSIONS: Strategies other than raising Medicaid payment levels will be needed to achieve equitable access to office-based primary care for the poor residing in cities.

Ambulatory Care↗
PubMed1996

Current trends in physicians' practice arrangements. From owners to employees.

OBJECTIVE: To examine current trends in practice organization among postresident patient care physicians in the United States. DESIGN AND SETTING: The American Medical Association's Socioeconomic Monitoring System (SMS), a series of periodic surveys of nationally representative samples of nonfederal postresident patient care physicians. Physicians were divided into 3 categories based on the organization of their main practice. They were classified as employee physicians if they had no ownership interest in their practice, as self-employed solo physicians if they were in 1-physician practices in which they had an ownership interest, and as self-employed group physicians if they were in multiple-physician practices in which they had an ownership interest. PARTICIPANTS: Nonfederal, postresident patient care physicians who provided more than 47 000 responses to SMS surveys between 1983 and 1994. MAIN OUTCOME MEASURE: The proportion of nonfederal postresident patient care physicians who were employees between 1983 and 1994. RESULTS: Between 1983 and 1994, the proportion of patient care physicians practicing as employees rose from 24.2% to 42.3% (P<.001), the proportion self-employed in solo practices fell from 40.5% to 29.3% (P<.001), and the proportion self-employed in group practices fell from 35.3% to 28.4% (P<.001). Most of these changes occurred in the latter half of the 12-year period. These trends, which are evident in virtually every segment of the patient care physician population, are especially prominent among young physicians. The growing proportion of employee physicians is associated with increases in the earnings of employee physicians relative to those of self-employed solo physicians. CONCLUSIONS: Current trends in the US health care system are rapidly changing the career opportunities of patient care physicians and, hence, physicians' choice of practice arrangement.

Group Practice↗
PubMed1992

Medicaid and access to child health care in Chicago.

In this article we examine how increasing the reimbursement of physicians and expanding Medicaid eligibility affect access to care for children in Cook County, Illinois, which overlies Chicago. Using Medicaid claims and other data at the zip-code level, we compare the places where Medicaid children live with the places where all the physicians who treat children and those who accept Medicaid patients have their practices. Our findings suggest that the recent changes in legislation are unlikely to benefit extremely poor children, who are more likely to live in depressed inner-city areas, where there are few physicians. "Near-poor" children whose homes are dispersed throughout the county, who are now eligible for Medicaid as a result of the recent changes, are likely to see improvements in their access to care. Further changes in policy, aimed at enhancing the capacity of institutions providing care, could improve access for the children of the inner city.

Adolescent↗
PubMed1991

The supply of renal physicians: an analysis of data from the American Medical Association Physician Masterfile.

This study uses data from the American Medical Association (AMA) Physician Masterfile to describe current demographic trends among physicians specializing in adult and pediatric nephrology. The analysis shows that renal physicians are younger than the physician population as a whole. Compared with other specialty groups, renal physicians are less likely to be in patient-care activities and are more likely to be in research. In recent years, the population of renal physicians has grown at a much faster rate than the rest of the physician population. A projection analysis indicates that the adult nephrologist population will more than double in size between 1987 and 2010. Among adult nephrologists, the number of women is expected to grow much faster than the number of men. Rapid growth is expected in the older age categories, whereas the number of adult nephrologists 35 years of age and younger is expected to decrease slightly.

Adult↗
PubMed1991

Medicaid patients' access to office-based obstetricians.

Recent expansion of the eligibility of low-income pregnant women for Medicaid-funded prenatal care may be jeopardized by undersupplies of obstetricians and gynecologists (OB/GYNs) in rural and urban low-income areas and by widely reported declines in the number of OB/GYNs willing to accept Medicaid patients. This paper examines the availability of office-based obstetric care to Medicaid patients in Illinois. We present and test a model of the determinants of Medicaid participation by private, office-based OB/GYNs that highlights the role of residential segregation and practice economics. We find that a large growth in demand for obstetrical care or the enhancement of Medicaid fees is unlikely to have a major effect on OB/GYN participation in Medicaid. We conclude that improving access will require expanding the supply of providers in underserved areas.

Eligibility Determination↗
PubMed1991

The role of local hospitals in physician rural location decisions.

This study has two objectives. First, it identifies how much the presence of community hospital beds adds to the stock of physicians practicing in nonmetropolitan counties. Second, it estimates the impact hospital closures or other reductions in beds have on the net flow of physicians into rural counties. The study relies primarily on data from the 1981 and 1986 Physician Masterfiles of the American Medical Association. We find that hospital bed reductions and closures essentially do not affect the availability of physicians--they have apparently already left by the time the downsizing occurs. Further, population change and the number of physicians already in the county determine for the most part the entry or exit of physicians.

Career Choice↗
PubMed1990

The growing proportion of female physicians: implications for US physician supply.

This study analyzes how the growing proportion of women in the United States physician population will affect the amount and type of physician services available to the US population. Female physicians work fewer hours per week, are slightly less likely to be in patient care, and tend to enter different specialties than male physicians. Female physicians also have higher retirement rates than male physicians, but due to their lower mortality rates, have work lives nearly as long as male physicians. We examined how the changing composition of the physician population will affect the availability of physician services by comparing historical and projected trends for the number of active post-residency physicians with comparable trends for a full-time-equivalent measure of physician supply. The full-time-equivalent measure takes into account the different labor supply behavior of key subpopulations (e.g., women and graduates of US versus foreign medical schools). The results suggest that the changing composition of the physician population will reduce the growth of effective physician supply between 1986 and 2010 but only by four percentage points.

Adult↗
PubMed1990

Medicaid in the inner city: the case of maternity care in Chicago.

The growing concentration of lower-income groups, including Medicaid patients, in homogeneous inner-city areas such as Chicago casts considerable doubt on the effectiveness of expanding Medicaid eligibility and raising physician reimbursement to improve access to maternity care. There are few private office-based physicians providing prenatal care in these areas, and most pregnant women and infants are treated by private-office-based physicians in very high-volume practices, prompting concern about the quality of care. Increasing the supply of providers is required to enhance access to maternity services in inner cities. Expanding eligibility and raising reimbursement rates are more apt to benefit "near-poor" women, who are more spatially dispersed, than clustered-poor female populations.

Aid to Families with Dependent Children↗
PubMed1987

Physicians' decisions to limit Medicaid participation: determinants and policy implications.

Although most primary care physicians participate in state Medicaid programs, they may accept all Medicaid patients, or they may choose to limit their participation. This decision allows physicians to adjust their Medicaid caseloads to a desired level, and it has important implications for the access of low-income patients to health care. Surveys of pediatricians in 1978 and 1983 indicate that the proportion of pediatricians limiting their Medicaid participation increased significantly from 26 percent to 35 percent (p less than .001). In addition, in both 1978 and 1983, limited participants saw significantly fewer Medicaid patients than full participants. This paper describes a number of strategies available to federal and state policymakers for fostering full Medicaid participation. Multivariate analyses indicate that increasing reimbursement levels is an important strategy for encouraging full Medicaid participation. In addition, full participants will increase their Medicaid caseloads in response to a variety of Medicaid policy incentives, while limited participants are found to respond to fewer policy incentives. The authors conclude that caution will be needed to ensure that health care cost-containment strategies such as capitation or selective contracting do not inadvertently discourage participation among both full and limited Medicaid participants.

Health Services Accessibility↗
PubMed1987

Changes in the supply of internists: the internal medicine population from 1978 to 1998.

Between 1978 and 1985, the number of active internists in the United States increased from 64,000 to 91,000, and by 1998 the number will have increased to 141,000. This growth represents an increase of 121% for a 20-year period, during which time the population of the United States is expected to increase only 19%. Thus, the number of adults older than 17 years per active internist will drop from 2464 to 1401. Between 1978 and 1998, we expect the number of subspecialty internists to increase 206%, in contrast to a 77% increase expected for general internists. The proportion of female internists will increase from 7% to 21%. The proportion of the active internist population who are foreign medical graduates will remain stable at about 21% throughout the projection period, but within this group the proportion who are United States citizens is expected to increase while the proportion who are foreign citizens is expected to decline.

Adult↗
PubMed1986

Recent trends in pediatrician participation in Medicaid.

Many Medicaid policy changes occurred in recent years including those resulting from the Omnibus Budget Reconciliation Act of 1981 and the Tax Equity and Fiscal Responsibility Act of 1982. At the same time, the supply of providers increased and the health care market became more competitive. This paper presents evidence about how these developments are affecting pediatricians' participation in state Medicaid programs. Surveys conducted in 1978 (N = 814) and 1983 (N = 791) indicate that the proportion participating declined only slightly from 85.1% to 82.0%. The average Medicaid case load of participants remained at 15%, although extent of participation of individual pediatricians fluctuated. Previous research demonstrates that physicians' Medicaid participation is affected by reimbursement level, administrative complexity, and generosity of eligibility and benefits. Our data confirm these influences. However, the longitudinal design of the analyses reported here also captures shifts in the relative influence of these factors. The influence of policy factors has diminished over time, while the influence of changes in physician supply has increased. Increased physician supply, however, is associated with decreased Medicaid participation. Thus, diminished access to pediatric care for low-income children may result from recent changes in Medicaid and in the broader health care environment.

Health Services Accessibility↗