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Vast territory surrounded by vast territory

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Vast territory surrounded by vast territory a development and maintenance theory of access to primary health care on the frontier
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Development and maintenance theory of access to primary health care on the frontier
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Bailey, Barbara E
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English
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ix, 225 leaves : illustrations ; 29 cm

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Rural health services -- United States ( lcsh )
Rural health services ( fast )
United States ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Includes bibliographical references (leaves 212-225).
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Submitted in partial fulfillment of the requirements for the degree, Doctor of Philosophy, Public Administration.
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School of Public Affairs
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by Barbara E. Bailey.

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Full Text
VAST TERRITORY SURROUNDED BY VAST TERRITORY:
A DEVELOPMENT AND MAINTENANCE THEORY OF ACCESS
TO PRIMARY HEALTH CARE ON THE FRONTIER
by
Barbara E. Bailey
B.S., University of Missouri Kansas City, 1966
M.A., University of Missouri Kansas City, 1974
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Public Administration
1997


1997 by Barbara E. Bailey
All rights reserved.


This Thesis for the Doctor of Philosophy
degree by
Barbara E. Bailey
has been approved
I !
Linda deLeon


Bailey, Barbara E. (Ph.D., Public Administration)
Vast Territory Surrounded by Vast Territory: A Development and Maintenance
Theory for Access to Primary Health Care on the Frontier
Thesis directed by Professor Peter deLeon
ABSTRACT
This study examines maintenance of access to health care through use of nurse
practitioners and physician assistants (NP/PA) in remote areas of this country where
the population density is six or fewer persons per square milethe frontier.
Logit analysis is used to examine the characteristics of fifty communities
(based on a survey of 500 residents) who have been successful in maintaining access
to care through retaining a NP/PA for longer than three years compared to
communities unable to recruit a provider, or the provider left in less than three years.
Data on the characteristics of the providers were gathered through interviews
conducted with thirty NP/PAs, fifteen who had remained in frontier communities, and
fifteen who had not. Herzbergs Dual-Factor Theory of Job Satisfaction is used to
categorize the sources of satisfaction and dissatisfaction among these providers. A
series of factors previously reported to influence retention was also tested through a
logistic regression application.
The logit analysis indicated that the community characteristics having the
IV


greatest influence on maintenance of health care providers include a combination of
socio-economic factors and community leadership. The findings showed that the
odds of a community with low per capita income and poor community leadership
being unsuccessful in maintaining a NP/PA were ten times greater than a community
with high per capita income and good leadership. The "perception" of economic
strength was also a major factor in successful communities. For the providers, the
logistic regression procedure failed to confirm previously identified factors such as
marital status, age, residence of origin; however, the qualitative findings differentiated
between factors that produced job satisfaction (the work itself and recognition) and
dissatisfaction (working conditions, call schedule, excessive time commitment).
The findings suggest a need for a more comprehensive approach to overall
community development, termed a "development and maintenance theory." Greater
emphasis must be placed on community development designed to.enhance the quality
of leadership and the socio-economic status of the community, enabling communities
to work with providers to reduce the "dissatisfiers" in the practice.
This abstract accurately represents the content of the candidate's thesjs. I recommend
its publication.
Signed.
Peter deLeon
v


DEDICATION
This thesis is dedicated with gratitude and appreciation to the health care
providers and communities leaders who work to make access to primary health care a
reality on the frontier. Their dedication and perseverance has been the inspiration for
this paper.


CONTENTS
Acknowledgments..............................................ix
CHAPTER
1. INTRODUCTION ............................................. 1
Purpose of the Study................................ 7
Scope of the Study................................. 10
Organization of the Thesis......................... 11
2. REVIEW OF THE LITERATURE................................. 13
Health Economics................................... 14
Rural Health Research...............................31
Location of Practice Site.......................... 37
Motivation-Hygiene Theory.......................... 47
Review ............................................ 56
3. METHODOLOGY.............................................. 58
Introduction....................................... 58
Research Hypotheses................................ 58
Data Collection..... .............................. 60
Data Gathering: The Communities ................ 62
H2 Data Gathering: The Providers .................. 67
Treatment of the Data ............................. 72
4. FINDINGS................................................. 77
H, The Communities ................................ 77
vii


H2 The Providers....................................... 100
Herzberg's Dual Factor Theory
Applied to the Providers .............................. 117
Intrinsic Factors............................... 119
Extrinsic Factors .............................. 125
5. CONCLUSIONS AND RECOMMENDATIONS.............................. 140
Discussion of Findings................................. 140
The Communities........................................ 141
The Providers ......................................... 148
Recommendations........................................ 153
Implications for Policy Makers.................. 155
Implications for Communities.................... 159
Implications for Health Care Providers.......... 163
Implications for Health Professions Educational
Institutions.................................... 165
Conclusion............................................. 169
APPENDIX
A. State Representatives Who Assisted in the Study.............. 173
B. Cover Letter and Community Survey Instrument................. 174
C. Provider Interview Instrument................................ 183
D. Maps of Study Communities.................................... 189
E. Crosstabulations of Community Data........................... 195
F. Crosstabulations of Provider Data............................ 201
G. Herzbergs Factors Applied to Providers...................... 208
REFERENCE LIST ....................................................... 212
viii


ACKNOWLEDGMENTS
Although the writing of a dissertation has been described as a long and lonely
task, it cannot be accomplished without the help and support of a quiet legion of
family, friends, co-workers, and especially the committee. I want to take this
opportunity to express my gratitude and appreciation to that quiet legion, friends
who brought goodies and vitamins, my staff who were quietly, but consistently
encouraging, and especially to the members of my committee who were both
supportive and helpful during the long gestation period of this paper. They are:
Peter deLeon, Chair, who encouraged, advised, applauded, coaxed, and
consoled during this process,
Linda deLeon, who advised and provided the foundation for the methodology,
Curt Stine, who brought the realities of working with students to the task,
Sheri Eisert, who challenged and questioned in a benevolent and helpful way,
Loren Amundson, who with his experience and knowledge in rural health,
provided inspiration to complete the task. Special appreciation is extended to Dr.
Amundson for his involvement from South Dakota, his willingness to accomodate my
schedule, and his gentle prodding.
I also want to thank the state representatives who provided names of
communities, community leaders, and health care providers who participated in the
study. The names of those individuals are included in Appendix A. Without them,
this study could not have been completed.
Of course, it is the spouse who suffers most during this time, so to my
husband, Don, I express my love, my thanks, and my appreciation for his support, his
understanding, and for his computer expertise in making it look good.
IX


CHAPTER 1
INTRODUCTION
In his health message of 1971, President Richard Nixon stated,
Just as our National Government has moved to provide equal
opportunity in areas such as education, employment and voting, so we
must now work to expand the opportunity for all citizens to obtain a
decent standard of medical care. We must do all we can to remove any
racial, economic, social or geographic barriers which now prevent any
of our citizens from obtaining adequate health protection. For without
good health, no man can fully utilize his other opportunities (Lewis,
Fein, and Mechanic 1976, 5).
In 1991, twenty years later, The American Journal of Public Health reported
that although the number of physicians in the U.S. had increased nearly four times
more rapidly than the population between 1975 and 1988, physicians remained
concentrated in urban centers with the ratio of physicians per 100,000 persons
equaling 226 in metropolitan areas, but only 98 per 100,000 in nonmetropolitan or
rural areas (Frenzen 1991, 1141).
In 1993, the issues of rural health care reform were considered of such
magnitude that a "Rural Health Care Summit" was held in Little Rock, Arkansas. A
paper commissioned for this meeting stated that one of the measures of success of the
health reform package developed by the Clinton Administration will be how it
addresses the unique needs of the approximately one-fourth of the population that live
in rural areas of this country (Christianson and Moscovice 1993). Further, the
literature suggests that rural residents, on average, are in poorer health than urban
1


residents, frequently having a higher prevalence of chronic illness and disability
(Summer 1991; Rowland and Lyons 1989), and that rural residents under age sixty-
five are more likely than urban residents to lack private or public health insurance
coverage. Rural residents are also less likely to be covered by Medicaid (Braden and
Beauregard 1994; Franzen 1993; Rowland and Lyons 1989).
Data from the 1987 (published in 1994) National Medical Expenditure Survey
show that rural residents eighteen years of age and older tended to assess their health
status less favorably than did residents of urban areas, with 28 percent indicating poor
or fair health. Rural adults were also more likely to state that they had been diagnosed
with a chronic condition than were adults in urban areas. It was also interesting to
note that although in-office waiting times showed no difference between urban and
rural areas, rural residents were almost twice as likely to have to travel for over thirty
minutes to reach their source of care than were residents of other areas. This survey
confirmed many of the statements previously made about the poverty and health status
of the rural population in America and their access to and utilization of health care
(Braden and Beauregard 1994).
According to an Institute of Medicine study of the physician workforce in this
country, access to care ranks as the second-highest priority issue for health policy,
after expenditures. Concern about access to health care was expressed long before the
rise in the cost of health care began receiving primary attention, and gave rise to the
increase in physician supply over the past two decades. The concern for access was
2


particularly directed toward the elderly, the poor, and the residents of rural areas
(Institute of Medicine 1996, 53). These comments, concerns, and data suggest that
problems surrounding health care services in rural areas are at a serious level, and
constitute a public policy issue deserving of serious consideration.
With the emphasis currently being placed on health care and welfare reform at
both the state and national levels, the issue of accessibility to quality health care
demands the attention of public policy makers and public administrators alike
(McCloskey and Luehrs 1990). The rising costs of health care, estimated to reach
$1.7 trillion by the year 2000, an amount equal to 18.1 percent of the Nation's gross
domestic product (Burner, Waldo, and McKusick 1992, 1-2), focus primary attention
on the issue of financial accessibility. However, it is just as important to realize that
geographic access problems will not automatically disappear when some type of state
or national health plan is enacted and implemented. Removal of financial barriers may
not affect the geographic distribution of health care professionals; in fact, it is possible
that such action could exacerbate the problem, for distribution of physicians to rural
areas is by no means guaranteed. For example, removal of financial barriers may
increase the demand of the previously underserved in urban areas, conceivably
resulting in even more health care professionals choosing to practice in cities, further
reducing the numbers available for service in rural and frontier areas.
Illustrative of this potential problem is the statement in The New York Times
of Adam Clymer who visited South Dakota in 1994. After spending some time in the
3


state, he wrote, "Several days of conversations here made it clear that the big problem
is less how to pay for health care than to make sure that there is health care to pay for"
(Clymer 1994). The rapid growth of managed care organizations (MCOs), largely
based in urban areas, is another factor affecting the distribution of health care
providers, since these organizations tend to utilize a greater proportion of generalist
providers (Cobum et al. 1994). These are the same physicians who have traditionally
been more likely to locate in rural areas. This competition can play out by enticing
rural providers to relocate to urban areas (Orfoff and Tymann 1995).
This distribution or allocation problem is heightened by the fact that the United
States has been training a disproportionate number of subspecialist physicians at the
expense of generalists such as family practitioners or general internists, resulting in
shortages of primary care physicians in many areas. In 1931, more than four out of
five private practice physicians were in general practice. By 1965, the proportion had
dropped to less than one-half. By 1988, the proportion in the generalist specialties had
decreased to approximately one out of three, and by 2010, estimates predict the
number to drop to 28 percent (Council on Graduate Medical Education 1992, 18).
The Institute of Medicine recently released a study called The Nation's Physician
Workforce, in which an apparent current oversupply of physicians was discussed.
Although the committee was not in agreement nor prepared to declare an oversupply,
it did state that "It is difficult to see that an oversupply will have much effect on
problems of access to care in this country; an abundance of physicians will not solve
4


the problems of maldistribution by geographic area or specialty" (Institute of Medicine
1996,4). This statement on the part of the Institute of Medicine clearly refutes the
"theory of diffusion" that formed the basis for state and federal governmental
interventions of the 1960s and 1970s, when grants dollars were made available to
increase both the numbers of physicians in training programs as well as the number of
medical schools. The theory that the principles of the market place would force
physicians into underserved areas has not proved to be true. The observed inability or
unwillingness of physiciansin particular, medical specialiststo practice outside urban
population centers makes the issue of care in sparsely populated rural areas even more
severe. Nor is it likely to improve on its own.
The policy problem, then, is who will provide quality primary health care for
the population in the most rural and isolated parts of this country, which have become
known as "frontier" areas by the Department of Health and Human Services (U.S.
Congress, Senate 1990, 174), as we move into the 21st century. By for, the majority
of these isolated areas is found in the western part of the country. The six states that
make up DHHS Region VIEColorado, Montana, North Dakota, South Dakota,
Utah, and Wyomingare all considered "frontier" states by virtue of having six or
fewer persons per square mile in half or more of their counties.
The total number of counties in these states is 290, of which 185 (nearly 65
percent) are classified as "frontier," with a population of 1,307,839 based on 1990
census data. Of the 185 frontier counties in the region, almost three-quarters (131)
5


lost population from 1980 to 1990 thus increasing the number of "frontier" counties
from 177 to 185. The total number of primary care physicians (PCPs) located in these
counties in 1992 was 438, for a ratio of 40 primary care physicians per 100,000
persons. There were also 165 nurse practitioners and physician assistants serving
these counties.1 These data are consistent with those reported by Frenzen (1991,
1143) that show the primary care physician to 100,000 population ratio in remote rural
areas to be 38.2 in 1988 compared to 95.9 per 100,000 in metropolitan areas.
Further complicating the issue are principles of equal access. The population
of these areas find themselves effectively discriminated against in terms of quality
health services almost totally as a function of their geographic location. This issue of
equity is articulated by Amy Gutman in the volume titled, In Search of Equity: Health
Needs and the Health Care System:
A principle of equal access to health care demands that every person
who shares the same type and degree of health need be given an equally
effective chance of receiving appropriate treatment of equal quality so
long as that treatment is available to anyone (Gutman 1983, 44).
Access to health care in the frontier states is not only a major concern at the
national level, but also of both the states' governors and their legislatures. Thus, there
is an urgency on the part of various agencies within state and federal governments to
draft proposals and implement policies that will assist in addressing this issue.
1 Provider figures obtained from state primary care access plans submitted to the Public Health
Service, February 1993.
6


Purpose of the Study
The problem, although increasingly pressing, is not new (Mott and Roemer
1948). In the late 1960s and early 1970s, there were several policy responses to what
was then being called a crisis in rural health care. Federal programs were developed to
increase the number of medical schools and medical graduates, with an emphasis on
increasing the number of physicians who would go into practice in rural areas, a
hoped-for application of "difiusion theory." Another important development during
this time period was the establishment of "midlevel practitioners" (MLPs)nurse
practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs).
These professional groups, sometimes referred to in the aggregate as non-physician
providers (NPPs), developed rapidly to redress geographic maldistribution of primary
care providers, in response to what was described as a "crisis in rural health" in the
early 1970s (U.S. Congress OTA 1990, 249).
A six-volume series of guidebooks, The Rural Health Center Development
Series, was published in 1979 by the Health Services Research Center of the
University of North Carolina (Chapel Hill) to help underserved rural communities
understand the potential and problems in the development of primary care health
centers staffed by what were then referred to as "new health practitioners." The series
was the culmination of a three-year project that studied community-operated nonprofit
health centers staffed by NPs and PAs, supervised by physicians from nearby towns.
This nationwide experience indicated that the NP/PA system provided high-quality
7


outpatient care for the majority of common illnesses and injuries (Bernstein, Hege, and
Farran 1979). Further, it appeared that NP/PAs were likely to locate in rural areas
unable to support the practice of a physician.
Yet, nearly two decades later, the issue of access to health care in rural areas
continues to be of primary concern to rural citizens and policy makers alike. The
Office of Shortage Designation of the U.S. Public Health Service lists 2,617
geographic areas of the country designated as Health Professions Shortage Areas
(HPSA) based on a primary care physician to population ratio of 1:3,500 as of
December 31, 1995 (Office of Shortage Designation 1996). A physician to population
ratio of 1:3,000 may be used if unusually high need or insufficient capacity is
demonstrated using such indicators as poverty rate, infant mortality rate, rate of low
birthweight, and indicators of access to primary health care services, taking into
account the distance to such services. Of these 2,617 areas, 1,613 (62 percent) are
rural. These figures compare with a total of 1,921 primary care shortage areas, of
which 1,350 (70 percent) were rural in December 1979 (U.S. Congress OTA 1990,
295). In short, despite numerous efforts, the rural health crisis of the 1970s has
continued essentially unabated well into the 1990s.
It is interesting to note that for primary medical care HPSA designations, only
medical doctors (i.e., physicians in the primary care specialtiesgeneral or family
practice, pediatrics, general internal medicine, and obstetrics and gynecology) are
counted. The HPSA process does not count NP/PAs. These NPP providers were
8


consciously left out of the counts to avoid preventing areas that would otherwise
qualify (such as areas with small populations and no physician but one nurse
practitioner or physician assistant) from achieving HPSA designation and possible
eligibility for other kinds of federal assistance (Lee 1991). Since NP/PAs are not
included in the calculations to determine shortage area designation, it is difficult to
obtain an accurate picture of the overall availability of primary health care services in
these areas. It is unclear, for instance, to what extent the use of a system based on
local NP/PAs linked to primary care physicians for consultation and referral to serve
areas of geographic maldistribution has met or failed to meet the health services
criteria or expectations of its designers. With various types of state and national health
care reform proposals receiving attention, it is important to examine the adoption and
maintenance of this non-physician based system of health care if we are to avoid the
mistakes of the past, and, more importantly, to increase the accessibility to primary
health care for those persons who choose to live in frontier areas. Given the
shortcomings of the "diffusion theory" to explain a Mure of migration of physicians
into rural underserved areas, it now seems appropriate to focus on the characteristics
of communities and providers who maintained access to care in these areas the
advancement of a "development and maintenance theory." Picture this as a demand
and supply equation. Work on the supply side (e.g. more physicians) has not remedied
the problem, so it is appropriate to examine in greater detail the demand side of the
equation.
9


The purpose of this study, then, is to utilize statistical association methods to
determine: 1) the characteristics of frontier communities that enable them to maintain
access to care; and 2) the characteristics of the NP/P As that establish practices and
remain in these communities providing primary care services. The two should, of
course, reinforce one another. It is important to note that this thesis does not address
the issue of the initial move by a health care professional to a rural community.
Neither does it address "diffusion" of health care professionals into these areas.
Rather, it focuses on the need for development and maintenance of community
infrastructure combined with the careful match of provider characteristics to assure
access to health care in this volatile atmosphere of change in the health care
environment.
Scope of the Study
This paper examines the relationship between the characteristics of both the
community and provider in successful and unsuccessful non-physician based systems
of primary health care. The study sample examines fifty communities located
throughout the six states of DHHS Region VIII, Colorado, Montana, North Dakota,
South Dakota, Utah, and Wyoming. Fifty frontier communities from among the six
states were selected, twenty-five that sustained a NP/P A practice for three or more
years, and a contrasting group of twenty-five communities that were either
unsuccessful in establishing a NP/PA practice, or failed to maintain such a practice for
10


a three-year period. A survey instrument was designed and administered to a sample
of ten residents in each community who had been identified as "opinion or community
leaders".
Similarly, providers who remained in NP/PA practices in frontier areas for
three or more years were contrasted to providers who left similar communities. Data
collection was accomplished through interviews of NPs and PAs. The interview
consisted of a set of standardized questions followed by two open-ended questions
that allowed the respondents to discuss both positive and negative aspects of their
experiences. In this type of structured or ethnographic interview, the interviewer asks
most of the questions, using repetition to clarify the subjects' responses and
encouraging them to expand on their answers by providing specific examples (Marshall
and Rossman 1989).
Although communities and providers included in the study were obtained from
a variety of sources including census data, state and regional health care recruitment
lists, State Board of Nursing lists, Physician Assistant membership lists, the primary
sources consisted of data compiled by the State Offices of Rural Health and State
Primary Care Associations for location of both communities and providers.
Organization of the Thesis
This paper is organized in five chapters. The introduction defines the purpose
and scope of the study. The second chapter contains a review of the literature in
11


health care economics, rural health, practice location, and job satisfaction, providing
an historical perspective of the issues involved in access to health care and the factors
related to the maintenance of access to primary health care. Chapter 2 also establishes
the theoretical framework upon which this study is based, discussing findings of
previous studies and expanding on them. The methodological section, Chapter 3,
describes the research design, the data sources, and the statistical methods to be used
to estimate the relationships between maintenance of access to primary health care in
frontier areas and a variety of independent variables. The results of the analyses are
included in Chapter 4 and show the relative importance of the independent variables in
predicting maintenance of a non-physician based primary health care system. Chapter
5 contains the conclusions and discusses the policy and public administration
implications for policy makers, communities, health care providers, and health
professions educational institutions as they relate to improving the processes involved
in community development activities, recruiting and appropriately matching provider
and community, and maintaining services in frontier areas of this country.
12


CHAPTER 2
REVIEW OF THE LITERATURE
This study is designed to examine characteristics of both rural/ffontier
communities and health care professionals to determine common attributes that seem
to enable some communities to maintain access to primary health care services by
retaining a health care professional in the area. While numerous definitions of primary
health care exist, for this study, the provisional definition of primary care adopted by
the Institute of Medicine Committee on the Future of Primary Care will be used. It
states:
Primary care is the provision of integrated, accessible health care
services by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained
partnership with patients, and practicing in the context of family and
community (Institute of Medicine 1994).
The study draws from the base of health economics, an extension of welfare
economics, specifically the supply/demand issue of health care provider availability.
Herzberg's Theory of Job Satisfaction is used as the base for the assessment of
provider characteristics. Literature addressing various aspects of rural health and the
utilization of nurse practitioners and physician assistants has also been included to
complete the groundwork for this study.
13


Health Economics
Economics is an immense field that somehow is thought to affect nearly
everything one does. This literature review is not intended to be comprehensive, but
rather to highlight some of the salient aspects related to rural health care, specifically
the distribution of health care providers based on the theory of supply and demand.
The standard components of welfare economics include the theory of producer
behavior, the theory of consumer behavior, and general equilibrium. Welfare
economics is the study of how society allocates its scarce resources, how it transforms
inputs into outputs, and how it then distributes (or redistributes) those outputs to its
consumers (Detsky 1978, 9). It strives to identify the necessary and sufficient
conditions to generate a socially optimal production and distribution of goods and
services (Marmor and Christianson 1982). An understanding of the allocation of
scarce resources and the inverse relationship between supply and demand are basic to
a study of economics.
In health economics, a great deal of work has been done over the years
regarding physician supply and demand as reflected in the distribution of medical
services (Gordon, Meister, and Hughes 1992; Hicks and Glenn 1991; Hicks and Glenn
1989; Newhouse et al. 1982; Institute of Medicine 1978; Newhouse 1978; Eisenberg
and Cantwell 1976; U.S. Department of Health, Education, and Welfare 1976). In
feet, a 1991 study projects the size and composition of the primary care physician
population in metropolitan and nonmetropolitan areas to the year 2010 (Kletke,
14


Marder, and Willke 1991). These projections, based on need and demand studies in
light of demographics, are firmly embedded in welfare economics.
Allan S. Detsky (1978), in The Economic Foundations of National Health
Policy, goes to considerable length to review the basic principles and concepts of
welfare economics and to relate them to the health care industry. Included is the
theory of producer behavior (where the physicians and hospitals are considered the
producers of service), the theory of consumer behavior (where the patient is the
consumer of these services), and general equilibrium (which, according to economic
theory, should occur in a perfect market place where demand stimulates supply).
Detsky explains the various reasons that the market for medical services violates the
basic assumptions of classic welfare economics. These differences from the standard
assumptions include: uncertainty over both the incidence of illness as well as the
effectiveness of diagnostic and therapeutic procedures; information gaps, due to the
technical nature of the product and service, placing the consumer at a decided
disadvantage; rationality or irrationality resulting from the emotion-charged nature of
illness and death; and the whole concept of need and demand as it relates to control by
the physician combined with societal values.
Referring to health care as a "merit good," deemed by society to be distributed
according to need rather than ability to pay, Detsky discusses several governmental
interventions designed to make health care more "rational" and "equitable." The most
recognizable of these interventions is the public hospital, which provides care (i.e., a
15


merit good) to those who cannot afford to pay. Another standard intervention has
been the investment by the government in support of the education of health care
professionals through both grants to educational institutions to increase class size, and
provision of scholarships and loans to students pursuing health professions. These
interventions were a direct attempt to influence the "supply" of health care
professionals in response to projected shortages based on studies of need and demand,
as well as (secondarily) to lower the costs of medical services.
In their chapter on "Health Issues", Sharp, Register, and Leftwich (1992)
describe the major economic problems in the health care industry as those involving
efficiency in the supply of health services and equity in their distribution. Factors
helping to explain the growth in personal health care services include population
growth, inflation in the economy, and increases in medical care prices in excess of
general price inflation. Other factors include the underlying forces operating in the
market for health care services, such as changes in consumer tastes and preferences,
changes in the demographic features of the population (especially the aging of the
population), and increased utilization of resources in any given treatment resulting in a
higher real cost of personal health care services (Sharp, Register, and Leftwich 1992,
248). They also discuss the general uncertainty and unpredictability of illness.
Another special characteristic of health services included in the discussion is the role of
the physician, who operates on both the demand and supply sides of the market by
providing services to the consumer, while at the same time, determining what the
16


consumer needs in relation to service, medication, and hospitalization.
Consumer ignorance due to a lack of objective information on the efficacy of
treatment or quality of care is another characteristic affecting the efficiency of health
care. In a "perfect" market place, information is available to the consumer on a real-
time basis to allow for informed decision making. In the present medical services
regimen, however, almost no objective information is available concerning the quality
of health services; moreover, physicians are reluctant to give evaluations of the work
of other physicians. While certain medical treatments such as immunization to prevent
communicable disease provide "social spillover benefits" that enhance the health status
of all members of society, the benefits of other medical procedures, such as organ
transplantation, are available only to the individual users of these services and hence
are highly localized. They may, however, have a tremendous impact on the cost of
medical services, with possible "negative spillover benefits" extending to the
population as a whole in terms of increased costs of medical care.
Philip Jacobs (1987), in The Economics of Health and Medical Care, uses an
economic approach to understanding health problems, based on the identification of
scarcity as a fundamental cause of many of the problems. "Scarcity" is defined as a
deficiency in the quantity or quality of goods and services that are available in relation
to those amounts that people desire (Jacobs 1987, xv). Side-by-side with deficiencies
in health care at a given price (e.g., too few providers, too few nursing homes, and too
few emergency medical services) are the issues of "too many". These include high
17


cost procedures whose effectiveness is either unproved or short-lived, and hospital
services for the terminally ill that consume a disproportionate share of resources.
Thus, the issues in health care delivery from ambulances to hospices require a
study of the entire resource-allocation process.
Economists use models that serve as representations of reality, focusing on
"if...then..." kinds of statements. Jacobs carefully constructs an individual price-
quantity model using the basic economic hypothesis, "the lower the direct price offered
to the consumer (all other factors held constant), the greater the number of units of
that commodity he or she will demand" (Jacobs 1987,45). This is clearly
demonstrated in studies of health insurance coverage that have revealed greater
utilization of health care services by insured patients than by uninsured (Newhouse
1978; Helms, Newhouse, and Phelps 1978). For instance, in a study of Stanford
University employees and their dependents, the number of visits recorded for
individuals who were enrolled in the same plan in both 1966 and 1968 were examined.
In 1966, the plan completely covered physicians' services. In 1968, the plan was
adapted so that persons paid a co-insurance rate of 25 percent of the bill for physician
services. It was found that when compared to 1966, when services were free, there
was a 25 percent reduction in number of physician visits (Newhouse 1978, 10). In
addition, a Minnesota study reported that the uninsured averaged 2.47 physician visits
per year while those with insurance averaged 3.61 visits (Kralewski, Liu, and Shapiro
1992, 182). Clearly, studies have shown that the number of physician visits increases
18


with the presence of medical insurance.
Jacobs's (1987) discussion then moves beyond treating health care as an
everyday commodity (for example, rent or utilities) and explores modifications that
must be made to the model to take into consideration the special circumstances
surrounding health and medical care. One of these circumstances is the relationship
between medical care and life and death. In some circumstances, the demand curve
for medical services may be very steep, as in the case of a medical emergency, while in
others, the slope will be less steep as the degree of emergency declines or the
availability of substitution increases. Differences in consumer demand (taste) and the
uncertainty of illness must also be considered as they relate to supply and demand.
Jacobs (1987) also explores the impact of insurance on quantity of care demanded,
showing that as the direct price falls in terms of payment for services, the quantity of
patient visits demanded increases. This is, again, consistent with the previously
mentioned findings of Newhouse (1978), Helms, Newhouse, and Phelps (1978), and
Kralewski, Liu, and Shapiro (1992).
Of particular importance to the present study is a concept not mentioned by
other authors, that is, the situation where the money paid for medical care is not an
adequate reflection of the total resource commitment made by the patient. This is
described as an incomplete rendering of the patient's "opportunity costs." For
example, travel time from areas with a deficiency of health care to an area where there
is an adequate supply, waiting time, and temporary housing costs must also be
19


factored into the over all costs of medical care. These may be significant if one must
travel from an isolated area to obtain needed care. Berk, Bernstein, and Taylor (1983)
found that travel time for persons residing in HPS As was almost four times as likely to
exceed 30 minutes to the usual site of care than that of other rural residents. A
comparison of frontier areas with HPS As shows a high degree of redundancy, further
supporting the assumption of increased costs associated with access to primary health
care services in frontier areas due to the added indirect costs of traveling to obtain
care. Further supporting the increased cost to patients from frontier areas was the
finding of Welch, Larson, and Welch (1993), who reported that patients traveling long
distances use more resources and incur higher hospital costs than do local patients.
Two possible reasons were suggested. First, that seeking health care is delayed
because of distance, resulting in a more serious condition at the time of treatment.
Second, the lack of resources for follow up care, may result in longer hospitalizations
or more intensive care being given at the time of treatment (Welch, Larson, and Welch
1993).
In Health Economics: Efficiency. Quality, and Equity. Steven R. Eastaugh
(1992) takes a quite different approach to the discussion of health economics. The
basic introductory discussion of economics with the accompanying supply/demand
curves is missing, as is the justification for why health economics differ from everyday
economics. Instead, Eastaugh focuses on more comprehensive approaches to
maintaining health rather than on therapeutic medical care, and emphasizes cost-
20


benefit, cost-effectiveness, quality enhancement, and technology assessment. A
discussion of supplier-induced demand is included as it relates to the rising costs of
medical care, with studies cited showing the ability of physicians to affect consumer
demand by the way in which they practice medicine, the diagnostic laboratory tests
ordered, the medications prescribed, the treatments provided, and the referrals made.
If physicians are unable to maintain a target level of demand using a traditional fee-for-
service model, they can still maintain a target income by raising fees in response to a
declining demand for services. Eastaugh points out that one group of physicians
(general practitioners) has been unable to maintain a target income because the market
for their services is relatively more competitive and the need more elastic as compared
to surgeons, for example. It should be pointed out, however, that with the current
move to managed care where both costs and utilization are "managed," by the primary
care provider (PCP) as the appointed gatekeeper, the primary care providers are in
much greater demand, and in true economic fashion, are seeing their incomes increase
(Staub 1994).
Supplier-induced demand may be further illustrated by a 1982 study by
Wennberg and Gittelsohn (1982) that showed that the amount and cost of treatment in
a community have more to do with the number of physicians and medical specialties
than with the health of the residents. For example, the rate of surgery and other forms
of medical treatment were examined in 193 small areas in six New England states.
The overall rate of surgery varied more than twofold among the areas, with the total
21


rate correlated strongly with the number of surgeons and number of hospital beds.
While one would expect that the number of surgeries would be greater in areas having
more surgeons, the rates of three common surgical procedures (hysterectomy,
prostatectomy, and tonsillectomy) varied even morewith the highest rate being she
times the lowest one. This result appeared to be based more on the style of practice of
the individual physician than on the specific need of the patient (Wennberg and
Gittelsohn 1982), with an implication that physicians' incomes might be (at least a
partial) consideration in the identification of surgical need.
In a discussion of health care professional policies, Eastaugh (1992) addresses
nursing education and "physician extenders" (PEs), a term that includes both nurse
practitioners and physician assistants. Stating that federal support of PE training
programs has been one of the primary federal responses to the perceived shortage and
maldistribution of providers of primary care, Eastaugh emphasizes that the growth in
programs "was a by-product of the unmet consumer demand for primary care and the
perceived neglect of the human side of medicine" (Eastaugh 1992,279). In general,
PEs tend to take a more family-oriented approach to health care, including education
in an attempt to improve patient compliance with treatment while trying to convince
the patient that a healthier life-style is often attainable as well as more affordable. This
emphasis on prevention, health promotion, and care for the chronically ill seemed to
fill a gap in health care services according to Eastaugh. The result of this response to
the perceived shortage and maldistribution of PCPs was a fivefold increase in the
22


supply of PEs from 1970 to 1980, with reduced growth from 1981 to 1991 (Eastaugh
1992), due primarily to reduced federal support of educational programs. As
arguments for a "doctor shortage" or, more accurately, geographic and specialty
maldistribution continued, the promise of the physician extender seemed to portend an
improved access to care, preventive health education counseling, and gains in
productivity.
In 1977, the Congress passed the Rural Health Clinics (RHC) Services Act (PL
95-210), which allowed Medicare and Medicaid payments to be made to clinics
located in rural areas for health care services furnished by or under the direction of an
NP or PA without the physical presence of a physician. The Act has led to the
establishment of NP/PA-staffed rural health clinics in areas unable to recruit and retain
a full-time physician. Physician supervision is generally provided from a remote site
(Bell, Raetzman, and Aiuppa 1991, 4; NRHA 1994b). With advances in
telecommunication and telemedicine, specialty consultation is increasingly being
provided from remote sites as well. A report from The Second Invitational Consensus
Conference on Telemedicine and the National Information Infrastructure held in
Augusta, Georgia (May 1995) states that telemedicine enables the efficient use of NPs
and PAs under virtual physician supervision via telecommunications without
jeopardizing the health, well-being, or safety of the patient. The article further states
that the practice of telemedicine is especially important in remote medically
underserved areas where there is substantial need for care and the resources are limited
23


(Bashshur, Puskin, and Silva 1995).
Studies by the Department of Health and Human Services (U.S. DHHS 1991)
have indicated the difficulty in determining whether and to what extent NP/PAs act to
improve medical productivity and decrease average costs by performing delegable
tasks, and whether they free physician time to perform more costly and complex
tertiary medical care. Or, in economic terms, to what extent do NP/PAs act as
substitutes and/or complements for physician time? Studies of the cost-effectiveness
of NP/PAs have been carried out since the beginnings of the programs to support the
utilization of these health care providers. Some have lumped NP/PAs together,
looking at the physician substitution factor (Record et al. 1980; Mendenhall, Repicky,
and Neville 1980; Bicknell, Walsh, and Tanner 1974). Other studies (Eastaugh and
Regan 1990; Cawley 1986; Hershey and Kropp 1979; Nelson, Jacobs, Cordner, and
Johnson 1975; Zeckhauser and Eliastam 1974) have looked at either NPs or PAs,
describing the differences between the two professional groups.
Because NPs are also registered nurses and come from a nursing background,
their approach to patient care is both complementary and substitutive as nursing and
medical care functions overlap. Their services are usually considered to be more
comprehensive substitutive services because of their educational backgrounds in health
promotion, prevention, and education (Sweet 1986). PAs have traditionally been used
to expand access to care, and are often used to provide medical services in
underserved areas (Regan and Harbert 1991). In the case of both NPs and PAs,
24


however, their respective salaries are considerably less than that of physicians, so it
can be said that a less expensive overhead component has been substituted in the place
of a more expensive one, even after taking into consideration the fact that NP/PAs
provide a more limited scope of service.
Another possible positive outcome of the use of NP/PAs beyond increasing
productivity and improving access in typically rural underserved areas is simply to
make physicians more nominally aware of the need for the caring and educational
components of primary health care services. The tangible benefits to society of health
promotion, self-care, and prevention activities must be factored into any benefit-cost
study of NP/PAs (Eastaugh 1992). To the extent possible, it is also desirable to
include the less-tangible benefits to society such as the importance of feeling good
about one's sel£ having a feeling of some control over one's health through preventive
practices, and improved quality of life.
Donald Pathman (1991) reviewed three general approaches used to determine
the number of health professionals required to serve specific populations, highlighting
their application in rural health professions requirement estimates. The methodologies
are: (1) the provider-to-population ratio comparison approach; (2) the needs-based
approach, which determines provider requirements based on the numbers needed to
care appropriately for a population's medical morbidity, and (3) the demand-based
approach, which identifies medical provider requirements by determining the numbers
necessary to meet a population's actual provider use (patient demand). Pathman
25


indicated that the strength of the physician-to-population ratio approach is its
computational simplicity, requiring only modest data and expertise. The weakness,
however, is also this simplicity. Regardless of what is chosen as the comparative ratio
standard, any two populations of equal size will be found to have identical physician
requirements. This model fails to take into consideration differences in demographics,
morbidities, geography, barriers to access, or preferences of patients in utilization of
health care. The early designations of primary care HPSAs were based primarily on
provider-to-population ratios (1:3,500). However, Public Law 101-597, cited as the
"National Health Service Corps Revitalization Amendments of 1990," specifically
identified additional indicators of need to include: 1) the rate of low birthweight births;
2) the rate of infant mortality; 3) the rate of poverty; 4) access to primary health
services, taking into account the distance to such services. This action moved the
designation process for HPSAs toward a need-based approach.
The strength of the needs-based approach is its cost-consciousness. The
number of physicians required is based on a recognized disease burden by identifying
the numbers required to care for disease and provide for disease prevention. It
provides a medical care system as it "ought to be," at least as defined by health care
professionals. The weaknesses include the requirement for tremendous data on
disease prevalence and physician productivity and work hours. Despite the seeming
appearance of "objectivity," many of the data rely on expert opinion of disease
categories to be included (disease incidence, number of physician encounters and time
26


per encounter in the provision of quality care), upon which there is little agreement in
the health care community.
Unlike needs-based methods, which rely on professional ideas of biologic need,
demand-based methods look at actual patient health services utilization. Although
demand-based approaches have been described as applied econometric models, in
practice, they are often employed by non-economists who examine changes in
utilization due to changing health and disease status of a population, demographics,
health insurance coverage, and medical practice content and organization. The
strengths of this approach include the observation that utilization rates reflect actual
patient demand for health services, enabling health planners to anticipate the numbers
of physicians required to care for patients who actually will "show up." In rural areas,
where limitation to access and tendencies to use informal healers such as folk healers
(e.g., "medicine men," among Native American populations, or curanderos in Hispanic
populations) are greater, this approach is most relevant. Further, demand-based
methods account for the use of physician services not dictated by the biomedical
mode, such as office visits for psychosocial needs for which there is no biological
cause or cure.
Weaknesses include the significant data requirements on size and morbidity of
rural populations. These data are difficult to obtain due to the limitations of the health
statistics capability of most states. Mortality data is obtained from death certificates,
but morbidity data, with the exception of specific reportable diseases, is not routinely
27


reported. Further, traditional demand-based approaches do not take into consideration
the effects of unmet needs, i.e., biologic disease that does not receive care when care is
known to be effective. Contributing to this area are religious beliefs that prevent
acceptance of health care services including immunizations as well as treatment.
Demand is also affected by people who are simply frightened of medical care, and
prefer to "take their chances." None of these models capture "unmet demand," i.e.,
the portion of "desired" use of services not translated into actual use because of access
barriers, including financial, cultural, and geographic. (Pathman 1991, 329-341).
Hicks and Glenn (1991) developed a "critical mass model" used to determine
the population needed to support various specialties of physicians. This model was
adapted from a previously developed demand and supply model, in an attempt to
examine the issues of "critical mass" from a rural health care perspective (Hicks and
Glenn 1991, 357). The initial model determined the average number of times a year a
"typical" person used the services of a physician. The second step was to allocate the
aggregate number of visits among the first contact physician and the various specialty
physicians. The third step was to divide the number of patient encounters supplied by
each type of physician by the number of physician encounters demanded by the
population, deriving an estimate of the critical mass of population necessary to support
a physician in each specialty. This "critical mass" model indicated that a population of
approximately 10,000 would be needed to support what are described as first contact
specialists, e.g., internal medicine, obstetrics and gynecology, pediatrics and general
28


surgery. Quantitative adjustments were then made for rural conditions. For example,
studies have shown that for a variety of reasons, rural people have fewer physician
encounters per year, on average, than urban citizens. However, on average, rural
physicians provide more overall patient encounters than their urban and suburban
counterparts. The reason for this situation is unclear, but it has persisted over the
years (Hicks and Glenn 1991). One of the possible explanations is that rural residents
are less likely to have employer-based health insurance (Coward, Clarke, and
Seccombe 1993), and as noted previously, those with limited or no insurance generate
fewer physician encounters. Further, rural physicians working in areas demonstrating
a shortage of health care providers tend to work longer hours, seeing a greater number
of patients. As a result, the net effect of these differences between rural and national
averages is a higher critical mass of serviced population needed in rural areas to
support any given physician at a defined full-employment level.
The "critical mass" model developed by Hicks and Glenn was based on 1983
national averages, and described the population needed to support a general/family
practice physician as 2970. Adjusting for rural conditions, an analogous population
base of 3,990, or an increase of 25 percent, would be needed in a rural area. These are
questionable figures, however, because they assume the availability of a full range of
specialists. In areas where there is only a general or family physician with no
specialists locally, computations show that only about 2,000 people, or a 33 percent
decrease are required as the critical mass (Hicks and Glenn 1991, 360-363) because
29


PCPs typically have to treat a wider range of illnesses. Given that NP/PAs reportedly
spend more time with each patient than do physicians (U.S. Congress, OTA 1990),
this figure compares favorably with that of Moscovice and Rosenblatt who reported a
minimum population base of 1,500 to support a NP/PA site (Moscovice and
Rosenblatt 1979, 505).
Moscovice and Rosenblatt (1979) and Rosenblatt and Moscovice (1978)
studied the economic growth and development of rural primary care practices in the
mid-1970s. Their research included a determination of the length of time and the
population necessary for different types of health care delivery systems to become
financially self-sufficient, that is, able to maintain themselves without a community or
governmental subsidy. These systems included physician-based as well as NP/PA-
based systems, with some in highly isolated areas. Their findings showed that growth
of NP/PA sites was slower than physician sites, but self-sufficiency was being
approached in 2 Vi years, and might be reached in three to four years. This compares
favorably with physician self-sufficiency in rural areas, especially those having a
hospital. They also reported that a minimum population base of 1,500 people was
required to support such a system, while a population base of2,000 to 3,000 would be
necessary to support a physician practice (Rosenblatt and Moscovice 1978).
Certainly, market forces play a major role in the distribution of health care
professionals, with the supply in an area based to a large extent on both the need and
demand for services. However, as noted previously, health care does not adhere to
30


classic economic theory. Many other factors affect this distribution as well. The
impact of health insurance on number of encounters provided has been shown, as has
the failure of the "supply-side" approach of increasing numbers of health care
providers. Attention has also been given to the demand side of the equation with work
on the population necessary to support a physician or NP/PA practice. Less
information is available regarding the impact of managed care organizations on the
distribution of health care providers, but this changing environment must also be
considered if society is to address the equity problems of the distribution of health care
services.
Rural Health Research
During the 1970s, millions of federal and non-profit organization dollars were
directed toward the problems of rural health care delivery and the perceived condition
of medical underservice in these areas. Funding initiatives of both the federal
government and private foundations addressed the issue of access to services,
concentrating on the availability (or shortage) of human resources. A major focus of
these initiatives was the development of community-based practices or primary care
centers to take the place of the "old country doc" who was rapidly disappearing from
the scene (Murrin 1982). It soon became clear that in planning for health care services
in rural areas, special consideration had to be given to availability, taking into account
the social and cultural factors that affect the expectations and behavior of rural health
31


care consumers as well as those of health care providers.
In light of the wide diversity in rural America, a complex web of social,
cultural, and economic values has enormous impact on the way health care needs are
expressed as expectations by persons in different communities. Defining minimally
adequate levels of service and dealing with the question of equity in access to care are
problematic in health policy analysis, for they raise the issue of whether health care
resource allocations should be fundamentally based on "need" or on "demand" for
service (DeFriese and Ricketts 1989, 932). Subscribing to the principle of equal
access described by Gutmann (1983) in the previous chapter would, in fact, necessitate
that, in a resource-constrained environment, the urban dweller (rich and poor) have
reduced access to health care in order that their rural counterparts be afforded an
equally effective chance to receive treatment of equal quality; i.e., the urban dwellers
effectively subsidize their rural cousins.
During the social reforms of the 1960s and 1970s, health care in the United
States was increasingly viewed as a "right" rather than a privilege regardless of social,
economic, or most important for this study geographic disparities. Public
expectations about medical care and social services were rapidly rising and consumers
were becoming better informed, more demanding, and more involved in the issues of
availability, accessibility, and fragmentation of health care services (Aday et al. 1993).
Social consciousness was sharpened, perhaps in part due to the Civil Rights and
feminist movements of this time. The most sweeping health care legislation in this
32


countrys history was passed in 1965 in the form of Medicare and Medicaid (Marmor
1973). These Acts focused attention largely on the health care needs of the elderly
(Medicare), and to a lesser extent on the needs of the poor and underserved
(Medicaid).
This period also emphasized a concern for rural health care and a concomitant
growth and development of NP/PAs who began to fill a gap in service delivery in small
rural areas. According to the Office of Technology Assessment's report on Health
Care in Rural America (1990, 250), NP/PAs provide care, within their areas of
competence, whose quality is equivalent to that of care provided by physicians, and
often at a comparatively lower cost. The functions performed by NPs and PAs include
health assessments, physical examinations and basic diagnostic tests, management of
minor acute and chronic illnesses, development of treatment plans, and the
coordination and referral of health care services. Prescriptive authority varies among
the states. The OTA study also indicated that NPs and PAs generally saw fewer
patients, spending more time with each than did physicians, providing valuable
nonmedical services such as counseling and health education, and focusing on the
prevention of disease. These groups developed rapidly, primarily in response to
concerns over geographic maldistribution of primary care providers.
In June 1992, a second Congressionally mandated study of health professions
training needs in rural (including frontier) areas was completed. The report focused
attention on the supply of health professionals and whether such supply was adequate
33


to meet the demands for health care services in rural communities (National Rural
Health Association 1992). The study contained a comprehensive discussion of the
issues that had to be considered in attempting to develop guidelines for adequacy of
supply in low-population density areas. While most methodologies are
physician/medical care based, this particular report stated that the preferred method
used must be one that accepted the widest possible range of professional staff mixes
and took into consideration community values and concepts of adequacy of services
and the effects of both distance and low population density (National Rural Health
Association 1992, 82-83). The determination of an adequate service level would thus
be based on the health care needs of a regional population extrapolated from survey
data that are either locally generated or extracted from national data adjusted for the
population mix in the region. The resulting plan would be a structure of health care
requirements designed to meet the diverse needs of the population, using a range of
provider types. NP/PAs were to be an essential part of such an approach. This model
seems consistent with Pathman's description of the needs-based approach.
Another difficulty in determining an adequate service level revolves around the
definition of a "regional population" or a "rational service area" located within a large
geographic area. The concept of a "rational service area" is used by the U.S. Public
Health Service in the designation of Health Professional Shortage Areas (HPSA), a
specific designation made by the Secretary of the Department of Health and Human
Services that provides eligibility for participation in several federal assistance
34


programs. The presence of a source of primary health care within 30 minutes travel
time (as opposed to simple geographical proximity) has been established as a national
standard for primary medical care, taking into consideration various types of roads and
terrain (Lee 1991,439; Jacoby 1991, 429).
More recently, a method for tracking and analyzing geographic access to rural
health care services and personnel has been developed through the use of isochrones
executed via a computerized combination of road map and population data in a
Geographic Information System (GIS). Isochrones are conceptually similar to a
service area, and are defined as the geographic area around a point that is within "x"
number of miles or minutes "travel time" of this point. Once the isochrone has been
geographically delineated, a determination can be made of how many persons live
within or outside of the isochrone. These populations can then be characterized with
respect to any other data elements that are included in the population data base, in the
case here, an ambulatory health care facility (Root and Challender 1993). Because
most shortage area designations are currently based on geopolitical boundaries such as
counties or census tracts, the correlation between shortage areas and service areas is
sometimes difficult. For example, in the states included in this study, counties are
frequently very large, and inappropriate for identification of a service area. Further,
population centers frequently are located near the borders of other counties, resulting
in rational service areas that cross county boundaries. Given the fact that provider
data are maintained by county, this makes designation of areas other than counties, or
35


subdivisions of counties difficult. Therefore, a methodology such as the one described
above would produce more meaningful shortage area designations. This approach
seems promising and should be examined further.
A recent study by Shi and his colleagues (1993) demonstrated that the major
factors involving the use of NP/PAs in rural community and migrant health centers
were significantly influenced by both supply and demand factors. Among supply
factors, there is a significant and positive relationship between the number of total
center staff and the number of NP/PAs employed; i.e., the number of nonphysician
providers employed was estimated to increase by .23 for every additional staff
employed. The study did not differentiate among different types of staff, so it seems
fair to question whether the addition of janitorial or other ancillary staff not involved in
patient care would result in the same .23 increase in NP/PAs. The study also revealed
a significant but inverse relationship between the number of physicians and the number
of NP/PAs employed, indicating that the latter primarily serve as substitutes for
physicians in rural community and migrant health centers. The demand variable,
geographic location, and the centers' staffing policies are also significant determinants
of the use of NP/PAs with health centers in the Midwest and South more likely to
employ nonphysician providers than those in the Northeast. While this study does not
specifically examine the factors influencing practice location, the correlation between
utilization and practice location can be made, suggesting a greater relative need for
primary care providers in some rural areas of the country is being met through the use
36


of NP/PAs.
Several notable studies of issues effecting access to health care in rural areas
have demonstrated that the issue is extremely complex. Although significant changes
have been made including passage of Medicare and Medicaid and the development of
NPs and PAs, the goal of having access to primary care services within a 30 minute
time frame is far from being met. Emphasis has been placed on the need to utilize both
the widest possible range of professional staff mixes combined with community values
and concepts of adequacy of services, taking into consideration the effects of both
distance and low population density.
Location of Practice She
While the factors influencing the choice of a location to establish a practice on
the part of physicians have been studied on numerous occasions (Conte, Imershein,
and Mcgill 1992; Rosenthal, Rosenthal, and Lucas 1992; Riley, Myers, and
Schneeweiss 1991; Frenzen 1991; Kindig and Movassaghi 1989; Chaulk, Bass, and
Paulman 1987; Newhouse et al. 1982; Rosenblatt and Alpert 1979; Mason 1975), the
physical location decisions regarding NP/PAs have not been studied as extensively
(U.S. Congress OTA 1990, 319). The 1982 Newhouse study, prepared for the Kaiser
Family Foundation, U.S. Department of Health and Human Services, and the Robert
Wood Johnson Foundation, purposefully deleted towns with populations of less than
2,500 from the sample because of the costliness of coding population data for such
37


towns. Nonetheless, the study did examine the outcomes of a decline in numbers of
generalist physicians and the disproportionate affect on small towns where generalist
physicians make up a greater proportion of professional health care providers. The
study, based on location theory, looked at size of town as the major determining factor
but acknowledged that all towns of a given population are not equal, differing in
demand per person, number of persons in surrounding areas, and amenities. As a
result, no exact population figure or "critical mass" estimate necessary to support a
physician could be determined. Traditional market forces were discussed, but only as
they related to size of market area needed to support various specialist physicians.
Other studies (Hicks and Glenn 1991; Moscovice and Rosenblatt 1979) have examined
the population necessary to support a "full service" health care system that is large
enough to provide full service in terms of primary care plus hospital and some
specialty services. The population necessary to support this level of service was
suggested to be a minimum of 10,000.
Other studies have identified a wide range of potential factors important in
determining a physician's choice of practice location including spouse's opinion,
availability of hospital consultants and services, colleague interaction, and after-hours
coverage (Rosenthal, Rosenthal, and Lucas 1992). A study of residents in family
practice programs located in Washington, Oregon, Idaho, and North Dakota
attempted to compare the recruitment practices of small communities and urban cities
(Riley, Myers, and Schneeweiss 1991). The study sought to determine 1) whether
38


some sources of information about practice opportunities were considered more
important than others, 2) when residents began to identify practice opportunities, 3)
what factors contributed to an unsuccessful site visit, and 4) what components were
included in a site visit. The results indicated that referrals from medical school faculty
to residents were the most valued source of information. Indeed, most job searches
were initiated in the first six months of the final year of residency. Substantial
problems included an unreceptive or uncooperative physician community and a
reluctant spouse or partner, especially for those making visits to rural communities.
Interestingly, rural communities tended to provide a broader mix of professional and
personal activities during the community visit (Riley, Myers, and Schneeweiss 1991).
It was noteworthy that in this study, a rural community was defined as one of less than
10.000 population, a mid-sized town as having a population of 10,000 to 30,000, and
cities as population centers having 30,000 or more inhabitants. The reason for using
10.000 or fewer for rural was explained as that used as the working definition by many
Northwest hospital administrators and researchers. Given that the study involved
locations in Washington, Oregon, Idaho, and North Dakota where the number of
communities with populations under 10,000 dominate (in North Dakota only fourteen
of fifty-three counties, much less towns, have populations of 10,000 or greater based
on 1990 census data), it seems clear that the emphasis was on communities large
enough to support a hospital. This leaves large numbers of towns with populations
between 2,500 to 10,000 excluded from the study.
39


More recently, two decades of experience in the University of Washington
family medicine residency network was studied to identify differences between
graduates in rural and urban locations (Baldwin et al. 1995). Urban areas were
defined as those included in the Metropolitan Statistical Areas (MS As) as defined by
the Office of Management and Budget. The rural areas were divided into three
groups: 1) counties adjacent to MS As, 2) nonadjacent counties with 20,000 or more
urban population, and 3) nonadjacent counties with fewer than 20,000 urban
population (Baldwin et al. 1995,63). The last group was considered to be the most
rural and isolated of all locations. Unfortunately, this is a very general description, and
leaves the actual size of the community that can successfully support a family practice
physician undetermined. Nonetheless, the conclusions support previous findings
(Hicks and Glenn 1991) showing that rural physicians tend to establish private
practices more often than urban graduates who practice in a much broader range of
settings including health maintenance organizations, teaching practices, and salaried
clinics. Further, the patient care workload of rural graduates was substantially higher
than that of urban graduates, having more patient encounters in all settings. This again
is consistent with previously cited studies showing greater patient encounters in rural
areas (Hicks and Glenn 1991; U. S. Department of Health, Education, and Welfare
1976). As might be expected, the on-call schedule for the University of Washington
study was also significantly greater for those graduates in rural areas, and emergency
room contacts were four times greater. Another difference between urban and rural
40


practices was the broader range of procedures performed by the rural physicians, and
the reduced number of support personnel, both health care and administrative staff,
available to assist the physician (Baldwin et al. 1995, 65).
Clearly, these findings have implications for training programs as well as for
communities who are seeking health care providers. The findings suggest that training
programs should attempt to prepare providers interested in rural areas for the higher
patient care workload and the demands of the on-call schedule. Providers must also
learn to work with fewer support personnel. Communities, also, should understand
the greater demands placed on providers in rural areas and try to provide the
additional support necessary. It should be pointed out that the findings may not be
generalizable across the country, however, since the study targeted a group of family
practice residents who were primarily from allopathic medical schools. Data from the
American Academy of Family Physicians indicate that approximately 15 percent of
physicians practicing in rural areas are graduates of osteopathic schools and another
15 percent are international graduates (AAFP 1993; U.S. Congress, OTA 1990).
Therefore, it is not possible to state that the findings of the University of Washington
study would be consistent in another group. The study does, however, demonstrate
significant differences between rural and urban practices, and might then suggest that
there are also differences in the characteristics of physicians who establish practices in
these areas.
While some transference of information from physician practice location
41


selection to that of NPs and PAs may be possible, as has been pointed out previously
in this paper, most physician location studies have targeted communities larger than
the frontier areas included in this study. Although the number of practice location
studies of NPs and PAs is limited, the studies do tend to target smaller rural areas.
A study of the patterns of practice of NPs in a rural underserved area of South
Carolina revealed that the reasons for selecting a practice site in rank order were: role
autonomy, good salary benefits, adequate medical backup, and educational
opportunities. The surveyed NPs reported that the major contribution of their
presence in these areas was their ability to increase access to care for a significant
number of patients, especially the disadvantaged groups such as the working poor
through utilizing professional judgment and practicing independently (Lawler and
Valand 1988).
Among the long-standing areas of underservice, those portions of the country
referred to as "frontier" are the most removed from health care services. Bigbee
(1992) described these areas as opportunities for NPs to provide primary care services.
While there was no discussion of practice location decision-making on the part of
NP/P As working in these areas, Bigbee did identify frontier areas as favorable for the
development of NP practices. She continued and described three steps necessary to
establish a frontier practice: identify a frontier practice as a personal and professional
mission; establish an economic base (or demand structure) according to community
input and assessment data; and creatively design the practice and services for the
42


frontier population and environment. Analogous to the Lawler and Valands (1988)
findings, Bigbee's characteristics of NPs that might be successful in the establishment
of such a practice included: 1) comfort with high levels of autonomy in a variety of
primary care roles including practice development and management; 2) community
organization; 3) fund-raising; and 4) experience with broad-based acute, emergent and
chronic care. In addition, the NP must be attracted to living in sparsely populated
areas often surrounded by great expanses of natural beauty. Given the limited
availability of other cultural or social opportunities found in more densely populated
areas, out-door recreational opportunities must be attractive to the practitioner and
family (Bigbee 1992).
Amundson (1993) discussed the myth and reality in the rural health service
crisis, focusing on community responsibility. He indicated that there is a strong
tendency for rural community providers and leaders to externalize explanations for the
deterioration of local services, blaming the reimbursement system, the lure of the
cities, the inappropriate training in academic health centers, or the desire to use high
technology in patient care. The article further stated "that the primary reason for the
threat or demise of human services in most rural communities is the failure of
communities to meet the needs and expectations of local residents and to effectively
address local problems in the delivery system" (Amundson 1993, 177). While
indicating that the primary responsibility for the situation resides within many rural
communities, the strongest potential for maintaining services also resides within the
43


communities. According to Amundson, effective efforts at community-based solutions
require attention to three general areas: 1) application of principles for successful
community-based health work including emphasis on overall community development;
2) recognition that the money currently spent on human sendees in most rural
communities should be controlled by the communities, meaning that local services
must be utilized, keeping the money at home; and (3) creation of a national network of
organizations with the skills and resources to work effectively with communities on
community-based solutions (Amundson 1993, 183-185).
Similarly, in an initiative called Colorado Healthy Communities, support is
being provided to selected communities to "take back" the community, demonstrating
responsibility for both problems and outcomes. Or, as Tyler Norris, Director of the
Colorado Healthy Communities Initiative (CHCI) stated in his introductory comments
in the Colorado Healthy Communities Handbook, "The Colorado Healthy
Communities Initiative challenges individuals and communities to reclaim
responsibility for their health, and recognize that they are both the source and the
beneficiary of the actions they undertake" (Norris 1993). One of the several steps in
the Healthy Communities Process involves use of The Civic Index, a self-evaluation
tool developed by the National Civic League to enhance the ability of communities to
solve their problems, meet their challenges, and set directions for the future. The Civic
Index consists of ten components that have been found to be fundamental to a
communitys health and ability to work effectively. Those components include
44


citizen participation, community leadership, government performance, volunteerism
and philanthropy, intergroup relations, civic education, community information
sharing, capacity for cooperation and consensus building, community vision and pride,
and intercommunity cooperation (Norris 1993, 77-79).
The Northwest Area Foundation is a foundation committed to promoting the
economic revitalization of the upper Midwest and Northwest region of the country and
improving the standard of living for the region's most vulnerable citizens. From 1986
to 1993, the Foundation funded projects designed to increase community participation
in addressing the problems of health care in rural communities. Some of the general
lessons learned from the experiences with rural health care systems included: 1)
expanded citizen participation combined with expert technical assistance can be
essential in improving health services; 2) interventions are most effective in
communities where the health care system problems are clear, but have not reached a
point where options for correction have been lost; 3) piecemeal solutions are unlikely
to be effective because the needs of rural health care are seldom confined to a single
problem; 4) a single individual acting as a community change agent supported by a
local advisory group was a critical factor; 5) meaningful involvement of an exogenous
group of people outside the hospital structure in strategy development is important in
the communitys commitment to improve health services; 6) community goal setting
meetings gave residents a strong sense of inclusiveness; 7) the most effective strategies
integrated the perspectives of local decision makers and health care providers with
45


expert outside resources (National Rural Health Association 1994a). While this report
only addressed the experiences of projects designed to increase community
participation, the findings seem to support the comments of both Amundson and
Norris regarding the importance of community involvement in addressing the issues of
health care services in rural areasthat the problems may be more internal to the
community than external.
Finally, research at the University of Washington suggests that intracommunity
factors are largely responsible for failing rural systems, namely: 1) quality-of-care
issues; 2) poor leadership; 3) ineffectual performance by providers, managers and
trustees; and 4) the effect of poor teamwork and chronic conflict among local
providers (Amundson and Rosenblatt 1991). Given these findings, it appears that if
access to primary care services in frontier areas is to be maintained, at least two
concepts need to be explored the characteristics of the providers themselves that
may contribute to job satisfaction or dissatisfaction and the characteristics of the
communities that contribute to the development of viable health care systems and the
retention of health care professionals. In other words, we find another version of the
familiar supply-demand theory.
Briefly stated then, the literature reveals numerous studies of the influences on
the practice site decisions of physicians, but fewer studies of the same decisions on the
part of NPs and PAs. The majority of these studies have focused on larger towns of
10,000 or more, with very few examining the needs of communities of 2,500 or less.
46


Some of the most noteworthy influences effecting practice site decisions for NPs and
PAs included role autonomy, adequate medical backup, and opportunities for
continuing education. Necessary skills cited included a need for community
development and fund-raising skills, and in sparsely populated areas, an affinity for
outdoor activities. More recently, attention had been given to the need to improve the
overall community infrastructure, including economic base, community leadership and
cooperation with other communities, and commitment to improving the health of the
community.
Motivation-Hygiene Theory
In 1964, Frederick Herzberg advanced a dual-factor theory of job satisfaction
and dissatisfaction based on studies of accountants and engineers. Herzberg stated
that satisfaction and dissatisfaction are two unipolar traits rather than being opposite
ends of a bipolar continuum. Herzberg then identified factors inherent in the work
situation that are "satisfying", and that arise from the content of the work, i.e., are
intrinsic to the work itself. Increases in these factors are correlated with heightened
productivity. They were called "motivators." Environmental factors surrounding the
job or the context in which work is performed were associated with dissatisfaction and
were termed "hygiene" factors.
Among those factors deemed "satisfiers" or "motivators" are achievement,
47


recognition, the work itself, responsibility, and advancement. The last three were
identified as being of greater importance for lasting change of attitudes.
"Dissatisfiers," the hygiene factors, included company policy and administration,
supervision, salary, interpersonal relations, and working conditions (Herzberg 1966,
72-74). Follow-up studies identified the following additional factors: possibility of
growth was found to be a motivator, and status, job security, and effect on personal
life were identified as hygiene factors (Herzberg 1966, 77).
Herzberg also suggested that human attitudes are associated with needs, and
related them to Maslow's famous hierarchy of need. In this case, motivators are
associated with psychological growth as in the example of achievement. Hygiene
factors correlate more closely with animal needs that serve to reduce displeasure, but
since they do not possess the qualities necessary for psychological growth, they cannot
be conducive to the gratification of human needs. Thus, Herzberg indicated that the
two sets of factors have separate themes. Motivators describe one's relationship to
what is done job content, achievement of a task, recognition for task achievement,
the nature of the task, responsibility for a task, and professional advancement or
growth in task capability. The "dissatisfiers" or hygiene factors describe one's
relationship to the context or environment in which the job is done. In other words,
one cluster of factors relates to what the person does and the other to the situation in
which it is done.
A second level of Herzberg's analysis suggested that hygiene or maintenance
48


events led to job dissatisfaction because of a need to avoid unpleasantness while the
motivator events led to job satisfaction because of a need for growth or self-
actualization. Hence, the factors involved in producing job satisfaction are separate
and distinct from the factors that lead to job dissatisfaction. The opposite of job
satisfaction is not dissatisfaction, but rather no job satisfaction. Conversely, the
opposite of job dissatisfaction is no job dissatisfaction, not satisfaction with one's job
(Herzberg 1966).
Herzberg's theory has been used in several studies of nursing personnel
including nurse practitioners (Capan, Beard, and Mashbum 1993; Koelbel, Fuller, and
Misener 1991; Tri 1991; White and Maguire 1973). Other studies of this nature have
examined factors related to job satisfaction and autonomy as correlates of job retention
(Dunkin et al. 1992; Hanson, Jenkins, and Ryan 1990; Bream and Schapiro 1989;
Lender and Leach 1986). Still others have looked at factors and work setting that help
or hinder the practice of NPs (Hupcey 1993; Coward et al. 1992; Riner 1989). The
similarities of findings related to job satisfaction are great and show correlation with
Herzberg's motivator and hygiene factors.
The White and Maguire study (1973) utilized the same type of interview
method used by Herzberg in which respondents were asked to describe a time tell a
story when they felt particularly satisfied about the job. After this story was related,
the respondents were asked to relate a dissatisfying experience. The factors found
most often in the stories of job satisfaction included the work itself, achievement,
49


recognition, responsibility, and growth/advancement. Those found most often in the
stories of dissatisfaction were supervision, hospital policy, working conditions,
interpersonal relations, and salary. The findings were again consistent with Herzberg's
motivation-hygiene theory.
Koelbel, Fuller, and Misener (1991) used the Index of Job Satisfaction
(Brayfield and Rothe 1951) and the Minnesota Satisfaction Questionnaire Short
Form to test Herzberg's theory. A questionnaire was utilized to obtain the data from
132 NPs. The data revealed that respondents reported less satisfaction with extrinsic
factors than with intrinsic factors. Practitioners reported satisfaction when they helped
other people, used their abilities, had steady employment, varied their work, and
practiced without compromising their moral values, factors described as intrinsic. The
least satisfying job elements were the extrinsic factors of compensation, lack of
opportunity for advancement, company policies and practices, lack of recognition, and
supervision/human relations. While some differences exist, in general, Herzberg's
theory that intrinsic factors are sources of job satisfaction, while extrinsic factors are
sources of job dissatisfaction was confirmed (Koelbel, Fuller, Misener 1991).
Autonomy, sense of accomplishment, and time spent in patient care ranked as
the top three factors contributing to job satisfaction among nursing personnel in a
study of job satisfaction and characteristics of the practice setting completed by Tri
(1991). A seven-point scale was used as a summary measure of overall job
satisfaction, and for calculating relationships between certain practice-setting
50


characteristics and the level of job satisfaction reported. Correlation matrixes were
utilized to determine the relationships between certain practice-setting characteristics
and the NPs' overall satisfaction with the position (Tri 1991,49). Again, factors that
contributed to satisfaction included: autonomy, portion of time in patient care; sense
of accomplishment; challenge of learning and growing; amount of self-determination
offered; number and kinds of patients; quality of care within the setting; relationship
with peers; flexibility; and the ability to express creativity. Tri found that factors
contributing to dissatisfaction were: salary; compatibility of goals with organization;
environmental support for innovation; administrative duties; relationship with those to
whom one reported; time spent in educational activities; development of one's own
clinical skills; number and kinds of patients; support for outside activity; and
relationship with physicians.
Interestingly, the Tri study then proceeded to look at the correlation between
perceived skill levels and job satisfaction, initially using four skill levels novice,
intermediate, advanced, and expert. These groups were collapsed into two groups for
analysis that revealed significant differences between the skilled and less skilled
groups, with the less skilled being more dissatisfied with development of own clinical
skills, relationship with physicians, challenge of learning and growing, amount of self-
determination offered, flexibility, relationship with other disciplines, and relationship
with peers. Benner's 1984 work, From Novice to Expert was cited, indicating that
rule-governed behavior is typical of the novice, and is extremely limited and inflexible
51


(Benner 1984). Thus, the less-skilled NPs have less experience and may search for
rules to guide their performance, feeling frustrated with the nature of the NP role in
primary care where there are few hard-and-fast rules to guide performance.
Hanson, Jenkins, and Ryan (1990) examined the personal characteristics,
factors of job satisfaction, and autonomy that could lead to job retention for nurses in
rural Georgia. Contrary to their expectation, they found that personal characteristics
such as age, education, salary, marital status, and number of dependents are not strong
predictors of job retention. While some of these factors correlated negatively with
impending job change, the strongest relationships were those related to nursing
autonomy. The strongest correlations were found between autonomy and number of
times the nurse had looked for another job, and autonomy and intention to quit. Work
satisfaction, satisfaction with compensation, satisfaction with supervisor, and
satisfaction with promotional opportunities all correlated significantly with intention to
quit. Hupcey (1993) examined factors that helped and hindered practice. The top five
helping factors included acceptance and support from physicians, support from
coworkers, support from other NPs, independence in the work setting. Hindering
factors included lack of administrative support, lack of physician support, lack of
coworker support, and resistance of staff nurses.
The likelihood of registered nurses leaving rural settings was analyzed by Pan
et al. (1995). This logit analysis examined the effect of factors such as marital status,
age, position held, income, job satisfaction, and satisfaction with community. The
52


: I
findings indicated that nurses' feelings about their jobs and their communities had a
stronger effect on decisions to leave the position than did the other factors. The
margin between the highest and lowest net effects was between four and six times for
these two variables. Job satisfaction played the most important role in the nurses'
decisions about leaving their current jobs while demographic characteristics such as
marital status and age had only moderate effects on job decisions. Although
Herzberg's theory was not a part of this study, it does seem to support the basic
concept. The factors included in "job satisfaction" were not identified, rather,
respondents were simply asked to describe their level of satisfaction with their jobs and
with their communities.
An ethnographic study of job satisfaction among home care nurses (Chubon
1991) asked, as part of a larger study of job stress, what provided job satisfaction to
the service providers. Those aspects that contributed to job satisfaction included: the
independence of their practice; the opportunity to design and implement interventions
deemed appropriate; development of meaningful relationships with patients; challenge
of solving problems; and supportive relationships with coworkers. A recurring theme
in the descriptions given by the nurses was appreciation for compliments and
recognition of their accomplishments. While factors contributing to dissatisfaction
were not examined, it was interesting that salary was never mentioned as a factor in
job satisfaction. Again, independence, creativity, and problem-solving, factors that can
be described as intrinsic to the work, produced feelings of job satisfaction.
53


All of the preceding studies have come out of the nursing literature, addressing
either nurses or nurse practitioners. Literature referring to physician job satisfaction
has not been found. Similarly, little was found in the literature relating to job
satisfaction as it pertains to physician assistants. A report by Perry (1976) looked at
the general characteristics, job performance, and job satisfaction of PAs who
graduated in 1974 or before. Since PA programs were just developing in the 1970s,
the data were limited. However, the study did report that PAs were found to be
working predominantly in primary care specialties and in smaller communities. Among
factors that would fall within Herzberg's dissatisfiers was the PAs' perception of
limited opportunity for growth and advancement. The strongest correlates of job
satisfaction were the degree of physician supervisory support and the amount of
responsibility for patient care. Again, Perry found that satisfaction was related to
having responsibility for patient care within a supportive environment.
Bard-Lozecki (1977) studied PAs working within a mental health setting to
determine job satisfaction in relation to daily task performance, preference for tasks,
perceived effects of working with psychiatric patients, comfortableness with amount
and type of supervision received, relationships with coworkers, opportunities for
professional growth and promotion, salary and benefits. The results indicated that job
satisfaction was related to individual experiences, rather than to environmental aspects.
While this study did not look at factors contributing to dissatisfaction, the fact that job
satisfaction correlated with individual or intrinsic events supports Herzberg's dual-
54


factor theory that intrinsic factors contribute to job satisfaction while extrinsic factors
are related to dissatisfaction.
The growth of the managed care industry has increased demand for both
generalist physician and non-physician providers, largely for economic reasons.
Because the organizational structure of the managed care organization is significantly
different from the traditional private practice of the physician or the physician-NP/P A
relationship, some studies have attempted to address job satisfaction in managed care
or HMO settings (Freeborn and Hooker 1995; Freeborn 1985). In their study of the
satisfaction of physician assistants and other nonphysician providers in a managed care
setting, Freeborn and Hooker (1995) found that physician assistants were most
satisfied with the amount of responsibility, support from coworkers, job security,
working hours, supervision, and task variety. They were less satisfied with workload,
control over the pace of the work, and opportunities for advancement. Another major
contributing factor to PA job satisfaction was professional and personal support of the
supervising physician. While these findings are not directly comparable to the
"motivators" and "hygiene" factors described by Herzberg, those factors contributing
to less satisfaction are consistent with the dissatisfiers described in other studies based
on Herzberg's theory. It should be pointed out, however, that the Freeborn and
Hooker study was limited to only one large HMO located in the northwestern part of
the United States. Because this is one of the oldest and largest managed care plans, it
is questionable whether these findings are generalizable to other managed care systems
55


or to rural health care personnel, at least at this point in time.
In briefi Herzberg's Motivation-Hygiene Theory has been used as the base for
numerous studies of job satisfaction over the years. The results seem to confirm the
importance of the intrinsic (motivation) factors in job satisfaction compared to the
extrinsic (hygiene) factors in job dissatisfaction. In particular, studies of health care
personnel have shown that autonomy and independence, achievement, recognition, and
responsibility were frequently mentioned as factors influencing job satisfaction.
Factors identified with job dissatisfaction included supervision, working conditions and
policies, interpersonal relations, and salary.
Review
Overall, the literature supports the conclusion that the issues surrounding the
maintenance of access to primary health care in sparsely populated rural areas are
complex and not easily addressed. They are multi-faceted, requiring not only an
examination of the health care providers who serve these areas, but also the
characteristics of the providers who have chosen not to serve such areas. There must
also be an examination of the communities themselves, looking at the economic
development on-going, the resources present, and the leadership available. While state
and federal interventions have shifted emphasis from diffusion theory based on
increasing numbers of providers to strategic polices designed to address retention of
providers through the greater provision of support services such as access to
56


continuing education programs and on-site practice management assistance, the
literature would suggest that the problem is broader than simply "retention" of
providers by attempting to increase job satisfaction. Rather, a shift to a "development
and maintenance" theory of community infrastructure that provides the basis for an
integrated health care system capable of reacting to the volatile health care
environment is suggested. This study attempts to examine variables relating to both
the community and the provider that will perhaps provide the basis for an integrated
health care system and raise the odds of maintaining access to primary health care in
our most isolated and vulnerable areas, the frontier.
57


CHAPTER 3
METHODOLOGY
Introduction
The purpose of any study has at its foundation the desire to discover
something, to learn the reason for, to try to determine why. But before one can
discover, leam the reason for, or determine why, there must be a research plan. One
must define precisely what is to be learned, and then, determine the appropriate way to
implement the plan. The starting point is the research question. The challenge here is
in properly stating the question so that it will point in the direction of an answer. The
research question to be examined in this dissertation is why some small population
communities are able to maintain access to primary health care services through the
use of NPs and PAs, when other similar communities are unable to do so.
Research Hypotheses
The purpose of this study is to examine the characteristics of both the
community and provider in successful and unsuccessful NP/PA-based systems of
health care delivery in frontier areas of the United States, identifying and analyzing
those characteristics that lead to differing outcomes. Based on the review of the
literature in the areas of health economics, rural health including practice location, and
58


Herzberg's dual-factor theory of Job Satisfaction, two research hypotheses are posited,
the first dealing with community characteristics, the second with provider
characteristics. The study specifically examines the characteristics of both the
community and provider that are related to maintaining these practices in a frontier
community.
Ht The long-term maintenance of a NP/PA-based system of
primary health care is a function of the following
community characteristics:
o proximity (30 minutes travel time) to a
community of 10,000 or greater
o socio-economic status of the community
o availability of health insurance
o "critical mass" equal to or greater than
1,500 residents located in a rational
service area
o effective leadership at the local level
o utilization of local resources
In formulaic terms, this may be expressed as:
S = S(miles30, soec, ins, critmas, comled, locres), in which
S = status of the community either successful or unsuccessful,
miles30 = proximity to a community of 10,000 or greater,
soec = socio-economic status of the community (later tracked as
percap = per capita income of the county, and ecoperc = perception
of economic strength of the community),
ins = availability of health insurance,
critmas = critical mass equal to or greater than 1,500 residents,
comled = community leadership,
locres utilization of local resources.
N = 500
59


H2 The maintenance of a NP/PA-based system of health
care is a function of the following provider (i.e., NP/PA)
characteristics:
o provider/spouse residence of origin
o rural experience during training
o sense of autonomy/desire for independence of action
o sense of responsibility and achievement
o affinity for outdoor activities
o age/years of experience
o marital status
o supportive medical community including consulting physician
and provision for backup
In formulaic terms, this may be expressed as:
S = S(grewup, rurrot, autonomy, achresp, outdoor, years, marital, medcom), in which:
S = status of the provider either maintained or non-maintained,
grewup = residence of origin,
rurrot = rural experience during training,
autonomy = autonomy (later tracked as autoresp = autonomy and
responsibility),
achresp = sense of achievement and responsibility (later tracked as
ackreg = acknowledgment and recognition of achievement),
outdoor = affinity for outdoor activities,
years = years of experience,
marital = marital status,
medcom = supportive medical community.
N = 30
Data Collection
This study builds on the previous research of Moscovice (1989), Rosenblatt
and Moscovice (1978), Amundson, Hagopian, and Robertson (1991), Lawler and
60


Valand (1988), and Shi et al. (1993). It is designed to expand the knowledge bases
relating to the establishment and maintenance of NP/PA practices in frontier areas,
thus enabling these citizens access to quality primary health care services.
The research conducted by Shi and his colleagues (1993) examined utilization
of NP/PAs in a specific group of federally assisted primary health care centers in the
nation's medically underserved rural areas. The current area of investigation is
restricted to the least densely populated areas of six states Colorado, Montana,
North Dakota, South Dakota, Utah, and Wyoming targeting NP/PAs working not
only in federally assisted rural community and migrant health centers (C/MHCs), but
also in rural health clinics (RHCs) and other public or private practices in communities
with populations of2,500 persons or less, located in counties having six or fewer
persons per square mile.
Communities that sustained a NP/PA practice for three years or longer were
included in the study as "successful" while a contrasting group of communities that
were either unable to establish such a practice, or failed to maintain it for a three year
period were included as "unsuccessful." Similarly, an attempt was made to examine
the characteristics of providers who remained in NP/PA practices in frontier areas for
three or more years compared to those of providers who entered such practices, but
left the practice and the area in less than three years.
Based on the literature review, six independent variables affecting the ability of
a community to maintain access to health care services were identified. Thus, the
61


dependent variable for is "status of the community," either successful or
unsuccessful in retaining a health care professional, while the independent variables
include:
o proximity (within 30 minutes travel time) to a larger community of
10,000 or greater (Connor, Kralewski, and Hill son 1994; Hicks and
Glenn 1991; Kindig and Movassaghi 1989; Brooks and Johnson 1986;
Newhouse et al. 1982; Moscovice and Rosenblatt 1978)
o socio-economic status of the community (Connor, Kralewski, and
Hillson 1994; Bigbee 1992; Makuc et al. 1991; Newhouse et al. 1982;
Moscovice and Rosenblatt 1978)
o availability of health insurance (Frenzen 1993; Kralewski, Liu, and
Shapiro 1992; Makuc et al. 1991; Newhouse 1978)
o "critical mass" equal to or greater than 1500 located in a rational
service area (Hicks and Glenn 1991; Lee 1991; Moscovice and
Rosenblatt 1979)
o effective leadership at the local level (NRHA 1994a; Amundson 1993;
Norris 1993; Elder and Amundson 1991)
o utilization of local resources (Connor, Kralewski, and Hillson 1994;
Bronstein and Morrisey 1991; Hart, Lishner, and Amundson 1991)
Ht Data Gathering: The Communities
Given the number of variables to be examined in "naturally occurring groups,"
survey research was determined to be the most feasible approach (Aday 1989;
Nachmias and Nachmias 1987). Numerous existing community surveys were
examined for possible use in the study including the National Health Interview Survey
(U. S. Department of Health and Human Services 1992), the National Medical
Expenditure Survey (Edwards and Berlin 1989), a national survey of the utilization of
nurse practitioners, physician assistants, and certified nurse midwives (Shi et al. 1993),
62


and the Assessment Protocol for Excellence in Public Health (APEXPH) developed by
the National Association of County Health Officials (NACHO 1991). Ultimately, the
community survey was structured primarily on the Community Health Survey used by
the Community Health Services Development Program (CHSD), a partnership of The
University of Washington School of Medicine, Department of Family Medicine, and
the WAMI (Washington, Alaska, Montana, Idaho) Area Health Education Centers.
The CHSD graciously provided a draft copy of its generic survey, which, when used
by CHSD, is customized to meet the needs of the individual community.
The Community Health Survey provides information about the community's
attitudes and opinions concerning health services in the area, and is an outgrowth of a
W.K. Kellogg Foundation-funded Rural Hospital Project carried out from 1985
through 1988. The Community Health Survey has been conducted in over sixty rural
communities where samples of 1,000 people in each community are surveyed. The
reliability of the original instrument has been carefully checked through pre- and post-
test survey analysis and found to be high. The validity, while more difficult to
establish in survey research, has also been determined to be high based on the
consistency of pre- and post-test results combined with the general knowledge of the
communities involved. Reliability and validity have continued to be confirmed through
consistent utilization and analysis of the data (Dyck 1995; Hart, Lishner, and
Amundson 1991; Amundson, Hagopian, and Robertson 1991).
The CHSD survey was augmented with questions from the Community
63


Assessment utilized by the School of Medicine at the University of North Dakota in
their community diagnosis process (Ludtke and Ahmed 1990). In addition, portions of
the Civic Index from the Colorado Healthy Communities Handbook, developed by
The Colorado Trust and the National Civic League (Norris 1993) relating to citizen
participation have been adapted to a Likert scale and used to help assess community
leadership, one of the independent variables identified in the literature. The Civic
Index has been used by the National Civic League in the United States Healthy
Communities Initiative (USHCI) to direct an effective community-wide discussion of
community infrastructure. The USHCI is a cooperative project of the U.S. Public
Health Service and the National Civic League that has been involved since 1989 in
promoting a concept of healthy communities through stimulating local and statewide
projects nationally (Norris 1993). Following a facilitated town-meeting during which
community participants engage in a discussion of the components of the Index,
participants score their community on each of the components, determining how their
community is performing in each area. This activity forms the basis for developing
short and long-term goals.
While evidence that reliability tests have been conducted on the questions that
form the Index is not provided, the utilization of these questions in numerous
communities over the past six years has resulted in consistent application of the Index
scores, attesting to the reliability of the instrument. In addition, because the questions
addressing community leadership had previously been used as the basis for community
64


discussions, and had been crafted into a Likert-like scale for this study, a reliability
analysis was conducted on variables measured by these questions. Because the items
on a scale are designed to measure different aspects of a common concept, it is
assumed that they are positively correlated with each other. Cronbach's Alpha was
used to test this assumption on the eleven items addressing community leadership.
Based on an Alpha range from 0 to 1, the resulting score of .857 is considered high,
indicating that the scale measuring leadership attributes is quite reliable and acceptable
for use in this study.
Validity of the Civic Index is also confirmed based on the long-term utilization
of the instrument and the successes of the communities that have been involved in the
process. Consistency with other instruments designed to describe the key elements of
a healthy community, e.g., Elements of Healthy Cities from Leonard Duhl (1990),
Healthy Cities Project from the World Health Organization (WHO 1988), and the
model developed by the United Way of America called "Building Healthier
Communities: The United Way" (1990), supports both face and content validity.
The survey instrument for this study was developed and field tested in frontier
communities in the State of Nebraska. Based on the results of the field test, the
instrument was revised and put into final form. Communities to be included in the
study were identified by the staff of an organization within each state that works with
health professional recruitment and community development. In most cases, this has
been either the State Office of Rural Health or the State Primary Care Association.
65


(The names of those persons and the organizations they represent are included in
Appendix A.)
Each of the six state representatives was asked to identify five "successful"
communities along with a community contact and five "unsuccessful" communities and
contact person, for a total of sixty communities to be included in the survey. All
communities were to be located in "frontier" counties, a designation with which the
state representatives were familiar. The community contact was generally a health
care provider, an administrator, or the chair of a health care professional recruitment
committee. For purposes of this study, "successful" is defined as a community that has
maintained the services of a nurse practitioner or physician assistant for three or more
years. "Unsuccessful" is defined as a community that has been unsuccessful in
recruiting a NP/PA during a three year period, or had recruited a health care
professional who left in less than three years. The time period of 1991 to 1994 was
specified; however, these dates had to be expanded to assure an adequate sample.
Each community contact person was reached by telephone if possible or in
writing if necessary. The purpose of the study was explained, and each person asked
to identify nine other persons they would consider to be "community leaders," persons
whose names came immediately to mind when a task needed to be accomplished in the
community.
Once the names and addresses of leaders from the identified communities were
obtained, the survey instrument was mailed. The community contacts were asked
66


permission to use their names in the cover letters that introduced the researcher and
purpose of the study, indicating that they had been identified (for example) by "John
Doe of the Frontier Health Center as a community leader who might be willing to
assist in a study..." Each cover letter was individually addressed and further, indicated
that their community had been identified by the person at the state level organization
as a good place to study. (An example of the cover letter and survey instrument may
be found at Appendix B.) A self-addressed stamped envelope was included for ease in
response. The surveys were coded on both the return envelope and on the survey
instrument to allow for response tracking. A follow up letter and second survey was
sent to non-respondents approximately one month after the first. In a limited number
of cases, a second follow up was sent one month later. Due to difficulties in
identifying communities, the final study sample totaled five hundred "community
leaders" rather than six hundred as initially anticipated ten community leaders from
each of twenty-five "successful" and twenty-five "unsuccessful" communities.
H7 Data Gathering: The Providers
The second research hypothesis based on Herzberg's Theory of Job
Satisfaction required confirmation of provider characteristics identified through the
literature review. Herzberg's Theory identifies two categories of factors that affect job
satisfaction, "extrinsic" or environmental factors such as salary, supervision, and
working conditions that contribute to job dissatisfaction, and "intrinsic factors such as
67


recognition, achievement, responsibility, and advancement that influence job
satisfaction (Herzberg 1966; Koelbel, Fuller, and Misener 1991). The dependent
variable for H2 is retention of the health care provider for three years or longer, and is
referred to as status, maintained or non-maintainedThe independent variables
include:
o provider/spouse residence of origin (Rhodes and Day 1989; Ernst and
Yett 1985)
o rural experience during training (Fryer et al. 1994; Rhodes and Day
1989; Martini et al. 1994)
o sense of autonomy/desire for independence of action (Tri 1991; Bard-
Lozecki 1977; Lawler and Valand 1988; Hanson, Jenkins, and Ryan
1990; Hupcey 1993;)
o sense of responsibility and achievement (White and Maguire 1973;
Perry 1976; Tri 1991; Bard-Lozecki 1977)
o affinity for outdoor activities (Bigbee 1992)
o age/years of experience (Benner 1984; Hanson, Jenkins, and Ryan
1990; Tri 1991)
o marital status (Hanson, Jenkins, and Ryan 1990; Pan et al. 1995)
o supportive medical community including consulting physician and
provision for backup (Lawler and Valand 1988; Perry 1976; Rosenthal,
Rosenthal, and Lucas 1992; Riley, Myers, and Schneeweiss, 1991;
Hupcey 1993)
Data collection for H2 was accomplished through interviews of NPs and PAs
using an interview instrument that consists of twenty-one standard questions
addressing basic demographic data as well as attitudes and opinions relating to the
community and practice in general. Two open-ended questions, consistent with the
interview methodology used by Herzberg, were also included. The first question asks
the respondents to describe a time when they felt "exceptionally good or bad" about
the job. Following this account, the respondents are asked to describe a time when
68


they felt the opposite. Consistent with Herzberg's methodology, prompting questions
were prepared to enhance the consistency of the responses. The responses to the
open-ended questions were recorded and transcribed to facilitate analysis of the
information.
The initial sampling frame for the testing of H2 was drawn from NP/PAs who
have practiced for three or more years in a target community contrasted with a similar
group that had tried practicing in a frontier community, but left in less than three years.
Assistance in identifying these groups of providers was obtained through the state
Offices of Rural Health or another organization that works with recruitment and
retention of health care personnel in each surveyed state. The names of five NP/PAs
who have been maintained in frontier communities and five who have left such areas
were requested from each state representative, for a total of sixty NP/PAs to be
interviewed for the study. This sample size proved to be overly ambitious from two
perspectives. First, the state representatives had a very difficult time identifying
providers who had left targeted communities and second, the time necessary to contact
these very busy providers, schedule an appointment, and conduct the interview became
prohibitive. As a result, the sample size was reduced to thirty NP/PAs, fifteen of
whom were maintained, and fifteen of whom had left frontier communities.
Again, several existing survey instruments were examined for possible use
including the Index of Job Satisfaction (Brayfield and Rothe 1951) and the Minnesota
Satisfaction Questionnaire Short Form (Weiss 1967), and the National Medical
69


Provider Survey (Tourangeau and Ward 1992). The final interview instrument was a
composite based largely on a MEDEX Graduate Survey conducted by the University
of Washington in 1990 (Larson, Hart, and Hummed 1992), and a physician retention
study conducted in Gadsden County Florida (Conte, Imershein, and Magill 1992).
These two surveys contain questions that address the intrinsic and extrinsic factors of
Herzberg's model, plus other factors identified in the literature as influencing provider
recruitment/retention. (An example of the interview instrument may be found at
Appendix C.)
As indicated previously, reliability and validity are difficult to measure in
survey research, but are essential concepts to be addressed. Reliability can be
enhanced by asking people only the things they are likely to know, by asking the same
information more than once (test-retest), by randomly assigning items to two sets and
comparing responses (split-half method), and by using measures known for their
reliability (Wagemaar and Babbie 1989). This interview instrument was based on
previously used instruments, one an interview instrument (Conte, Imershein, and
Magill 1992), and the other a self-administered questionnaire (Larson, Hart, and
Hummed 1992). The self-administered questionnaire was developed at the WAM3
Rural Health Research Center and was carefully pre-tested and adjustments made prior
to administration. Further, the instrument was designed to ask only the things the
respondents were likely to know, a technique designed to enhance the reliability of the
instrument (Wagenaar and Babbie 1989).
70


Validity was checked by examining the various instalments to determine
agreement with the concepts that appear to be inherent in retention of providers, job
satisfaction, satisfaction with the community, supportive environment for example.
This examination revealed that both instruments addressed similar measures identified
in the literature as relating to job satisfaction, demonstrating face validity. Both
instruments also included a range of meanings generally associated with job
satisfaction, demonstrating content validity (Babbie 1989). Based on this agreement
between the content of the previously used instruments, it is reasonable to believe that
the degree of validity in the study instrument is acceptable.
As with the community survey, the interview instrument was field tested on a
group of NP/PAs who have been maintained at a frontier site as well as several who
have not been maintained. Based on the results of the test interviews, some
modifications were made in the instrument, primarily in the questions relating to the
non-maintained providers, as the original instrument was designed for interviews with
providers who had been maintained.
Given the geographic distances involved, it was planned that approximately
one-half of the interviews would be conducted on site, with the remainder completed
by telephone. Based on the field test of the interview instrument, forty-five minutes to
one hour were allowed per interview. Time and travel constraints resulted in only ten
interviews being conducted on site, with the remaining twenty conducted by
telephone. All interviews were conducted by the researcher. The open-ended
71


questions were recorded and transcribed by the researcher as well to reduce the
possibility of inter-rater bias. In summary, the data gathering aspect of H2 resulted in a
study N of thirty.
Treatment of the Data
As stated previously, the purpose of the study is to examine characteristics of
both communities and health care providers, comparing these characteristics in
successful/unsuccessful communities and maintained/non-maintained health care
providers. Because both groups communities and providers were non-
experimental, the primary research method used to test both and H2 was
correlational-predictive. The data obtained through the community surveys and the
provider interviews were used to examine relationships between and among the
various identified variables.
While there are many statistical applications that will summarize and test
hypotheses, including regression analysis and analysis-of-variance, few are appropriate
for categorical data where observations are from populations that do not demonstrate
a normal distribution nor a constant variance (Norusis 1994; Aldrich and Nelson
1984). Since the study population for Hithe communitieswas specifically identified
by a local contact as being "community leaders," a normal distribution for this sample
cannot be assumed. The study population for H2the providerswas selected based
on criteria identifying the length of time they had remained in a frontier community.
Further, the participants were recommended by the state representatives. Thus,
72


neither sample can be expected to demonstrate a normal distribution.
It is essential to link the statistical method to the kind of research questions
being asked. This study is looking for relationships primarily among categorical
variables. Therefore, an extension of multiway frequency analysis (MFA), the purpose
of which is to discover associations among categorical qualitative variables
(Tabachnick and Fidell 1989), was used to analyze the data from the community
survey (Ht). The MFA extension used is loglinear analysis, which is useful in
uncovering potentially complex relationships among variables in a multiway
crosstabulation. Loglinear models are similar to multiple regression models.
However, in loglinear models, all variables used for classification are independent, and
the dependent variable is the number of cases in a cell of the crosstabulation (Norusis
1994; Knoke and Burke 1980).
In the community section of this study, one dependent variable has been
identifiedstatus of the community, successful or unsuccessful. Therefore, a multiple
regression-like application of MFA called logit analysis was used. In this application,
questions about associations are translated into tests of main effects, or associations
between the dependent variable and each independent variable. Further, the
interactions or associations between the dependent variable and the joint effects of two
or more independent variables can be determined (Tabachnick and Fidell 1989; Knoke
and Burke 1980). For example, does size of community have a greater effect than
community leadership skills? Or does proximity to a large community have a greater
effect than the availability of health insurance?
73

I


The community survey produced a plethora of information, resulting in the
need to perform data reduction activities ranging from simple aggregation of data to
factor analysis of questions dealing with community leadership. The factor analysis
procedure began with a total of eleven variables addressing aspects of community
leadership reflected in questions nineteen through twenty-nine in the Community
Survey instrument found in Appendix B. These were: residents voice opinions on
medical care issues, elected officials support changes that enhance medical care,
community boards and commissions are representative of the residents, leaders
champion medical care issues, leaders plan for the long-term health care needs of the
community, an effective network of volunteer organizations works on health care
issues, there is support for students entering health professions education, merchants
foster volunteerism, all groups have access to primary care services, an organization
convenes for community problem-solving, and our community enters into cooperative
agreements with other communities to solve health care problems. The outcome of
the analysis was two factors, labeled "community leadership" and "community
cooperation" that could then be used in the logit analysis. The model was based on the
associations between the dependent variable, status of the community, and eight
independent variables addressing proximity, economic base, availability of health
insurance, critical mass of people, effective leadership, and use of local resources.
Before any analysis can be performed, the data must be screened to identify
inaccurate data, missing data, and outliers or cases that are extreme and could distort
findings. The most common procedure for screening or cleaning data is to generate a
74


frequency table that will allow identification of missing data and obvious errors in data
entry. The frequency distributions revealed a fair amount of missing data, but a review
of the data, cross-checked against the source documents indicated six survey
questionnaires that had not been fully completed. As a result, these six cases were
deleted from the sample, leaving a total of432 cases in the study.
The data collection for H2the providers included standardized questions
designed to produce data that can be analyzed through traditional elementary statistical
methods such as frequency distributions, crosstabulations, and measures of dispersion.
To identify associations between the dependent variable, retention of the provider, and
the independent variables, logistic regression analysis was used rather than logit
analysis because the sample size was insufficient to allow for logit analysis. In logistic
regression, the probability of an event occurring compared to the probability that the
event will not occur is estimated using log odds ratios (Agresti 1996).
The analysis included the identification of associations between the dependent
variable, retention of the providermaintained or non-maintainedwith ten
independent variables. In logistic regression, as in all other statistical procedures, the
codes for the independent variables must be meaningful. One cannot simply take a
nominal variable and assign arbitrary numeric codes and expect them to be useful.
When using a two-category variable such as experience of a rural rotation during
training, yes or no, each case can be coded 0 or 1 to indicate participation or not.
However, if there is a variable with more than two categories, new variables must be
created to represent the categories. The number of new variables, referred to as
75


"dummy" variables, required to represent a categorical variable is one less than the
number of categories (Norusis 1994; Chatteijee and Price 1991). In this study,
dummy variables were created for three categorical variables, autonomy,
responsibility, achievement and recognition.
In addition to the standardized questions examined through logistic regression,
the two open-ended questions that gathered information based on Herzberg's Dual
Factor Theory were analyzed using a content analysis of the transcribed responses
with identification and classification of key terms to determine consistency with
Herzberg's theory. Matrices displaying responses of the maintained/non-maintained
providers categorized by the researcher as "intrinsic" and "extrinsic" factors formed
the basis for the inductive analysis of the qualitative data. This approach to inductive
analysis has been referred to as logical analysis where classification schemes are
crossed with one another to generate new insights or allow further exploration of the
data set (Marshall and Rossman 1989, 116). The findings from this analysis were used
to confirm or refute Herzberg's Theory, and linked with the quantitative data in
formulating recommendations for future study or action.
Basic descriptive statistics are used to provide comparative information
regarding the characteristics of NP/PAs who were maintained versus non-maintained.
As with the data from the community survey, screening procedures were completed on
the standardized data to enhance accuracy. Because these data are from interviews
where the interviewer directed the discussion, no missing data were identified and all
cases were usable.
76


CHAPTER 4
FINDINGS
Ht The Communities
Data collection for the community survey portion of this study began in
February 1995 and was completed in May 1996. In all, a total of672 initial and follow
up surveys were sent to 500 persons living in frontier communities located in the six-
state area. Four hundred thirty-eight surveys were returned for a response rate of
nearly 88 percent. Of these, six had to be discarded due to missing information, for a
final response rate of 86 percent. According to Babbie (1989), a response rate of 70
percent is considered very good. The high response rate is attributed to several things.
First, the sample was not technically random; rather the participants had been
identified as "community leaders," and as such, were likely to be somewhat more
responsive than participants identified through a truly random sample. Second, in the
subjective view of the researcher, health care is important to people living in these
areas, and it is only infrequently that they are asked to express an opinion. The survey
instrument invited the respondents to provide any additional comments they might
wish to make, and many of them wrote notes ranging from a few sentences to several
pages. Some went so far as to send back studies that had previously been conducted
of the health care needs in their areas. A high percentage requested copies of the final
study.
77


Table 4.1 shows the characteristics of the study communities in terms of size,
per capita income, and persons per square mile in the county or minor civil division
displayed as successful or unsuccessful in maintaining a NP/PA.
Table 4.1
Description of Communities
Size of Community________Per Capita Income___Persons Per Square Mile
0-1,500 1,500- 2,500 > 2,500 5,000- 8,500 8,501- 10,000 > 10,000 .3-1 1.1-3 3.1-5.7
Success- ful 15 7 3 5 15 9 6 10 S
Unsuc- cessful 12 11 2 2 10 9 1 15 10
Total 27 18 5 7 25 18 7 25 18
N = 50
The communities ranged in size from a small mountain community of 223
people (in the winter 2,000 in the summer) to a fairly large community of 8,500.
Although the selection criteria specified frontier communities of2,500 or fewer
people, the state representatives included a total of five communities that exceeded
this level, two with populations of approximately 3,000, one of4,000, one of 5,000,
and the largest of 8,500. These communities were maintained in the study because
they had all struggled with recruitment and retention of health care professionals for
the past several years, and the state representatives were interested in having them
included. Fully 90 percent of the communities met the criteria of 2,500 or fewer
population. All, including the five communities with populations exceeding 2,500,
were located in frontier counties with populations of six or fewer persons per square
78


mile. The persons per square mile ranged from a low of 0.3 persons per square mile in
a Montana community to a high of 5.7 in South Dakota.
The per capita income of the study communities, based on county census data,
shows that the greatest number of communitiesboth successful and
unsuccessfulhave per capita incomes in the mid-range, between $8,501 and
$10,000. In all, a total of eight communities were surveyed in Colorado, ten in
Montana, six in North Dakota, ten in South Dakota, eight in Utah, and eight in
Wyoming. Maps with the names and locations of these communities are located in
Appendix D.
Table 4.2 shows some of the demographic characteristics obtained through the
survey.
Table 4.2
Demographics of Survey Participants
Age by Group______________Sex_______________Ethnicity*___________Size of Household
23- 40 41- 50 51- 60 >60 F M W H NA A/P 1-2 3-4 5&>
92 162 97 78 158 274 410 10 7 1 197 141 94
*W=white, H=Hispanic, NA=Native American, A/P=Asian/Pacific Islander
Household Income_____________________Length of Time in Community
< 15,000 15,001- 35,000 35,001- 50,000 50,001- 75,000 > 75,000 1-10 Yrs 11-20 Yrs 21-30 Yrs 31-40 Yrs 41-50 Yrs >50 Yrs
ii 104 118 126 61 100 99 77 54 59 42
N = 432
The participants varied in age, ranging from twenty-three to eighty-three, with
the average age just under fifty. The greatest number (162) fell in the forty-one to fifty
79


year old category, while seventy-eight of the respondents were over age sixty. One
hundred fifty-eight (37 percent) of the respondents were female, while two hundred
seventy-four (63 percent) were male. Family size varied from one-person families to
nine-member families, with the greatest number (163, or 38 percent) living in two-
member households.
Annual household income was requested in categories, with eleven
respondents (2.5 percent) reporting less than $15,000, while the greatest number, one
hundred twenty-six (29 percent) reported household income in the $50,000 to $74,999
range. Sixty-one households (14 percent) reported incomes in excess of $75,000.
There was considerably less diversity in the ethnic makeup of the participants. Four
hundred ten respondents (94.9 percent) classified themselves as white, ten (2.3
percent) self-identified as Hispanic, seven (1.6 percent) as Native American, and one
(.2 percent) as Asian/Pacific Islander. Four persons (.9 percent) declined to provide
this information. The length of time respondents had lived in their communities varied
from one year to seventy-three years, with the greatest number (100 people or 23
percent) having lived in their communities from one to ten years. The next highest
category was eleven to twenty years, with ninety-nine people reporting this length of
time. Forty-two persons had lived in their communities over fifty years.
Respondents were asked to select from a list of thirteen health care services
ranging from ambulance service to x-ray the top five most important services to
have available in their communities, and rank these services in priority order from one
80


to five. The top five services as defined by all respondents in order of priority,
included:
1. primary care provider (physician, nurse practitioner, physician
assistant),
2. ambulance service,
3. emergency room,
4. pharmacy, and
5. x-ray.
A comparison of these priorities in the successful and unsuccessful communities
revealed virtually no differences. See Figure 4.1.
Figure 4.1
Most Important Services by Community
Successful and Unsuccessful
The analysis of the associations between the dependent and independent
variables began with an initial screening of the data to identify whether there were
81


actually any effects to be investigated. This was accomplished by running a
hierarchical loglinear analysis that provided the expected frequency for each effect
compared to the observed frequency, goodness-of-fit statistics for the model, and tests
of partial associations for each effect. A saturated model that included all possible
effects was produced in which the expected and observed frequencies were identical,
and the goodness-of-fit statistic, Likelihood Ratio Chi-Square, was .000 with a
significance of 1.000, reflecting a perfectly fitting model. This was to be expected,
since all effects were included in the initial screening. When a saturated model is used,
the value of the chi-square statistic is always 0 (Norusis 1994, 159).
When screening is carried out in the testing of overall fit of a model, both
Pearson Chi-Square and the Likelihood Ratio Chi-Square are generally available. The
Likelihood Ratio Chi-Square is preferred because it allows for consistency in testing
overall fit, screening, and testing for differences among hierarchical models.
Inadequate expected frequencies may increase a Type I error rate when the Pearson
Chi-Square is used. The Likelihood Ratio also has the property of additivity of
effects, and thus is useful when examining three and four-way associations of several
variables such as those included in Ht (Tabachnick and Fidell 1989).
The hierarchical loglinear analysis produced tests of partial association that
examined all dependent and independent variables individually and in combination at
each level (i.e., all combinations of two variables, three variables, and so on until all
combinations had been examined). The results suggested that only three-way
82


associations (e.g., status of community, use of local resources, and community
leadership, or other combinations of three variables) are significant based on tests that
K-way effects are zero using both Likelihood Ratio Chi-Square and Pearson Chi-
Square. These results are included as Table 4.3.
Table 4.3
Tests that K-way Effects are Zero
K DF LR.CHISQ PROB PEARSON chisq PROB ITERATION
1 12 607.013 .0000 1237.959 .0000 0
2 62 427.106 .0000 675.434 .0000 0
3 180 261.739 .0001 971.231 .0000 0
4 321 296.732 .8306 341.661 .2048 0
5 360 18^18 1.0000 12.083 1.0000 0
6 248 2.896 1.0000 1.519 1.0000 0
7 96 .219 1.0000 .112 1.0000 0
8 16 .000 1.0000 .000 1.0000 0
The row labeled 3 in Table 4.3 evaluates the 3-way associations of the eight
variables included in the community study, and shows statistical significance using the
Likelihood ratio (262) and the Pearson chi-square criteria (971). Both show a
probability of .000, indicating that the hypothesis that the three-way effects are
independent should be rejected. However, the tests of four-way and higher-order
effects (rows four through eight) show probability levels greater than .05 indicating
that the associations of four or more variables are independent. This is important to
this study, given the number of variables and the relatively small sample size compared
to the number of variables. This test provides information relating only to the number
83


of variables that are significantly associated, thus providing direction for further
analysis. Since one variable has been identified as a dependent variable, only those
effects containing "status," the dependent variable, are of interest in this study. The
challenge then, is to determine which of the three-way effects, or associations of
variables, should remain in the model.
The purpose of modeling is to find the unsaturated model with the fewest
effects that still closely mimics the observed frequencies. Screening helps to reduce
the need to examine all possible unsaturated models by allowing effects that are less
predictive to be removed during the screening process (Tabachnick and Fidell 1989,
251). A model should fit the data, be interpretable, and as simple or parsimonious as
possible.
As mentioned previously, one step in reducing the number of effects to be
considered is to identify only those effects that include the dependent variable,
"status." The next step is to review the partial Chi-square scores that are a result of
tests of partial associations to identify those combinations that contain status, and
are significant at the .05 level. A partial chi-square score is the difference between the
likelihood-ratio chi-square values of combinations of variables with and without the
effect in question. When examining the partial chi-square scores, one is seeking
significant effects identified by having the largest values of chi-square with
probabilities less than .05. In other words, when seeking effects to be included in the
best model, one looks for the highest chi-square values and lowest probability scores,
while in assessing goodness-of-fit for a model, one looks for statistical nonsignificance,
or low chi-square values with probabilities exceeding .05 (Tabachnick and Fidell
84


1989). The desired outcome in model selection is to reject the independence
hypothesis, as we are seeking relationships among the various effects. As indicated by
the K-way tests, no associations of variables greater than three-way proved to be
significant, therefore, further analysis focused on combinations of three or fewer
variables meeting the criteria identified above, i.e., contains status, and have
likelihood chi-square significance levels of less than .05.
An examination of the data revealed eight combinations of three or fewer
effects that were statistically significant (i.e., p < .05) and included the dependent
variable "status." These effects may be found in Table 4.4 below.
Table 4.4
Combinations of Variables Statistically Significant at p<05
Effect Name Partial X2 Prob
comled2*critmas*status 7.691 .0214
comcop2*locies*status 6.892 .0319
comled2*Iocres*status 7.236 .0268
comled2*percap3 status 10.741 .02%
miles30peicap3status 6.788 .0336
ecoperc2status 8.605 .0135
miles30*status 5.124 .0236
peicap3status 57.529 .0000
85


These labels relate to the following variables and their levels:
Label
Comcop2
Comlea2
Critmass
Ecoperc2
Locres
Miles30
Percap3
Status
Variable Description
Community Cooperation poor/medium/high
Community Leadership poor/fair/good
Critical Mass greater than 1500 yes/ho
Perception of Economic base poor/fair/good
Use of Local Resources yes/ho
30 Miles to Community of 10K or greater
Per Capita Income Grouped -
5000 8500
8501 10,000
10,001 and greater
Status of Community successful/unsuccessful
At this point in the analysis, only one variable, health insurance, dropped out of
the model. This was not surprising, as only 15 of432 people (about 3 percent)
reported having no insurance. Therefore, while this variable has been highly correlated
with utilization of health care services, given this sample of community leaders, it did
not serve to discriminate between communities that have been successful or
unsuccessful in maintaining services. The screening and model selection resulted in the
following effects being retained in the model for further analysis of H,.
Status = f (comcop2 *comIed2 *critmass *ecoperc2 *percap3 locres *miles3 0)
Before proceeding further with the analysis of the interactions of the variables,
an examination for multicollinearity was conducted because several of these variables
appeared on the surface to be highly correlated, e.g., community cooperation and
community leadership; perception of economic strength and per capita income; and
possibly use of local resources and per capita income. When variables are highly
correlated, it is difficult to separate the effects of the individual variables. Using the
Collinearity Diagnostics in the SPSS multiple regression program, the variables were
examined by inspecting eigenvalues and condition indexes of the independent
86


variables. These findings are in Table 4.5 below.
The eigenvalue redistributes the variance in the variables, consolidating it into a
few composite variables, rather than in many (Tabachnick and Fidell 1989). The
columns identified by variable labels in Table 4.5 show the coefficients of variance of
the study variables. The columns with high proportions of variance in two or more
coefficients for the same eigenvalue would indicate evidence of near-dependency
between or among the variables.
Table 4.5
Multico llinearity Measures of Independent VariablesCommunity
# Eigen Value Cond Index Cons tant COM COP2 COM LED2 CRIT MASS ECOP ERC2 LOC RES MILES 30 PERC AP3
1 6.182 1.00 .0006 .0023 .0026 .0067 .0024 .0031 .0086 .3674
2 .8715 2.66 .0001 .0005 .0005 .0021 .0013 .0000 .9646 .0004
3 .4441 3.73 .0005 .0146 .0128 .6490 .0198 .0180 .0003 .0009
4 .2045 5.50 .0030 .0478 .0388 >3129 .0115 J927 .0142 .0157
5 .1067 7.61 .0030 .1663 .0871 .0124 .0507 .2242 .0086 .3674
6 .0947 8.08 .0001 .0125 .0932 .0160 .6580 .0182 .0063 .1622
7 .0772 8.95 .0055 .5740 .6651 .0000 .0470 .0073 .0000 .0167
8 .0191 18.0 .9872 .1821 .0000 .0010 .2095 .3366 .0026 .4348
In Table 4.5 higher scores have been denoted in bold print. Notice that higher scores
appear for critmass and locres in eigenvalue 4, for locres and percap3 in eigenvalue 5,
for comcop2 and comled2 in eigenvalue 7, and for ecoperc2, locres, and percap3 on
87


eigenvalue 8. Therefore, there appears to be relationship between critical mass of a
community and use of local resources; use of local resources and per capita income;
community cooperation and community leadership; and perception of economic
strength, use of local resources and per capita income, although the differences in
scores on eigenvalue 8 would suggest a greater relationship between local resources
and per capita income than with perception of economic strength.
An examination of correlation coefficients also showed relationship between
and among comcop2, comled2, ecoperc2, and locres. The range of scores was from
.0000 to .4381 with the highest being for the relationship between comled2 and
comcop2. The next highest, 3.00, was the relationship between ecoperc2 and locres.
The remaining relationships were all less than 3.00. Although neither the scores
related to the eigenvalues nor the correlation coefficients were above .7, the score
where multicollinearity becomes a potential problem (Anderson, Sweeney, and
Williams 1981), the measures of multicollinearity supported the need for caution in the
use of several combinations of variables.
At this point in the analysis of Ht, seven independent variables plus the
dependent variable remained in the model. Because the tests of partial associations
had revealed that only three-way associations were significant, additional analysis was
necessary to identify which three had the strongest association. Crosstabulations of
the data were used, testing status against each of the other seven variables to further
reduce the number of variables in the model. The complete tables of the
88


crosstabulations displaying the relationships of all variables compared to "status" may
be found in Appendix E. Three statistics are included that are helpful in determining
the association between dependent and independent variables. These are the
Likelihood Ratio Chi-square, Cramer's V, and Lambda. Again, since Chi-square is a
test of independence, a probability of less than .05 would indicate that the hypothesis
of independence should be rejected. Both Cramer's V and Lambda range between 0,
when there is absolutely no relationship, to 1 where the independent variable perfectly
predicts the dependent variable. These tests revealed that only community leadership
(comled2), per capita income (percap3) and perception of economic stability
(ecoperc2) were highly associated with status. With the exception of per capita
income and perception of economic strength, other variables demonstrating possible
multicollinearity problems were deleted from further analysis.
Logit analysis was utilized to examine both the main effects and the
interactions among the four remaining variables status, community leadership,
perception of economic status, and per capita income. Goodness-of-fit statistics
indicated good fit of the model to the data with a non-significant Likelihood Chi-
Square of22.94 with 20 degrees of freedom, and significance of .292, well above the
.05 level.
When using a logit model, the dispersion, or spread, in the dependent variable
can also be examined. The statistics used to measure the spread are entropy and
89
I


concentration.2 In this study, neither the score for entropy nor concentration proved
to be significant at the .05 level. The scores were 116 and .153 respectively, showing
that the model could be expected to exhibit this good a fit by chance 12 percent or 15
percent of the time, depending on the measure used. The measures of dispersion
suggested that although the overall model fit adequately, it was marginal in explaining
the source of the dispersion. This was not considered a major concern as the
Goodness-of-Fit statistics supported the model.
Both hierarchical and nonhierarchical loglinear models were utilized in further
analysis of the data to determine both the strongest combination of variables, and the
independent variable having the greatest effect on the dependent variable. The
hierarchical approach was used to identify the best model through a backward step
elimination process. This resulted in the following variables showing the greatest
degree of relationship: status, percap3, and comIed2 (e.g., status of community,
successful or unsuccessful; per capita income; and community leadership).
The nonhierarchical approach is used when one is interested in the highest
order interaction or main effects. Parameter estimates are provided for each effect and
combination of effects. The strength and direction of the relationship can be
determined from these estimates through the use of log odds ratios or logits.
Although the tests of association included in the hierarchical approach indicated that
2 Entropy and concentration subdivide the total dispersion of the dependent variable into that
explained by the model and the residual or unexplained dispersion (Norusis 1994). A statistically
significant result is desirable as this indicates that the model fits the observed frequencies better than
expected by chance (Tabachnick and Fidell 1989).
90


only three-way associations were significant, and further identified status, comIed2,
and percap3 as being the best model for interactions, ecoperc2 was also identified as
significant when combined only with status. Therefore, ecoperc2 was included with
the other three variables in an attempt to determine the strongest relationship or main
effect of the three variables, community leadership, perception of economic base, and
per capita income on the dependent variable, status of community.
The values in Table 4.6 for each of the four variables are the parameter
coefficients or log odds ratios produced by loglinear models. Since it is somewhat
easier to think in terms of odds rather than log odds, the log odds were converted to
odds by calculating the natural antilogarithm of the parameter estimate (e raised to the
power of the estimate). The scores have also been placed in rank order for greater
ease in determining the relative importance or strength of each.
Table 4.6
Log Odds and Odds Ratios
Parameter Log Odds Odds 95% Confidence
Ratio Ratio Interval
Unsuccessful .5701 1.77* 1.04 3.00
Ecoperc poor .7184 2.05* 1.16-3.63
Comled poor .3422 1.41 .82-2.41
Comled fair .2380 1.27 .77 2.08
Ecoperc fair -.0248 .98 .58-1.63
Percap medium -1.4394 .24* .15 .38
Per cap low -1.9860 .14* .07 .27
* P<0.05
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Full Text

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VAST TERRITORY SURROUNDED BY VAST TERRITORY: A DEVEWPMENT AND MAINTENANCE THEORY OF ACCESS TO PRIMARY HEALTH CARE ON THE FRONTIER by Barbara E. Bailey B.S., Univenity of MissouriKansas City, 1966 M.A., University of MissouriKansas City, 1974 A thesis submitted to the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Doctor of Philosophy Public Administration 1997

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1997 by Barbara E. Bailey All rights reserved.

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This Thesis for the Doctor of Philosophy degree by Barbara E. Bailey has been approved Sheri Eisert I lo Date

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' l i Bailey, Barbara E. (Ph.D., Public Administration) Vast Territory Surrounded by Vast Territory : A Development and Maintenance Theory for Access to Primary Health Care on the Frontier Thesis directed by Professor Peter deLeon ABSTRACT This study examines maintenance of access to health care through use of nurse practitioners and physician assistants (NPIPA) in remote areas of this country where the population density is six or fewer persons per square mile-the frontier. Logit analysis is used to examine the characteristics of fifty communities (based on a survey of 500 residents) who have been successful in maintaining access to care through retaining a NPIPA for longer than three years compared to communities unable to recruit a provider, or the provider left in less than three years. Data on the characteristics of the providers were gathered through interviews conducted with thirty NPIPAs, fifteen who had remained in frontier communities, and fifteen who had not. Herzberg's Dual-Factor Theory of Job Satisfaction is used to categorize the sources of satisfaction and dissatisfaction among these providers A series of factors previously reported to influence retention was also tested through a logistic regression application. The logit analysis indicated that the community characteristics having the IV

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. i I I greatest influence on maintenance of health care providers include a combination of socio-economic factors and community leadership. The findings showed that the odds of a community with low per capita income and poor community leadership being unsuccessful in maintaining a NPIP A were ten times greater than a community with high per capita income and good leadership. The "perception" of economic strength was also a major factor in successful communities. For the providers, the logistic regression procedure failed to confirm previously identified factors such as marital status, age, residence of origin; however, the qualitative findings differentiated between factors that produced job satisfaction (the work itself and recognition) and dissatisfaction (working conditions, call schedule, excessive time conunitment). The findings suggest a need for a more comprehensive approach to overall community development, termed a "development and maintenance theory." Greater emphasis must be placed on community development designed to.enhance the quality of leadership and the socio-economic status of the community, enabling communities to work with providers to reduce the "dissatisfiers" in the practice This abstract accurately represents the content of the candidate's I recommend its publication. Peter deLeon v

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DEDICATION This thesis is dedicated with gratitude and appreciation to the health care providers and communities leaders who work to make access to primary health care a reality on the frontier. Their dedication and perseverance has been the inspiration for this paper. vi

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'I I CONTENTS Acknowledgments ................ . . . . . . . . . . . . . ix CHAPTER 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . 1 Purpose of the Study . . . . . . . . . . . . . . . . 7 Scope of the Study . . . . . . . . . . . . . . . . . 10 Organization of the Thesis . . . . . . . . . . . . . . 11 2. REVIEW OF TilE LITERATURE ........................... 13 Health Economics . . . . . . . . . . . . . . . . . 14 Rural Health Research ................................ 31 Location of Practice Site . . . . . . . . . . . . . . 37 Motivation-Hygiene Theory ........................... 47 Review .......................................... 56 3. METHODOLOGY ....................................... 58 Introduction . . . . . . . . . . . . . . . . . . . 58 Research Hypotheses . . . . . . . . . . . . . . . . 58 Data Collection . . . . . . . . . . . . . . . . . . 60 H1 Data Gathering: The Communities . . . . . . . . . 62 H2 Data Gathering: The Providers . . . . . . . . . . . 67 Treatment of the Data . . . . . . . . . . . . . . . 72 4. FINDIN'GS . . . . . . . . . . . . . . . . . . . . . . 77 H1 The Communities . . . . . . . . . . . . . . . . 77 Vll

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I I i I I I I I I I I 'I I H2 The Providers . . . . . . . . . . . . . . . . . l 00 Herzberg's Dual Factor Theory Applied to the Providers . . . . . . . . . . . . . . 11 7 Intrinsic Factors . . . . . . . . . . . . . . 119 Extrinsic Factors . . . . . . . . . . . . . . 125 5. CONCLUSIONS AND RECOMMENDATIONS . . . . . . . 140 APPENDIX Discussion ofFindings . . . . . . . . . . . . . . . 140 The Communities . . . . . . . . . . . . . . . . . 141 The Providers . . . . . . . . . . . . . . . . . . 148 Reconunendations ................................. 153 Implications for Policy Makers . . . . . . . . . 155 Implications for Communities . . . . . . . . . 159 Implications for Health Care Providers . . . . . . 163 for Health Professions Educational Institutions . . . . . . . . . . . . . . . . 165 Conclusion . . . . . . . . . . . . . . . . . . . 169 A. State Representatives Who Assisted in the Study . . . . . . . . 173 B. Cover Letter and Community Survey Instrument . . . . . . . . 174 C. Provider Interview Instrument . . . . . . . . . . . . . . . 183 D. Maps of Study Communities ............................... 189 E. Crosstabulations of Community Data . . . . . . . . . . . . 195 F. Crosstabulations of Provider Data . . . . . . . . . . . . . 201 G. Herzberg's Factors Applied to Providers . . . . . . . . . . . 208 REFERENCE LIST . . . . . . . . . . . . . . . . . . . . . . 212 VIII

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ACKNOWLEDGMENTS Although the writing of a dissertation has been described as a long and lonely task, it cannot be accomplished without the help and support of a "quiet legion" of fiunily, friends, co-workers, and especially "the committee." I want to take this opportunity to express my gratitude and appreciation to that "quiet legion," friends who brought ''goodies" and vitamins, my staff who were quietly, but consistently encouraging, and especially to the members of my committee who were both supportive and helpful during the long gestation period of this paper. They are: Peter deLeon, Chair, who encouraged, advised, applauded, coaxed, and consoled during this process, Linda deLeon, who advised and provided the foundation for the methodology, Curt Stine, who brought the realities of working with students to the task, Sheri Eisert, who challenged and questioned in a benevolent and helpful way, Loren Amundson, who with his experience and knowledge in rural health, provided inspiration to complete the task. Special appreciation is extended to Dr. Amundson for his involvement from South Dakota, his willingness to accomodate my schedule, and his gentle prodding. I also want to thank the state representatives who provided names of communities, community leaders, and health care providers who participated in the study. The names of those individuals are included in Appendix A Without them, this study could not have been completed. Of course, it is the spouse who suffers most during this time, so to my husband, Don, I express my love, my thanks, and my appreciation for his support, his understanding, and for his computer expertise in "making it look good." lX

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CHAPTER 1 INTRODUCTION In his health message of 1971, President Richard Nixon stated, Just as our National Government has moved to provide equal opportunity in areas such as education, employment and voting, so we must now work to expand the opportunity for all citizens to obtain a decent standard of medical care. We must do all we can to remove any racial, economic, social or geographic barriers which now prevent any of our citizens from obtaining adequate health protection. For without good health, no man can fully utilize his other opportunities (Lewis, Fein, and Mechanic 1976, 5). In 1991, twenty years later, The American Journal ofPublic Health reported that although the number of physicians in the U.S. had increased nearly four times more rapidly than the population between 1975 and 1988, physicians remained concentrated in urban centers with the ratio of physicians per 100,000 persons equaling 226 in metropolitan areas, but only 98 per 100,000 in nonmetropolitan or rural areas (Frenzen 1991, 1141 ). In 1993, the issues of rural health care reform were considered of such magnitude that a "Rural Health Care Summit" was held in Little Rock, Arkansas. A paper commissioned for this meeting stated that one of the measures of success of the health reform package developed by the Clinton Administration will be how it addresses the unique needs of the approximately one-fourth of the population that live in rural areas of this country (Christianson and Moscovice 1993). Further, the literature suggests that rural residents, on average, are in poorer health than urban 1

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1 I '' residents, frequently having a higher prevalence of chronic illness and disability (Summer 1991; Rowland and Lyons 1989), and that rural residents under age sixty-five are more likely than urban residents to lack private or public health insurance coverage. Rural residents are also less likely to be covered by Medicaid (Braden and Beauregard 1994; Franzen 1993; Rowland and Lyons 1989). Data from the 1987 (published in 1994) National Medical Expenditure Survey show that rural residents eighteen years of age and older tended to assess their health status less favorably than did residents of urban areas, with 28 percent indicating poor or fair health. Rural adults were also more likely to state that they had been diagnosed with a chronic condition than were adults in urban areas. It was also interesting to note that although in-office waiting times showed no difference between urban and rural areas, rural residents were almost twice as likely to have to travel for over thirty minutes to reach their source of care than were residents of other areas. This survey confirmed many of the statements previously made about the poverty and health status of the rural population in America and their access to and utilization of health care (Braden and Beauregard 1994). According to an Institute ofMedicine study of the physician workforce in this country, access to care ranks as the second-highest priority issue for health policy, after expenditures. Concern about access to health care was expressed long before the rise in the cost of health care began receiving primary attention, and gave rise to the increase in physician supply over the past two decades. The concern for access was 2

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particularly directed toward the elderly, the poor, and the residents of rural areas (Institute ofMedicine 1996, 53). These comments, concerns, and data suggest that problems surrounding health care services in rural areas are at a serious level, and constitute a public policy issue deserving of serious consideration. With the emphasis currently being placed on health care and welfare reform at both the state and national levels, the issue of accessibility to quality health care demands the attention of public policy makers and public administrators alike (McCloskey and Luehrs 1990). The rising costs of health care, estimated to reach $1.7 trillion by the year 2000, an amount equal to 18.1 percent of the Nation's gross domestic product (Burner, Waldo, and McKusick 1992, 1-2), focus primary attention on the issue of financial accessibility. However, it is just as important to realize that geographic access problems will not automatically disappear when some type of state or national health plan is enacted and implemented. Removal of financial barriers may not affect the geographic distribution of health care professionals; in fact, it is possible that such action could exacerbate the problem, for distnbution of physicians to rural areas is by no means guaranteed. For example, removal of financial barriers may increase the demand of the previously underserved in urban areas, conceivably resulting in even more health care professionals choosing to practice in cities, further reducing the numbers available for service in rural and frontier areas. Illustrative of this potential problem is the statement in The New York Times of Adam Clymer who visited South Dakota in 1994. After spending some time in the 3

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'I I I state, he wrote, "Several days of conversations here made it clear that the big problem is less how to pay for health care than to make sure that there is health care to pay for" (Clymer 1994) The rapid growth of managed care organizations (MCOs), largely based in urban areas, is another factor affecting the distribution of health care providers, since these organizations tend to utilize a greater proportion of generalist providers (Coburn et al. 1994). These are the same physicians who have traditionally been more likely to locate in rural areas. This competition can play out by enticing rural providers to relocate to urban areas (Orloff and Tymann 1995). This distribution or allocation problem is heightened by the fact that the United States has been training a disproportionate number of subspecialist physicians at the expense of generalists such as family practitioners or general internists, resulting in shortages of primary care physicians in many areas. In 1931, more than four out of five private practice physicians were in general practice. By 1965, the proportion had dropped to less than one-half. By 1988, the proportion in the generalist specialties had decreased to approximately one out of three, and by 2010, estimates predict the number to drop to 28 percent (Council on Graduate Medical Education 1992, 18). The Institute of Medicine recently released a study called "The Nation's Physician Workforce," in which an apparent current oversupply of physicians was discussed. Although the committee was not in agreement nor prepared to declare an oversupply, it did state that "It is difficult to see that an oversupply will have much effect on problems of access to care in this country; an abundance of physicians will not solve 4

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the problems ofmaldistribution by geographic area or specialty" (Institute ofMedicine 1996, 4). This statement on the part of the Institute ofMedicine clearly refutes the "theory of diffusion" that formed the basis for state and federal governmental interventions of the 1960s and 1970s, when grants dollars were made available to increase both the numbers of physicians in training programs as well as the number of medical schools. The theory that the principles of the market place would force physicians into underserved areas has not proved to be true. The observed inability or unwillingness of physicians-in particular, medical specialists-to practice outside urban population centers makes the issue of care in sparsely populated rural areas even more severe. Nor is it likely to improve on its own. The policy problem, then, is who will provide quality primary health care for the population in the most rural and isolated parts of this country, which have become known as "frontier" areas by the Department of Health and Human Services (U.S. Congress, Senate 1990, 174), as we move into the 21st century. By far, the majority of these isolated areas is found in the western part of the country. The six states that make up DimS Region VIII-Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming-are all considered "frontier" states by virtue of having six or fewer persons per square mile in half or more oftheir counties. The total number of counties in these states is 290, of which 185 (nearly 65 percent) are classified as "frontier," with a population of 1,307,839 based on 1990 census data. Of the 185 frontier counties in the region, almost three-quarters (131) 5

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lost population from 1980 to 1990 thus increasing the number of "frontier" counties from 177 to 185. The total number of primary care physicians (PCPs) located in these counties in 1992 was 438, for a ratio of 40 primary care physicians per 100,000 persons. There were also 165 nurse practitioners and physician assistants serving these counties.1 These data are consistent with those reported by Frenzen (1991, 1143) that show the primary care physician to 100,000 population ratio in remote rural areas to be 38.2 in 1988 compared to 95.9 per 100,000 in metropolitan areas. Further complicating the issue are principles of equal access The population of these areas find themselves effectively discriminated against in terms of quality health services almost totally as a function of their geographic location. This issue of equity is articulated by Amy Gutman in the volume titled, In Search of Equity: Health Needs and the Health Care System : A principle of equal access to health care demands that every person who shares the same type and degree of health need be given an equally effective chance of receiving appropriate treatment of equal quality so long as that treatment is available to anyone (Gutman 1983, 44). Access to health care in the frontier states is not only a major concern at the national level, but also ofboth the states' governors and their legislatures. Thus, there is an urgency on the part of various agencies within state and federal governments to draft proposals and implement policies that will assist in addressing this issue. Provider figures obtained from state primary care access plans submitted to the Public Health Service, February 1993 6

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. i Purpose of the Study The problem, although increasingly pressing, is not new (Mott and Roemer 1948). In the late 1960s and early 1970s, there were several policy responses to what was then being called a crisis in rural health care. Federal programs were developed to increase the number of medical schools and medical graduates, with an emphasis on increasing the number of physicians who would go into practice in rural areas, a hoped-for application of"diffusion theory." Another important development during this time period was the establishment of"midlevel practitioners" (MLPs)-nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs). These professional groups, sometimes referred to in the aggregate as non-physician providers (NPPs), developed rapidly to redress geographic maldistnbution of primary care providers, in response to what was described as a "crisis in rural health" in the early 1970s (U.S. Congress OTA 1990, 249) A six-volume series of guidebooks, The Rural Health Center Development Series, was published in 1979 by the Health Services Research Center of the University of North Carolina (Chapel Hill) to help underserved rural communities understand the potential and problems in the development of primary care health centers staffed by what were then referred to as "new health practitioners." The series was the culmination of a three-year project that studied community-operated nonprofit health centers staffed by NPs and PAs, supervised by physicians from nearby towns. This nationwide experience indicated that the NP/P A system provided high-quality 7

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, I I I outpatient care for the majority of common illnesses and injuries (Bernstein, Hege, and Farran 1979). Further, it appeared that NP/P As were likely to locate in rural areas unable to support the practice of a physician. Yet, nearly two decades later, the issue of access to health care in rural areas continues to be of primary concern to rural citizens and policy makers alike. The Office of Shortage Designation of the U.S. Public Health Service lists 2,617 geographic areas of the country designated as Health Professions Shortage Areas (HPSA) based on a primary care physician to population ratio of 1:3,500 as of December 31, 1995 (Office of Shortage Designation 1996). A physician to population ratio of 1:3,000 may be used if unusually high need or insufficient capacity is demonstrated using such indicators as poverty rate, infant mortality rate, rate of low birthweight, and indicators of access to primary health care services, taking into account the distance to such services. Ofthese 2,617 areas, 1,613 (62 percent) are rural. These figures compare with a total of 1,921 primary care shortage areas, of which 1,350 (70 percent) were rural in December 1979 (U.S. Congress OTA 1990, 295). In short, despite numerous efforts, the rural health crisis of the 1970s has continued essentially unabated well into the 1990s. It is interesting to note that for primary medical care HPSA designations, only medical doctors (i.e., physicians in the primary care specialties-general or family practice, pediatrics, general internal medicine, and obstetrics and gynecology) are counted. The HPSA process does not count NP/P As. These NPP providers were 8

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consciously left out of the counts to avoid preventing areas that would otherwise qualify (such as areas with small populations and no physician but one nurse practitioner or physician assistant) from achieving HPSA designation and possible eligibility for other kinds of federal assistance (Lee 1991). Since NP/PAs are not included in the calculations to determine shortage area designation, it is difficult to obtain an accurate picture of the overall availability of primary health care services in these areas. It is unclear, for instance, to what e,aent the use of a system based on local NP/P As linked to primary care physicians for consultation and referral to serve areas of geographic maldistribution has met or failed to meet the health services criteria or expectations of its designers. With various types of state and national heaith care reform proposals receiving attention, it is important to examine the adoption and maintenance of this non-physician based system of health care if we are to avoid the mistakes of the past, and, more importantly, to increase the accessibility to primary health care for those persons who choose to live in frontier areas. Given the shortcomings ofthe "diffusion theory" to explain a failure of migration of physicians into rural underserved areas, it now seems appropriate to focus on the characteristics of communities and providers who maintained access to care in these areas the advancement of a "development and maintenance theory." Picture this as a demand and supply equation. Work on the supply side (e.g. more physicians) has not remedied the problem, so it is appropriate to examine in greater detail the demand side of the equation. 9

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The purpose of this study, then, is to utilize statistical association methods to determine: 1) the characteristics of frontier communities that enable them to maintain access to care; and 2) the characteristics of the NP/PAs that establish practices and remain in these communities providing primary care services. The two should, of course, reinforce one another. It is important to note that this thesis does not address the issue of the initial move by a health care professional to a rural community. Neither does it address "diffusion" of health care professionals into these areas. Rather, it focuses on the need for development and maintenance of community infrastructure combined with the careful match of provider characteristics to assure access to health care in this volatile atmosphere of change in the health care environment. Scope of the Study This paper examines the relationship between the characteristics of both the community and provider in successful and unsuccessful non-physician based systems of primary health care. The study sample examines fifty communities located throughout the six states ofDilliS Region Vlll, Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. Fifty frontier communities from among the six states were selected, twenty-five that sustained a NP/P A practice for three or more years, and a contrasting group of twenty-five communities that were either unsuccessful in establishing a NP/P A practice, or failed to maintain such a practice for 10

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:I I i I I i a three-year period. A survey instrument was designed and administered to a sample often residents in each community who had been identified as "opinion or community leaders". Similarly, providers who remained in NP/P A practices in frontier areas for three or more years were contrasted to providers who left similar communities. Data collection was accomplished through interviews ofNPs and PAs. The interview consisted of a set of standardized questions followed by two open-ended questions that allowed the respondents to discuss both positive and negative aspects of their experiences. In this type of structured or ethnographic interview, the interviewer asks most of the questions, using repetition to clarify the subjects' responses and encouraging them to expand on their answers by providing specific examples (Marshall and Rossman 1989) Although communities and providers included in the study were obtained from a variety of sources including census data, state and regional health care recruitment lists, State Board ofNursing lists, Physician Assistant membership lists, the primary sources consisted of data compiled by the State Offices of Rural Health and State Primary Care Associations for location of both communities and providers. Organintion of the Thesis This paper is organized in five chapters. The introduction defines the purpose and scope of the study The second chapter contains a review of the literature in ll

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: I ' i 1 I ; I I I I health care economics, rural health, practice location, and job satisfaction, providing an historical perspective of the issues involved in access to health care and the factors related to the maintenance of access to primary health care. Chapter 2 also establishes the theoretical framework upon which this study is based, discussing findings of previous studies and expanding on them. The methodological section, Chapter 3, describes the research design, the data sources, and the statistical methods to be used to estimate the relationships between maintenance of access to primary health care in frontier areas and a variety of independent variables. The results of the analyses are included in Chapter 4 and show the relative importance of the independent variables in predicting maintenance of a non-physician based primary health care system. Chapter 5 contains the conclusions and discusses the policy and public administration implications for policy makers, communities, health care providers, and health professions educational institutions as they relate to improving the processes involved in community development activities, recruiting and appropriately matching provider and community, and maintaining services in frontier areas of this country. 12

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CHAPTER2 REVIEW OF THE LITERATURE This study is designed to examine characteristics ofboth ruraJifrontier communities and health care professionals to determine common attributes that seem to enable some communities to maintain access to primary health care services by retaining a health care professional in the area. While numerous definitions of primary health care exist, for this study, the provisional definition of primary care adopted by the Institute of Medicine Committee on the Future of Primary Care will be used. It states: Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (Institute ofMedicine 1994). The study draws from the base of health economics, an extension of welfare economics, specifically the supply/demand issue of health care provider availability. Herzberg's Theory of Job Satisfaction is used as the base for the assessment of provider characteristics. Literature addressing various aspects of rural health and the utilization of nurse practitioners and physician assistants has also been included to complete the groundwork for this study. 13

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; I i i Health Economics Economics is an immense field that somehow is thought to affect nearly everything one does. This literature review is not intended to be comprehensive, but rather to highlight some of the salient aspects related to rural health care, specifically the distribution of health care providers based on the theory of supply and demand. The standard components of welfare economics include the theory of producer behavior, the theory of consumer behavior, and general equilibrium. Welfare economics is the study of how society allocates its scarce resources, how it transforms inputs into outputs, and how it then distributes (or redistributes) those outputs to its consumers (Detsky 1978, 9). It strives to identify the necessary and sufficient conditions to generate a socially optimal production and distribution of goods and services (Marmor and Christianson 1982). An understanding of the allocation of scarce resources and the inverse relationship between supply and demand are basic to a study of economics. In health economics, a great deal of work has been done over the years regarding physician supply and demand as reflected in the distribution of medical services (Gordon, Meister, and Hughes 1992; Hicks and Glenn 1991; Hicks and Glenn 1989; Newhouse et al. 1982; Institute ofMedicine 1978; Newhouse 1978; Eisenberg and Cantwell 1976; U.S. Department ofHealth, Education, and Welfare 1976). In fact, a 1991 study projects the size and composition of the primary care physician population in metropolitan and nonrnetropolitan areas to the year 201 0 (Kletke, 14

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I : I Marder, and Willke 1991 ). These projections, based on need and demand studies in light of demographics, are firmly embedded in welfare economics. Allan S. Detsky (1978), in The Economic Foundations ofNational Health Policy.. goes to considerable length to review the basic principles and concepts of welfare economics and to relate them to the health care industry. Included is the theory of producer behavior (where the physicians and hospitals are considered the producers of service), the theory of consumer behavior (where the patient is the consumer of these services), and general equilibrium (which, according to economic theory, should occur in a perfect market place where demand stimulates supply). Detsky explains the various reasons that the market for medical services violates the basic assumptions of classic welfare economics. These differences from the standard assumptions include: uncertainty over both the incidence of illness as well as the effectiveness of diagnostic and therapeutic procedures; infonnation gaps, due to the technical nature of the product and service, placing the consumer at a decided disadvantage; rationality or irrationality resulting from the emotion-charged nature of illness and death; and the whole concept of need and demand as it relates to control by the physician combined with societal values. Referring to health care as a "merit good," deemed by society to be distributed according to need rather than ability to pay, Detsky discusses several governmental interventions designed to make health care more "rational" and "equitable." The most recognizable of these interventions is the public hospital, which provides care (i.e., a IS

PAGE 25

., I merit good) to those who cannot afford to pay. Another standard intervention has been the investment by the government in support of the education of health care professionals through both grants to educational institutions to increase class size, and provision of scholarships and loans to students pursuing health professions. These interventions were a direct attempt to influence the "supply" of health care professionals in response to projected shortages based on studies of need and demand, as well as (secondarily) to lower the costs of medical services. In their chapter on "Health Issues", Sharp, Register, and Leftwich (1992) describe the major economic problems in the health care industry as those involving efficiency in the supply of health services and equity in their distribution. Factors helping to explain the growth in personal health care services include population growth, inflation in the economy, and increases in medical care prices in excess of general price inflation. Other factors include the underlying forces operating in the market for health care services, such as changes in consumer tastes and preferences, changes in the demographic features of the population (especially the aging of the population), and increased utilization of resources in any given treatment resulting in a higher real cost of personal health care services (Sharp, Register, and Leftwich 1992, 248). They also discuss the general uncertainty and unpredictability of illness. Another special characteristic of health services included in the discussion is the role of the physician, who operates on both the demand and supply sides of the market by providing services to the consumer, while at the same time, determining what the 16

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; I i I consumer needs in relation to service, medication, and hospitalization. Consumer ignorance due to a lack of objective information on the efficacy of treatment or quality of care is another characteristic affecting the efficiency of health care. In a "perfect" market place, information is available to the consumer on a real-time basis to allow for informed decision making. In the present medical services regimen, however, almost no objective information is available concerning the quality of health services; moreover, physicians are reluctant to give evaluations of the work of other physicians. While certain medical treatments such as immunization to prevent communicable disease provide "social spillover benefits" that enhance the health status of all members of society, the benefits of other medical procedures, such as organ transplantation, are available only to the individual users of these services and hence are highly localized They may, however, have a tremendous impact on the cost of medical services, with possible "negative spillover benefits" extending to the population as a whole in terms of increased costs of medical care. Philip Jacobs (1987), in The Economics ofHealth and Medical Care, uses an economic approach to understanding health problems, based on the identification of scarcity as a fundamental cause of many of the problems. "Scarcity" is defined as a deficiency in the quantity or quality of goods and services that are available in relation to those amounts that people desire (Jacobs 1987, xv). Side-by-side with deficiencies in health care at a given price (e g., too few providers, too few nursing homes, and too few emergency medical services) are the issues of "too many". These include high 17

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. I cost procedures whose effectiveness is either unproved or short-lived, and hospital services for the terminally ill that consume a disproportionate share of resources Thus, the issues in health care delivery from ambulances to hospices require a study of the entire resource-allocation process. Economists use models that serve as representations of reality, focusing on "if. .. then ... kinds of statements. Jacobs carefully constructs an individual pricequantity model using the basic economic hypothesis, "the lower the direct price offered to the consumer (all other factors held constant), the greater the number of units of that commodity he or she will demand" (Jacobs 1987, 45). This is clearly demonstrated in studies of health insurance coverage that have revealed greater utilization of health care services by insured patients than by uninsured (Newhouse 1978; Helms, Newhouse, and Phelps 1978) For instance, in a study of Stanford University employees and their dependents, the number of visits recorded for individuals who were enrolled in the same plan in both 1966 and 1968 were examined. In 1966, the plan completely covered physicians' services. In 1968, the plan was adapted so that persons paid a co-insurance rate of 25 percent of the bill for physician services. It was found that when compared to 1966, when services were free, there was a 25 percent reduction in number of physician visits (Newhouse 1978, 10). In addition, a Minnesota study reported that the uninsured averaged 2.47 physician visits per year while those with insurance averaged 3.61 visits (Kralewski, Liu, and Shapiro 1992, 182). Clearly, studies have shown that the number of physician visits increases 18

PAGE 28

with the presence of medical insurance. Jacobs's (1987) discussion then moves beyond treating health care as an everyday commodity (for example, rent or utilities) and explores modifications that must be made to the model to take into consideration the special circumstances surrounding health and medical care. One of these circumstances is the relationship between medical care and life and death. In some circumstances, the demand curve for medical services may be very steep, as in the case of a medical emergency, while in others, the slope will be less steep as the degree of emergency declines or the availability of substitution increases. Differences in consumer demand (taste) and the uncertainty of illness must also be considered as they relate to supply and demand. Jacobs (1987) also explores the impact of insurance on quantity of care demanded, showing that as the direct price falls in terms of payment for services, the quantity of patient visits demanded increases. This is, again, consistent with the previously mentioned findings ofNewhouse (1978}, Helms, Newhouse, and Phelps (1978), and Kralewski, Liu, and Shapiro ( 1992). Of particular importance to the present study is a concept not mentioned by other authors, that is, the situation where the money paid for medical care is not an adequate reflection of the total resource commitment made by the patient This is described as an incomplete rendering of the patient's "opportunity costs." For example, travel time from areas with a deficiency of health care to an area where there is an adequate supply, waiting time, and temporary housing costs must also be 19

PAGE 29

I factored into the over all costs of medical care These may be significant if one must travel from an isolated area to obtain needed care. Berk, and Taylor (1983) found that travel time for persons residing in HPSAs was almost four times as likely to exceed 30 minutes to the usual site of care than that of other rural residents. A comparison of frontier areas with HPSAs shows a high degree of redundancy, further supporting the assumption of increased costs associated with access to primary health care services in frontier areas due to the added indirect costs of traveling to obtain care. Further supporting the increased cost to patients from frontier areas was the finding ofWelch, Larson, and Welch (1993), who reported that patients traveling long distances use more resources and incur higher hospital costs than do local patients. Two possible reasons were suggested. First, that seeking health care is delayed because of distance, resulting in a more serious condition at the time of treatment. Second, the lack of resources for follow up care, may result in longer hospitalizations or more intensive care being given at the time of treatment (Welch, Larson, and Welch 1993). In Health Economics: Efficiency. Quality, and EQuity, Steven R Eastaugh (1992) takes a quite different approach to the discussion ofhealth economics. The basic introductory discussion of economics with the accompanying supply/demand curves is missing, as is the justification for why health economics differ from everyday economics Instead, Eastaugh focuses on more comprehensive approaches to maintaining health rather than on therapeutic medical care, and emphasizes cost20

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I benefit, cost-effectiveness, quality enhancement, and technology assessment. A discussion of supplier-induced demand is included as it relates to the rising costs of medical care, with studies cited showing the ability of physicians to affect consumer demand by the way in which they practice medicine, the diagnostic laboratory tests ordered, the medications prescnbed, the treatments provided, and the referrals made. If physicians are unable to maintain a target level of demand using a traditional fee-for service model, they can still maintain a target income by raising fees in response to a declining demand for services. Eastaugh points out that one group of physicians (general practitioners) has been unable to maintain a target income because the market for their services is relatively more competitive and the need more elastic as compared to surgeons, for example. It should be pointed out, however, that with the current move to managed care where both costs and utilization are "managed," by the primary care provider (PCP) as the appointed gatekeeper, the primary care providers are in much greater demand, and in true economic fashion, are seeing their incomes increase (Staub 1994). Supplier-induced demand may be further illustrated by a 1982 study by Wennberg and Gittelsohn (1982) that showed that the amount and cost of treatment in a community have more to do with the number of physicians and medical specialties than with the health of the residents For example, the rate of surgery and other fonns of medical treatment were examined in 193 small areas in six New England states. The overall rate of surgery varied more than twofold among the areas, with the total 21

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. I I I i rate correlated strongly with the number of surgeons and number of hospital beds. While one would expect that the number of surgeries would be greater in areas having more surgeons, the rates of three common surgical procedures (hysterectomy, prostatectomy, and tonsillectomy) varied even more-with the highest rate being six times the lowest one. This result appeared to be based more on the style of practice of the individual physician than on the specific need of the patient (Wennberg and Gittelsohn 1982), with an implication that physicians' incomes might be (at least a partial) consideration in the identification of surgical need. In a discussion of health care professional policies, Eastaugh (1992) addresses nursing education and "physician extenders" (PEs), a term that includes both nurse practitioners and physician assistants Stating that federal support ofPE training programs has been one of the primary federal responses to the perceived shortage and maldistribution of providers of primary care, Eastaugh emphasizes that the growth in programs "was a by-product of the unmet consumer demand for primary care and the perceived neglect of the human side of medicine" (Eastaugh 1992, 279). In general, PEs tend to take a more family-oriented approach to health care, including education in an attempt to improve patient compliance with treatment while trying to convince the patient that a healthier life-style is often attainable as well as more affordable. This emphasis on prevention, health promotion, and care for the chronically ill seemed to fill a gap in health care services according to Eastaugh. The result of this response to the perceived shortage and maldistribution ofPCPs was a fivefold increase in the 22

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. I I I supply of PEs from 1970 to 1980, with reduced growth from 1981 to 1991 (Eastaugh 1992), due primarily to reduced federal support of educational programs. As arguments for a "doctor shortage" or, more accurately, geographic and specialty maldistribution continued, the promise of the physician extender seemed to portend an improved access to care, preventive health education counseling, and gains in productivity. In 1977, the Congress passed the Rural Health Clinics (RHC) Services Act (PL 95-210), which allowed Medicare and Medicaid payments to be made to clinics located in rural areas for health care services furnished by or under the direction of an NP or P A without the physical presence of a physician. The Act has led to the establishment ofNP/P A-staffed rural health clinics in areas unable to recruit and retain a full-time physician. Physician supervision is generally provided from a remote site (Bell, Raetzman, and Aiuppa 1991, 4; NRHA 1994b). With advances in telecommunication and telemedicine, specialty consultation is increasingly being provided from remote sites as well. A report from The Second Invitational Consensus Conference on Telemedicine and the National Infonnation Infrastructure held in Augusta, Georgia (May 1995) states that telemedicine enables the efficient use ofNPs and PAs under virtual physician supervision via telecommunications without jeopardizing the health, well-being, or safety of the patient. The article further states that the practice of telemedicine is especially important in remote medically underserved areas where there is substantial need for care and the resources are limited 23

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(Bashshur, Puskin, and Silva 1995). Studies by the Department ofHealth and Human Services (U.S. DHHS 1991) have indicated the difficulty in determining whether and to what extent NP/P As act to improve medical productivity and decrease average costs by performing delegable tasks, and whether they free physician time to perform more costly and complex tertiary medical care. Or, in economic terms, to what extent do NPIPAs act as substitutes and/or complements for physician time? Studies of the cost-effectiveness ofNP/PAs have been carried out since the beginnings of the programs to support the utilization ofthese health care providers. Some have lumped NP/PAs together, looking at the physician substitution factor (Record et al. 1980; Mendenhall, Repicky, and Neville 1980; Bicknell, Walsh, and Tanner 1974). Other studies (Eastaugh and Regan 1990; Cawley 1986; Hershey and Kropp 1979; Nelson, Jacobs, Cordner, and Johnson 1975; Zeckhauser and Eliastam 1974) have looked at eitherNPs or PAs, describing the differences between the two professional groups. Because NPs are also registered nurses and come from a nursing background, their approach to patient care is both complementary and substitutive as nursing and medical care functions overlap. Their services are usually considered to be more comprehensive substitutive services because of their educational backgrounds in health promotion, prevention, and education (Sweet 1986). PAs have traditionally been used to expand access to care, and are often used to provide medical services in underserved areas (Regan and Harbert 1991). In the case ofboth NPs and PAs, 24

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I however, their respective salaries are considerably less than that of physicians, so it can be said that a less expensive overhead component has been substituted in the place of a more expensive one, even after taking into consideration the fact that NP/P As provide a more limited scope of service. Another possible positive outcome of the use ofNP/PAs beyond increasing productivity and improving access in typically rural underserved areas is simply to make physicians more nominally aware of the need for the caring and educational components of primary health care services The tangible benefits to society of health promotion, self-care, and prevention activities must be factored into any benefit-cost study ofNP/PAs (Eastaugh 1992). To the extent possible, it is also desirable to include the less-tangible benefits to society such as the importance of feeling good about one's selt: having a feeling of some control over one's health through preventive practices, and improved quality of life. Donald Pathman ( 1991) reviewed three general approaches used to determine the number of health professionals required to serve specific populations, highlighting their application in rural health professions requirement estimates. The methodologies are: (1) the provider-to-population ratio comparison approach; (2) the needs-based approach, which determines provider requirements based on the numbers needed to care appropriately for a population's medical morbidity; and (3) the demand-based approach, which identifies medical provider requirements by determining the numbers necessary to meet a population's actual provider use (patient demand) Pathman 25

PAGE 35

indicated that the strength of the physician-to-population ratio approach is its computational simplicity, requiring only modest data and expertise. The weakness, however, is also this simplicity Regardless of what is chosen as the comparative ratio standard, any two populations of equal size will be found to have identical physician requirements. This model fails to take into consideration differences in demographics, morbidities, geography, barriers to access, or preferences of patients in utilization of health care The early designations of primary care HPSAs were based primarily on provider-to-population ratios (1:3,500). However, Public Law 101-597, cited as the ''National Health Service Corps Revitalization Amendments of 1990," specifically identified additional indicators of need to include: 1) the rate of low birthweight births; 2) the rate of infant mortality; 3) the rate of poverty; 4) access to primary health services, taking into account the distance to such services. This action moved the designation process for HPSAs toward a need-based approach. The strength of the needs-based approach is its cost-consciousness. The number of physicians required is based on a recognized disease burden by identifying the numbers required to care for disease and provide for disease prevention. It provides a medical care system as it "ought to be," at least as defined by health care professionals. The weaknesses include the requirement for tremendous data on disease prevalence and physician productivity and work hours Despite the seeming appearance of" objectivity," many of the data rely on expert opinion of disease categories to be included (disease incidence, number of physician encounters and time 26

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:I per encounter in the provision of quality care), upon which there is little agreement in the health care community Unlike needs-based methods, which rely on professional ideas of biologic need, demand-based methods look at actual patient health services utilization. Although demand-based approaches have been described as applied econometric models, in practice, they are often employed by non-economists who examine changes in utilization due to changing health and disease status of a population, demographics, health insurance coverage, and medical practice content and organization. The strengths of this approach include the observation that utilization rates reflect actual patient demand for health services, enabling health planners to anticipate the numbers of physicians required to care for patients who actually will "show up." In rural areas, where limitation to access and tendencies to use informal healers such as folk healers (e. g., "medicine men," among Native American populations, or curanderos in Hispanic populations) are greater, this approach is most relevant. Further, demand-based methods account for the use of physician services not dictated by the biomedical mode, such as office visits for psychosocial needs for which there is no biological cause or cure Weaknesses include the significant data requirements on size and morbidity of rural populations. These data are difficult to obtain due to the limitations of the health statistics capability of most states. Mortality data is obtained from death certificates, but morbidity data, with the exception of specific reportable diseases, is not routinely 27

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reported. Further, traditional demand-based approaches do not take into consideration the effects ofunmet needs, i.e., biologic disease that does not receive care when care is known to be effective. Contributing to this area are religious beliefs that prevent acceptance of health care services including immunizations as well as treatment. Demand is also affected by people who are simply fiightened of medical care, and prefer to "take their chances." None of these models capture "unmet demand," i.e the portion of"desired" use of services not translated into actual use because of access barriers, including financial, cultural, and geographic. (Pathman 1991, 329-341) Hicks and Glenn (1991) developed a "critical mass model" used to detennine the population needed to support various specialties of physicians. This model was adapted from a previously developed demand and supply model, in an attempt to examine the issues of"critical mass" from a rural health care perspective (Hicks and Glenn 1991, 357). The initial model detennined the average number of times a year a "typical" person used the services of a physician. The second step was to allocate the aggregate number of visits among the first contact physician and the various specialty physicians. The third step was to divide the number of patient encounters supplied by each type of physician by the number of physician encounters demanded by the population, deriving an estimate of the critical mass of population necessary to support a physician in each specialty. This "critical mass" model indicated that a population of approximately 10,000 would be needed to support what are described as first contact specialists, e.g., internal medicine, obstetrics and gynecology, pediatrics and general 28

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surgery. Quantitative adjustments were then made for rural conditions. For example, studies have shown that for a variety of reasons, rural people have fewer physician encounters per year, on average, than urban citizens. However, on average, rural physicians provide more overall patient encounters than their urban and suburban counterparts. The reason for this situation is unclear, but it has persisted over the years (Hicks and Glenn 1991). One of the possible explanations is that rural residents are less likely to have employer-based health insurance (Coward, Clarke, and Seccombe 1993), and as noted previously, those with limited or no insurance generate fewer physician encounters. Further, rural physicians working in areas demonstrating a shortage of health care providers tend to work longer hours, seeing a greater number of patients. As a result, the net effect ofthese differences between rural and national averages is a higher critical mass of serviced population needed in rural areas to support any given physician at a defined full-employment level. The "critical mass" model developed by Hicks and Glenn was based on 1983 national averages, and described the population needed to support a general/family practice physician as 2970. Adjusting for rural conditions, an analogous population base of3,990, or an increase of25 percent, would be needed in a rural area. These are questionable figures, however, because they assume the availability of a full range of specialists. In areas where there is only a general or family physician with no specialists locally, computations show that only about 2,000 people, or a 33 percent decrease are required as the critical mass (Hicks and Glenn 1991, 360-363) because 29 ; I ;

PAGE 39

PCPs typically have to treat a wider range of illnesses. Given that NP/P As reportedly spend more time with each patient than do physicians (U.S. Congress, OTA 1990), this figure compares favorably with that ofMoscovice and Rosenblatt who reported a minimum population base of 1,500 to support a NP/PA site (Moscovice and Rosenblatt 1979, 505). Moscovice and Rosenblatt (1979) and Rosenblatt and Moscovice (1978) studied the economic growth and development of rural primary care practices in the mid-1970s. Their research included a determination of the length of time and the population necessary for different types of health care delivery systems to become financially self-sufficient, that is, able to maintain themselves without a community or governmental subsidy. These systems included physician-based as well as NP/P A based systems, with some in highly isolated areas. Their findings showed that growth ofNP/P A sites was slower than physician sites, but self-sufficiency was being approached in 2 Y2 years, and might be reached in three to four years. This compares favorably with physician self-sufficiency in rural areas, especially those having a hospital. They also reported that a minimum population base of 1,500 people was required to support such a system, while a population base of2,000 to 3,000 would be necessary to support a physician practice (Rosenblatt and Moscovice 1978). Certainly, market forces play a major role in the distribution of health care professionals, with the supply in an area based to a large extent on both the need and demand for services. However, as noted previously, health care does not adhere to 30

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I i i I I i I i I I .[ i t classic economic theory. Many other factors affect this distribution as well. The impact of health insurance on number of encounters provided has been shown, as has the failure of the "supply-side" approach of increasing numbers of health care providers. Attention has also been given to the demand side of the equation with work on the population necessary to support a physician or NP/P A practice. Less information is available regarding the impact of managed care organizations on the distribution of health care providers, but this changing environment must also be considered if society is to address the equity problems of the distribution of health care services. Rural Health Research During the 1970s, millions of federal and non-profit organization dollars were directed toward the problems of rural health care delivery and the perceived condition of medical underservice in these areas. Funding initiatives of both the federal government and private foundations addressed the issue of access to services, concentrating on the availability (or shortage) of human resources. A major focus of these initiatives was the development of community-based practices or primary care centers to take the place of the "old country doc" who was rapidly disappearing from the scene (Murrin 1982). It soon became clear that in planning for health care services in rural areas, special consideration had to be given to availability, taking into account the social and cultural factors that affect the expectations and behavior of rural health 31

PAGE 41

care consumers as well as those of health care providers. In light of the wide diversity in rural America, a complex web of social, cultural, and economic values has enonnous impact on the way health care needs are expressed as expectations by persons in different communities. Defining minimally adequate levels of service and dealing with the question of equity in access to care are problematic in health policy analysis, for they raise the issue of whether health care resource allocations should be fundamentally based on "need" or on "demand" for service (DeFriese and Ricketts 1989, 932). Subscnoing to the principle of equal access described by Gutmann (1983) in the previous chapter would, in fact, necessitate that, in a resource-constrained environment, the urban dweller (rich and poor) have reduced access to health care in order that their rural counterparts be afforded an equally effective chance to receive treatment of equal quality; i.e., the urban dwellers effectively subsidize their rural cousins. During the social reforms of the 1960s and 1970s, health care in the United States was increasingly viewed as a "right" rather than a privilege regardless of social, economic, or most important for this study geographic disparities. Public expectations about medical care and social services were rapidly rising and consumers were becoming better informed, more demanding, and more involved in the issues of availability, accessibility, and fragmentation of health care services (Aday et al. 1993). Social consciousness was sharpened, perhaps in part due to the Civil Rights and feminist movements of this time. The most sweeping health care legislation in this 32

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country's history was passed in 1965 in the form ofMedicare and Medicaid (Marmor 1973). These Acts focused attention largely on the health care needs of the elderly (Medicare), and to a lesser extent on the needs of the poor and underserved (Medicaid). This period also emphasized a concern for rural health care and a concomitant growth and development ofNP/P As who began to fill a gap in service delivery in small rural areas According to the Office of Technology Assessment's report on Health Care in Rural America (1990, 250), NP/PAs provide care, within their areas of competence, whose quality is equivalent to that of care provided by physicians, and often at a comparatively lower cost The functions performed by NPs and PAs include health assessments, physical examinations and basic diagnostic tests, management of minor acute and chronic illnesses, development of treatment plans, and the coordination and referral of health care services Prescriptive authority varies among the states. The OTA study also indicated that NPs and PAs generally saw fewer patients, spending more time with each than did physicians, providing valuable nonmedical services such as counseling and health education, and focusing on the prevention of disease. These groups developed rapidly, primarily in response to concerns over geographic maldistribution of primary care providers In June 1992, a second Congressionally mandated study of health professions training needs in rural (including frontier) areas was completed. The report focused attention on the supply of health professionals and whether such supply was adequate 33

PAGE 43

to meet the demands for health care services in rural communities (National Rural Health Association 1992). The study contained a comprehensive discussion of the issues that had to be considered in attempting to develop guidelines for adequacy of supply in low-population density areas. While most methodologies are physician/medical care based, this particular report stated that the preferred method used must be one that accepted the widest possible range of professional staff mixes and took into consideration community values and concepts of adequacy of services and the effects of both distance and low population density (National Rural Health Association 1992, 82-83). The determination of an adequate service level would thus be based on the health care needs of a regional population extrapolated from survey data that are either locally generated or extracted from national data adjusted for the population mix in the region. The resulting plan would be a structure of health care requirements designed to meet the diverse needs of the population, using a range of provider types. NP/P As were to be an essential part of such an approach. This model seems consistent with Pathman's description of the needs-based approach. Another difficulty in determining an adequate service level revolves around the definition of a "regional population" or a "rational service area" located within a large geographic area. The concept of a "rational service area" is used by the U.S. Public Health Service in the designation of Health Professional Shortage Areas (HPSA), a specific designation made by the Secretary of the Department of Health and Human Services that provides eligibility for participation in several federal assistance 34

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I I programs. The presence of a source of primary health care within 30 minutes travel time (as opposed to simple geographical proximity) has been established as a national standard for primary medical care, taking into consideration various types of roads and terrain (Lee 1991, 439; Jacoby 1991, 429). More recently, a method for tracking and analyzing geographic access to rural health care services and personnel has been developed through the use of isochrones executed via a computerized combination of road map and population data in a Geographic Information System (GIS). Isochrones are conceptually similar to a service area, and are defined as the geographic area around a point that is within "x" number of miles or minutes "travel time" of this point. Once the isochrone has been geographically delineated, a determination can be made of how many persons live within or outside of the isochrone. These populations can then be characterized with respect to any other data elements that are included in the population data base, in the case here, an ambulatory health care facility (Root and Challender 1993). Because most shortage area designations are currently based on geopolitical boundaries such as counties or census tracts, the correlation between shortage areas and service areas is sometimes difficult. For example, in the states included in this study, counties are frequently very large, and inappropriate for identification of a service area. Further, population centers frequently are located near the borders of other counties, resulting in rational service areas that cross county boundaries. Given the fact that provider data are maintained by county, this makes designation of areas other than counties, or 35

PAGE 45

, I : I I subdivisions of counties difficult. Therefore, a methodology such as the one described above would produce more meaningful shortage area designations. This approach seems promising and should be examined further. A recent study by Shi and his colleagues (1993) demonstrated that the major factors involving the use ofNP/P As in rural community and migrant health centers were significantly influenced by both supply and demand filctors. Amor.g supply factors, there is a significant and positive relationship between the number of total center staff and the number ofNP/P As employed; i.e., the number of nonphysician providers employed was estimated to increase by .23 for every additional staff employed. The study did not differentiate among different types of stati: so it seems fair to question whether the addition of janitorial or other ancillary staff not involved in patient care would result in the same .23 increase in NP/P As. The study also revealed a significant but inverse relationship between the number of physicians and the number ofNP/P As employed, indicating that the latter primarily serve as substitutes for physicians in rural community and migrant health centers. The demand variable, geographic location, and the centers' staffing policies are also significant determinants of the use ofNP/PAs with health centers in the Midwest and South more likely to employ nonphysician providers than those in the Northeast. While this study does not specifically examine the factors influencing practice location, the correlation between utilization and practice location can be made, suggesting a greater relative need for primary care providers in some rural areas of the country is being met through the use 36

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, I I ofNP/PAs. Several notable studies of issues effecting access to health care in rural areas have demonstrated that the issue is extremely complex.. Although significant changes have been made including passage of Medicare and Medicaid and the development of NPs and PAs, the goal of having access to primary care services within a 30 minute time frame is far from being met. Emphasis has been placed on the need to utilize both the widest possible range of professional staff mixes combined with community values and concepts of adequacy of services, taking into consideration the effects of both distance and low population density. Location of Practice Site While the factors influencing the choice of a location to establish a practice on the part of physicians have been studied on numerous occasions (Conte, Imershein, and Mcgill 1992; Rosenthal, Rosenthal, and Lucas 1992; Riley, Myers, and Schneeweiss 1991; Frenzen 1991; Kindig and Movassaghi 1989; Chaulk, Bass, and Paulman 1987; Newhouse et al. 1982; Rosenblatt and Alpert 1979; Mason 1975), the physical location decisions regarding NP/P As have not been studied as extensively (U.S. Congress OTA 1990, 319). The 1982 Newhouse study, prepared for the Kaiser Family Foundation, U.S Department of Health and Human Services, and the Robert Wood Johnson Foundation, purposefully deleted towns with populations of less than 2,500 from the sample because of the costliness of coding population data for such 37

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towns. Nonetheless, the study did examine the outcomes of a decline in numbers of generalist physicians and the disproportionate affect on small towns where generalist physicians make up a greater proportion of professional health care providers. The study, based on location theory, looked at size of town as the major determining factor but acknowledged that all towns of a given population are not equal, differing in demand per person, number of persons in surrounding areas, and amenities. As a result, no exact population figure or "critical mass" estimate necessary to support a physician could be determined. Traditional market forces were discussed, but only as they related to size of market area needed to support various specialist physicians. Other studies (Hicks and Glenn 1991; Moscovice and Rosenblatt 1979) have examined the population necessary to support a "full service" health care system that is large enough to provide fuU service in terms of primary care plus hospital and some specialty services. The population necessary to support this level of service was suggested to be a minimum of 10,000. Other studies have identified a wide range of potential factors important in determining a physician's choice of practice location including spouse's opinion, availability of hospital consultants and services, colleague interaction, and after-hours coverage (Rosenthal, Rosenthal, and Lucas 1992). A study of residents in family practice programs located in Washington, Oregon, Idaho, and North Dakota attempted to compare the recruitment practices of small communities and urban cities (Riley, Myers, and Schneeweiss 1991). The study sought to determine 1) whether 38

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some sources of information about practice opportunities were considered more important than others, 2) when residents began to identifY practice opportunities, 3) what factors contributed to an unsuccessful site visit, and 4) what components were included in a site visit. The results indicated that referrals from medical school faculty to residents were the most valued source of information. Indeed, most job searches were initiated in the first six months of the final year of residency. Substantial problems included an unreceptive or uncooperative physician community and a reluctant spouse or partner, especially for those making visits to rural communities. Interestingly, rural communities tended to provide a broader mix of professional and personal activities during the community visit (Riley, Myers, and Schneeweiss 1991 ). It was noteworthy that in this study, a rural community was defined as one of less than 10,000 population, a mid-sized town as having a population of 10,000 to 30,000, and cities as population centers having 30,000 or more inhabitants. The reason for using 10,000 or fewer for rural was explained as that used as the working definition by many Northwest hospital administrators and researchers. Given that the study involved locations in Washington, Oregon, Idaho, and North Dakota where the number of communities with populations under 10,000 dominate (in North Dakota only fourteen of fifty-three counties, much less towns, have populations of 10,000 or greater based on 1990 census data), it seems clear that the emphasis was on communities large enough to support a hospital. This leaves large numbers of towns with populations between 2,500 to 10,000 excluded from the study. 39

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More recently, two decades of experience in the University of Washington family medicine residency was studied to identify differences between graduates in rural and urban locations (Baldwin et al. 1995}. Urban areas were defined as those included in the Metropolitan Statistical Areas (MSAs} as defined by the Office of Management and Budget. The rural areas were divided into three groups: 1) counties adjacent to MSAs, 2) nonadjacent counties with 20,000 or more urban population, and 3} nonadjacent counties with fewer than 20,000 urban population (Baldwin et al. 1995, 63). The last group was considered to be the most rural and isolated of all locations. Unfortunately, this is a very general description, and leaves the actual size of the community that can successfully support a family practice physician undetermined. Nonetheless, the conclusions support previous findings (Hicks and Glenn 1991) showing that rural physicians tend to establish private practices more often than urban graduates who practice in a much broader range of settings including health maintenance organizations, teaching practices, and salaried clinics. Further, the patient care workload of rural graduates was substantially higher than that of urban graduates, having more patient encounters in all settings. This again is consistent with previously cited studies showing greater patient encounters in rural areas (Hicks and Glenn 1991; U.S. Department ofHealth, Education, and Welfare 1976). As might be expected, the on-call schedule for the University ofWashington study was also significantly greater for those graduates in rural areas, and emergency room contacts were four times greater. Another difference between urban and rural 40

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practices was the broader range of procedures performed by the rural physicians, and the reduced number of support personnel, both health care and administrative staff, available to assist the physician (Baldwin et al. 1995, 65). Clearly, these findings have implications for training programs as well as for communities who are seeking health care providers. The findings suggest that training programs should attempt to prepare providers interested in rural areas for the higher patient care workload and the demands of the on-call schedule. Providers must also learn to work with fewer support personnel. Communities, also, should understand the greater demands placed on providers in rural areas and try to provide the additional support necessary. It should be pointed out that the findings may not be generalizable across the country, however, since the study targeted a group of family practice residents who were primarily from allopathic medical schools. Data from the American Academy of Family Physicians indicate that approximately 15 percent of physicians practicing in rural areas are graduates of osteopathic schools and another 15 percent are international graduates (AAFP 1993; U.S. Congress, OTA 1990). Therefore, it is not possible to state that the findings of the University ofWashington study would be consistent in another group. The study does, however, demonstrate significant differences between rural and urban practices, and might then suggest that there are also differences in the characteristics of physicians who establish practices in these areas. While some transference of information from physician practice location 41

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selection to that ofNPs and PAs may be possible, as has been pointed out previously in this paper, most physician location studies have targeted communities larger than the frontier areas included in this study. Although the number of practice location studies ofNPs and PAs is limited, the studies do tend to target smaller rural areas. A study of the patterns of practice ofNPs in a rural underserved area of South Carolina revealed that the reasons for selecting a practice site in rank order were: role autonomy, good salary benefits, adequate medical backup, and educational opportunities. The surveyed NPs reported that the major contribution of their presence in these areas was their ability to increase access to care for a significant number of patients, especially the disadvantaged groups such as the working poor through utilizing professional judgment and practicing independently (Lawler and Valand 1988). Among the long-standing areas ofunderservice, those portions of the country referred to as "frontier" are the most removed from health care services. Bigbee ( 1992) described these areas as opportunities for NPs to provide primary care services. While there was no discussion of practice location decision-making on the part of NP/P As working in these areas, Bigbee did identify frontier areas as favorable for the development ofNP practices. She continued and described three steps necessary to establish a frontier practice: identify a frontier practice as a personal and professional mission; establish an economic base (or demand structure) according to community input and assessment data; and creatively design the practice and services for the 42

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frontier population and environment. Analogous to the Lawler and Valand,s (1988) findings, Bigbee's characteristics ofNPs that might be successful in the establishment of such a practice included: 1) comfort with high levels of autonomy in a variety of primary care roles including practice development and management; 2) community organization; 3) fund-raising; and 4) experience with broad-based acute, emergent and chronic care. In addition, the NP must be attracted to living in sparsely populated areas often surrounded by great expanses of natural beauty. Given the limited availability of other cultural or social opportunities found in more densely populated areas, out-door recreational opportunities must be attractive to the practitioner and family (Bigbee 1992). Amundson (1993) discussed the myth and reality in the rural health service crisis, focusing on community responsibility. He indicated that there is a strong tendency for rural community providers and leaders to externalize explanations for the deterioration of local services, blaming the reimbursement system, the lure of the cities, the inappropriate training in academic health centers, or the desire to use high technology in patient care. The article further stated "that the primary reason for the threat or demise of human services in most rural communities is the failure of communities to meet the needs and expectations of local residents and to effectively address local problems in the delivery system" (Amundson 1993, 177). While indicating that the primary responsibility for the situation resides within many rural communities, the strongest potential for maintaining services also resides within the 43

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communities According to Amundson, effective efforts at community-based solutions require attention to three general areas: I) application of principles for successful community-based health work including emphasis on overall community development; 2) recognition that the money currently spent on human services in most rural communities should be controlled by the communities, meaning that local services must be utilized, keeping the money at home; and (3) creation of a national network of organizations with the skills and resources to work effectively with communities on community-based solutions (Amundson 1993, 183-185). Similarly, in an initiative called Colorado Healthy Communities, support is being provided to selected communities to "take back" the community, demonstrating responsibility for both problems and outcomes. Or, as Tyler Norris, Director of the Colorado Healthy Communities Initiative (CHCI) stated in his introductory comments in the Colorado Healthy Communities Handbook, "The Colorado Healthy Communities Initiative challenges individuals and communities to reclaim responsibility for their health, and recognize that they are both the source and the beneficiary of the actions they undertake" (Norris 1993). One of the several steps in the Healthy Communities Process involves use of The Civic Index, a self-evaluation tool developed by the National Civic League to enhance the ability of communities to solve their problems, meet their challenges, and set directions for the future. The Civic Index consists of ten components that have been found to be fundamental to a community's health and ability to work effectively. Those components include 44

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citizen participation, community leadership, government performance, volunteerism and philanthropy, intergroup relations, civic education, community infonnation sharing, capacity for cooperation and consensus building, community vision and pride, and intercommunity cooperation (Norris 1993, 77-79). The Northwest Area Foundation is a foundation committed to promoting the economic revitalization of the upper Midwest and Northwest region of the country and improving the standard of living for the region's most vulnerable citizens From 1986 to 1993, the Foundation funded projects designed to increase community participation in addressing the problems of health care in rural communities. Some of the general lessons learned from the experiences with rural health care systems included: I) expanded citizen participation combined with expert technical assistance can be essential in improving health services; 2) interventions are most effective in communities where the health care system problems are clear, but have not reached a point where options for correction have been lost; 3) piecemeal solutions are unlikely to be effective because the needs of rural health care are seldom confined to a single problem; 4) a single individual acting as a community change agent supported by a local advisory group was a critical factor; 5) meaningful involvement of an exogenous group of people outside the hospital structure in strategy development is important in the community's commitment to improve health services; 6) community goal setting meetings gave residents a strong sense of inclusiveness; 7) the most effective strategies integrated the perspectives of local decision makers and health care providers with 45

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i I I I expert outside resources (National Rural Health Association 1994a). While this report only addressed the experiences of projects designed to increase community participation, the findings seem to support the comments of both Amundson and Norris regarding the importance of community involvement in addressing the issues of health care services in rural areas-that the problems may be more internal to the community than external. Finally, research at the University ofWashington suggests that intracommunity factors are largely responsible for failing rural systems, namely: 1) quality-of-care issues; 2) poor leadership; 3) ineffectual performance by providers, managers and trustees; and 4) the effect of poor teamwork and chronic conflict among local providers (Amundson and Rosenblatt 1991). Given these findings, it appears that if access to primary care services in frontier areas is to be maintained, at least two concepts need to be explored the characteristics of the providers themselves that may contribute to job satisfaction or dissatisfaction and the characteristics of the communities that contribute to the development of viable health care systems and the retention of health care professionals. In other words, we find another version of the familiar supply-demand theory. Briefly stated then, the literature reveals numerous studies of the influences on the practice site decisions of physicians, but fewer studies of the same decisions on the part ofNPs and PAs. The majority of these studies have focused on larger towns of 10,000 or more, with very few examining the needs of communities of2,500 or less. 46 I I I

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Some of the most noteworthy influences effecting practice site decisions for NPs and PAs included role autonomy, adequate medical backup, and opportunities for continuing education. Necessary skills cited included a need for community development and fund-raising skills, and in sparsely populated areas, an affinity for outdoor activities. More recently, attention had been given to the need to improve the overall community infrastructure, including economic base, community leadership and cooperation with other communities, and commitment to improving the health of the community. Motivation-Hygiene Theory In 1964, Frederick Herzberg advanced a dual-factor theory of job satisfaction and dissatisfaction based on studies of accountants and engineers. Herzberg stated that satisfaction and dissatisfaction are two unipolar traits rather than being opposite ends of a bipolar continuum. Herzberg then identified factors inherent in the work situation that are "satisfying", and that arise from the content of the work, i.e., are intrinsic to the work itself Increases in these factors are correlated with heightened productivity. They were called "motivators." Environmental factors surrounding the job or the context in which work is performed were associated with dissatisfaction and were termed "hygiene" factors. Among those factors deemed "satisfiers" or "motivators" are achievement, 47

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recognition, the work itself, responsibility, and advancement The last three were identified as being of greater importance for lasting change of attitudes. "Dissatisfiers," the hygiene factors, included company policy and administration, supervision, salary, interpersonal relations, and working conditions (Herzberg 1966, 72-74). Follow-up studies identified the following additional factors: possibility of growth was found to be a motivator, and status, job security, and effect on personal life were identified as hygiene factors (Herzberg 1966, 77). Herzberg also suggested that human attitudes are associated with needs, and related them to Maslow's famous hierarchy of need. In this case, motivators are associated with psychological growth as in the example of achievement. Hygiene factors correlate more closely with animal needs that serve to reduce displeasure, but since they do not possess the qualities necessary for psychological growth, they cannot be conducive to the gratification of human needs. Thus, Herzberg indicated that the two sets of factors have separate themes Motivators describe one's relationship to mmt is done -job content, achievement of a task, recognition for task achievement, the nature of the task, responsibility for a task, and professional advancement or growth in task capability. The "dissatisfiers" or hygiene factors describe one's relationship to the context or environment in which the job is done. In other words, one cluster of factors relates to what the person does and the other to the situation in which it is done. A second level of Herzberg's analysis suggested that hygiene or maintenance 48

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events led to job dissatisfaction because of a need to avoid unpleasantness while the motivator events led to job satisfaction because of a need for growth or self actualization. Hence, the factors involved in producing job satisfaction are separate and distinct from the factors that lead to job dissatisfaction. The opposite of job satisfaction is not dissatisfaction, but rather no job satisfaction. Conversely, the opposite of job dissatisfaction is no job dissatisfaction, not satisfaction with one's job (Herzberg 1966). Herzberg's theory has been used in several studies of nursing personnel including nurse practitioners (Capan, Beard, and Mashburn 1993; Koelbel, Fuller, and Misener 1991; Tri 1991; White and Maguire 1973 ). Other studies of this nature have examined factors related to job satisfaction and autonomy as correlates of job retention (Dunkin et al. 1992; Hanson, Jenkins, and Ryan 1990; Bream and Schapiro 1989; Lemler and Leach 1986). Still others have looked at factors and work setting that help or hinder the practice ofNPs (Hupcey 1993; Coward et al. 1992; Riner 1989). The similarities of findings related to job satisfaction are great and show correlation with Herzberg's motivator and hygiene factors. The White and Maguire study (1973) utilized the same type of interview method used by Herzberg in which respondents were asked to describe a time -tell a story when they felt particularly satisfied about the job. After this story was related, the respondents were asked to relate a dissatisfying experience. The factors found most often in the stories of job satisfaction included the work itself, achievement, 49

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:I I recognition, responsibility, and growth/advancement Those found most often in the stories of dissatisfaction were supervision, hospital policy, working conditions, interpersonal relations, and salary. The findings were again consistent with Herzberg's motivation-hygiene theory. Koelbel, Fuller, and Misener ( 1991) used the Index of Job Satisfaction (Brayfield and Rothe 1951) and the Minnesota Satisfaction Questionnaire Short Fonn to test Herzberg's theory. A questionnaire was utilized to obtain the data from 13 2 NPs The data revealed that respondents reported less satisfaction with extrinsic factors than with intrinsic factors. Practitioners reported satisfaction when they helped other people, used their abilities, had steady employment, varied their work, and practiced without compromising their moral values, factors described as intrinsic. The least satisfying job elements were the extrinsic factors of compensation, lack of opportunity for advancement, company policies and practices, lack of recognition, and supervision/human relations. While some differences exist, in general, Herzberg's theory that intrinsic factors are sources of job satisfaction, while extrinsic factors are sources ofjob dissatisfaction was confirmed (Koelbel, Fuller, Misener 1991). Autonomy, sense of accomplishment, and time spent in patient care ranked as the top three factors contributing to job satisfaction among nursing personnel in a study of job satisfaction and characteristics of the practice setting completed by Tri (1991). A seven-point scale was used as a summary measure of overall job satisfaction, and for calculating relationships between certain practice-setting 50

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characteristics and the level of job satisfaction reported. Correlation matrixes were utilized to determine the relationships between certain practice-setting characteristics and the NPs' overall satisfaction with the position (Tri 1991, 49). Again, factors that contributed to satisfaction included: autonomy; portion of time in patient care; sense of accomplishment; challenge of learning and growing; amount of self-determination offered; number and kinds of patients; quality of care within the setting; relationship with peers; flexibility; and the ability to express creativity. Tri found that factors contributing to dissatisfaction were: salary; compatibility of goals with organization; environmental support for innovation; administrative duties; relationship with those to whom one reported; time spent in educational activities; development of one's own clinical skills; number and kinds of patients; support for outside activity; and relationship with physicians. Interestingly, the Tri study then proceeded to look at the correlation between perceived skill levels and job satisfaction, initially using four skill levels novice, intermediate, advanced, and expert. These groups were collapsed into two groups for analysis that revealed significant differences between the skilled and less skilled groups, with the less skilled being more dissatisfied with development of own clinical skills, relationship with physicians, challenge ofleaming and growing, amount of self determination offered, flexibility, relationship with other disciplines, and relationship with peers. Benner's 1984 work, From Novice to Ewert was cited, indicating that rule-governed behavior is typical of the novice, and is extremely limited and inflexible 51

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(Benner 1984). Thus, the less-skilled NPs have less experience and may search for rules to guide their performance, feeling frustrated with the nature of the NP role in primary care where there are few hard-and-fast rules to guide performance. Hanson, Jenkins, and Ryan (1990) examined the personal characteristics, factors of job satisfaction, and autonomy that could lead to job retention for nurses in rural Georgia Contrary to their expectation, they found that personal characteristics such as age, education, salary, marital status, and number of dependents are not strong predictors of job retention. While some of these factors correlated negatively with impending job change, the strongest relationships were those related to nursing autonomy. The strongest correlations were found between autonomy and number of times the nurse had looked for another job, and autonomy and intention to quit. Work satisfaction, satisfaction with compensation, satisfaction with supervisor, and satisfaction with promotional opportunities all correlated significantly with intention to quit. Hupcey (1993) examined factors that helped and hindered practice. The top five helping factors included acceptance and support from physicians, support from coworkers, support from other NPs, independence in the work setting. Hindering factors included lack of administrative support, lack of physician support, lack of coworker support, and resistance of staff nurses. The likelihood of registered nurses leaving rural settings was analyzed by Pan et al. (1995). This logit analysis examined the effect of factors such as marital status, age, position held, income, job satisfaction, and satisfaction with community. The 52

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' I : I i I I I I findings indicated that nurses' feelings about their jobs and their communities had a stronger effect on decisions to leave the position than did the other factors. The margin between the highest and lowest net effects was between four and six times for these two variables Job satisfaction played the most important role in the nurses' decisions about leaving their current jobs while demographic characteristics such as marital status and age had only moderate effects on job decisions. Although Herzberg's theory was not a part of this study, it does seem to support the basic concept. The factors included in "job satisfaction" were not identified, rather, respondents were simply asked to describe their level of satisfaction with their jobs and with their communities. An ethnographic study of job satisfaction among home care nurses (Chubon 1991) asked, as part of a larger study of job stress, what provided job satisfaction to the service providers. Those aspects that contributed to job satisfaction included: the independence of their practice; the opportunity to design and implement interventions deemed appropriate; development of meaningful relationships with patients; challenge of solving problems; and supportive relationships with coworkers A recurring theme in the descriptions given by the nurses was appreciation for compliments and recognition of their accomplishments While factors contributing to dissatisfaction were not examined, it was interesting that salary was never mentioned as a factor in job satisfaction Again, independence, creativity, and problem-solving, factors that can be described as intrinsic to the work, produced feelings of job satisfaction. 53

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All of the preceding studies have come out of the nursing literature, addressing either nurses or nurse practitioners. Literature referring to physician job satisfaction has not been found. Similarly, little was found in the literature relating to job satisfaction as it pertains to physician assistants. A report by Perry (1976) looked at the general characteristics, job performance, and job satisfaction of PAs who graduated in 197 4 or before. Since P A programs were just developing in the 1970s, the data were limited. However, the study did report that PAs were found to be working predominantly in primary care specialties and in smaller communities. Among factors that would fall within Herzberg's dissatisfiers was the PAs' perception of limited opportunity for growth and advancement. The strongest correlates of job satisfaction were the degree of physician supervisory support and the amount of responsibility for patient care. Again, Perry found that satisfaction was related to having responsibility for patient care within a supportive environment. Bard-Lozecki (1977) studied PAs working within a mental health setting to determine job satisfaction in relation to daily task performance, preference for tasks, perceived effects of working with psychiatric patients, comfortableness with amount and type of supervision received, relationships with coworkers, opportunities for professional growth and promotion, salary and benefits. The results indicated that job satisfaction was related to individual experiences, rather than to environmental aspects. While this study did not look at factors contributing to dissatisfaction, the fact that job satisfaction correlated with individual or intrinsic events supports Herzberg's dual-54

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I factor theory that intrinsic factors contribute to job satisfaction while extrinsic factors are related to dissatisfaction. The growth of the managed care industry has increased demand for both generalist physician and non-physician providers, largely for economic reasons Because the organizational structure of the managed care organization is significantly different from the traditional private practice of the physician or the physician-NPIPA relationship, some studies have attempted to address job satisfaction in managed care or HMO settings (Freeborn and Hooker 1995; Freeborn 1985) In their study of the satisfaction of physician assistants and other nonphysician providers in a managed care setting, Freeborn and Hooker (1995) found that physician assistants were most satisfied with the amount of responsibility, support from coworkers, job security, working hours, supervision, and task variety They were less satisfied with workload, control over the pace of the work, and opportunities for advancement. Another major contributing factor to P A job satisfaction was professional and personal support of the supervising physician. While these findings are not directly comparable to the "motivators" and "hygiene" factors described by Herzberg, those factors contributing to less satisfaction are consistent with the dissatisfiers described in other studies based on Herzberg's theory. It should be pointed out, however, that the Freeborn and Hooker study was limited to only one large HMO located in the northwestern part of the United States. Because this is one of the oldest and largest managed care plans, it is questionable whether these findings are generalizable to other managed care systems 55

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or to rural health care personnel, at least at this point in time In brie( Herzberg's Motivation-Hygiene Theory has been used as the base for numerous studies of job satisfaction over the years. The results seem to confirm the importance of the intrinsic (motivation) factors in job satisfaction compared to the extrinsic (hygiene) factors in job dissatisfaction. In particular, studies ofhealth care personnel have shown that autonomy and independence, achievement, recognition, and responsibility were frequently mentioned as factors influencing job satisfaction Factors identified with job dissatisfaction included supervision, working conditions and policies, interpersonal relations, and salary. Review Overall, the literature supports the conclusion that the issues surrounding the maintenance of access to primary health care in sparsely populated rural areas are complex and not easily addressed. They are multi-faceted, requiring not only an examination of the health care providers who serve these areas, but also the characteristics of the providers who have chosen not to serve such areas. There must also be an examination of the communities themselves, looking at the economic development on-going, the resources present, and the leadership available While state and federal interventions have shifted emphasis from diffusion theory based on increasing numbers of providers to strategic polices designed to address retention of providers through the greater provision of support services such as access to 56

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, I i continuing education programs and on-site practice management assistance, the literature would suggest that the problem is broader than simply "retention .. of providers by attempting to increase job satisfaction. Rather, a shift to a .. development and maintenance" theory of community infrastructure that provides the basis for an integrated health care system capable of reacting to the volatile health care environment is suggested. This study attempts to examine variables relating to both the community and the provider that will perhaps provide the basis for an integrated health care system and raise the odds of maintaining access to primary health care in our most isolated and vulnerable areas, the frontier. 57

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CHAPTER3 METHODOLOGY Introduction The purpose of any study has at its foundation the desire to discover something, to learn the reason for, to try to determine why. But before one can discover, learn the reason for, or determine why, there must be a research plan. One must define precisely what is to be learned, and then, determine the appropriate way to implement the plan. The starting point is the research question. The challenge here is in properly stating the question so that it will point in the direction of an answer. The research question to be examined in this dissertation is why some small population communities are able to maintain access to primary health care services through the use ofNPs and PAs, when other similar communities are unable to do so. Research fupotheses The purpose of this study is to examine the characteristics of both the community and provider in successful and unsuccessful NP/P A-based systems of health care delivery in frontier areas of the United States, identifYing and analyzing those characteristics that lead to differing outcomes. Based on the review of the literature in the areas of health economics, rural health including practice location, and 58

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I I Herzberg's dual-factor theory of Job Satisfaction. two research hypotheses are posited, the first dealing with community characteristics, the second with provider characteristics. The study specifically examines the characteristics of both the community and provider that are related to maintaining these practices in a frontier community. H1 The long-term maintenance of a NP/PA-based system of primary health care is a function of the following community characteristics: o proximity (30 minutes travel time) to a community of I 0,000 or greater o socio-economic status of the community o availability of health insurance o "critical mass" equal to or greater than I,SOO residents located in a rational service area o effective leadership at the local level o utilization of local resources In formulaic tenns, this may be expressed as: S = S(miles30, soec, ins, critmas, comled. Iocres), in which S = status of the community either successful or unsuccessful, miles30 = proximity to a community of I 0,000 or greater, soec = socio-economic status of the community (later tracked as percap =per capita income of the county, and ecoperc =perception of economic strength ofthe community), ins= availability of health hisurance, critmas =critical mass equal to or greater than I,500 residents, comled = community leadership, locres = utilization of local resources. N=SOO 59

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I I I I H2 The maintenance of a NP/P A-based system of health care is a function of the following provider NPIPA) characteristics: o provider/spouse residence of origin o rural experience during training o sense of autonomy/desire for independence of action o sense of responsibility and achievement o affinity for outdoor activities o age/years of experience o marital status o supportive medical community including consulting physician and provision for backup In formulaic ternis, this may be expressed as : S = S(grewup, rurrot, autonomy, achresp, outdoor, years, marital, medcom), in which: N=30 S = status of the provider either maintained or grewup = residence of ro"ot = rural experience during training, autonomy = autonomy (later tracked as autoresp = autonomy and responsibility), achresp = sense of achievement and responsibility (later tracked as ackreg = acknowledgment and recognition of achievement), outdoor = affinity for outdoor activities, years= years of marital = marital status, medcom = supportive medical community Data Collection This study builds on the previous research ofMoscovice ( 1989), Rosenblatt and Moscovice (1978), Amundson, Hagopian, and Robertson (1991), Lawler and 60

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Valand (1988), and Shi et al. (1993). It is designed to expand the knowledge bases relating to the establishment and maintenance ofNPIP A practices in frontier areas, thus enabling these citizens access to quality primary health care services. The research conducted by Shi and his coUeagues (1993) examined utilization ofNP/PAs in a specific group offederaUy assisted primary health care centers in the nation's medicaUy underserved rural areas. The current area of investigation is restricted to the least densely populated areas of six states Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming targeting NP/P As working not only in federally assisted rural community and migrant health centers (CIMHCs), but also in rural health clinics (RHCs) and other public or private practices in communities with populations of2,500 persons or less, located in counties having six or fewer persons per square mile. Communities that sustained a NP/P A practice for three years or longer were included in the study as "successful" while a contrasting group of communities that were either unable to establish such a practice, or failed to maintain it for a three year period were included as "unsuccessful." Similarly, an attempt was made to examine the characteristics of providers who remained in NPIP A practices in frontier areas for three or more years compared to those of providers who entered such practices, but left the practice and the area in less than three years. Based on the literature review, six independent variables affecting the ability of a community to maintain access to health care services were identified. Thus, the 61

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dependent variable for H1 is "status of the community," either successful or unsuccessful in retaining a health care professional, while the independent variables include: o proximity (within 30 minutes travel time) to a largP.r community of 10,000 or greater (Connor, Kralewski, and Hillson 1994; Hicks and Glenn 1991; Kindig and Movassaghi I989; Brooks and Johnson I986; Newhouse et al. 1982; Moscovice and Rosenblatt 1978) o socio-economic status of the community (Connor, Kralewski, and Hillson 1994; Bigbee 1992; Makuc et al. 1991; Newhouse et al. 1982; Moscovice and Rosenblatt I 978) o availability ofhealth insurance (Frenzen 1993; Kralewski, Liu, and Shapiro 1992; Makuc et al. 1991; Newhouse 1978) o "critical mass" equal to or greater than 1500 located in a rational service area (Hicks and Glenn 1991; Lee 1991; Moscovice and Rosenblatt 1979) o effective leadership at the local level (NRHA 1994a; Amundson 1993; Norris 1993; Elder and Amundson 1991) o utilization of local resources (Connor, Kralewski, and Hillson 1994; Bronstein and Morrisey 1991; Hart, Lishner, and Amundson 1991) H1 Data Gathering: The Communities Given the number of variables to be examined in "naturally occurring groups," survey research was determined to be the most feasible approach (Aday I 989; Nachmias and Nachmias 1987). Numerous existing community surveys were examined for possible use in the study including the National Health Interview Survey (U.S. Department ofHealth and Human Services 1992), the National Medical Expenditure Survey (Edwards and Berlin I 989), a national survey of the utilization of nurse practitioners, physician assistants, and certified nurse midwives (Shi et al. 1993), 62

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and the Assessment Protocol for Excellence in Public Health (APEXPH) developed by the National Association of County Health Officials (NACHO 1991). Ultimately, the community survey was structured primarily on the Community Health Survey used by the Community Health Services Development Program (CHSD), a partnership of The University of Washington School ofMedicine, Department of Family Medicine, and the W AMI (Washington, Alaska, Montana, Idaho) Area Health Education Centers. The CHSD graciously provided a draft copy of its generic survey, which, when used by CHSD, is customized to meet the needs of the individual community. The Community Health Survey provides information about the community's attitudes and opinions concerning health services in the area, and is an outgrowth of a W.K. Kellogg Foundation-funded Rural Hospital Project carried out from 1985 through 1988. The Community Health Survey has been conducted in over sixty rural communities where samples of 1,000 people in each community are surveyed. The reliability of the original instrument has been carefully checked through preand posttest survey analysis and found to be high The validity, while more difficult to establish in survey research, has also been detennined to be high based on the consistency of preand post-test results combined with the general knowledge of the communities involved. Reliability and validity have continued to be confirmed through consistent utilization and analysis of the data (Dyck 1995; Hart, Lishner, and Amundson 1991; Amundson, Hagopian, and Robertson 1991). The CHSD survey was augmented with questions from the Community 63

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Assessment utilized by the School of Medicine at the University ofNorth Dakota in their community diagnosis process (Ludtke and Ahmed 1990). In addition, portions of the Civic Index from the Colorado Healthy Communities Handbook, developed by The Colorado Trust and the National Civic League (Norris 1993) relating to citizen participation have been adapted to a Likert scale and used to help assess community leadership, one of the independent variables identified in the literature. The Civic Index has been used by the National Civic League in the United States Healthy Communities Initiative (USHCI) to direct an effective community-wide discussion of community infrastructure. The USHCI is a cooperative project of the U.S. Public Health Service and the National Civic League that has been involved since 1989 in promoting a concept of healthy communities through stimulating local and statewide projects nationally (Norris 1993). Following a facilitated town-meeting during which community participants engage in a discussion of the components of the Index, participants score their community on each of the components, determining how their community is perfonning in each area. This activity forms the basis for developing short and long-term goals. While evidence that reliability tests have been conducted on the questions that form the Index is not provided, the utilization of these questions in numerous communities over the past six years has resulted in consistent application of the Index scores, attesting to the reliability of the instrument. In addition, because the questions addressing community leadership had previously been used as the basis for community 64 I '!

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discussions. and had been crafted into a Likert-like scale for this study, a reliability analysis was conducted on variables measured by these questions. Because the items on a scale are designed to measure different aspects of a common concept, it is assumed that they are positively correlated with each other. Cronbach's Alpha was used to test this assumption on the eleven items addressing community leadership. Based on an Alpha range from 0 to l, the resulting score of .857 is considered high. indicating that the scale measuring leadership attributes is quite reliable and acceptable for use in this study. Validity of the Civic Index is also confirmed based on the long-term utilization of the instrument and the successes of the communities that have been involved in the process. Consistency with other instruments designed to describe the key elements of a healthy community, e.g., Elements of Healthy Cities from Leonard Duhl (1990), Healthy Cities Project from the World Health Organization (WHO 1988). and the model developed by the United Way of America called "Building Healthier Communities: The United Way" (1990), supports both face and content validity. The survey instrument for this study was developed and field tested in frontier communities in the State ofNebraska. Based on the results of the field test, the instrument was revised and put into final form. Communities to be included in the study were identified by the staff of an organization within each state that works with health professional recruitment and community development. In most cases, this has been either the State Office of Rural Health or the State Primary Care Association. 65

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(The names of those persons and the organizations they represent are included in Appendix A.) Each of the six state representatives was asked to identify five "successful" communities along with a community contact and five "unsuccessful" communities and contact person, for a total of sixty communities to be included in the survey. All communities were to be located in "frontier" counties, a designation with which the state representatives were familiar. The community contact was generally a health care provider, an administrator, or the chair of a health care professional recruitment committee. For purposes of this study, "successful" is defined as a community that has maintained the services of a nurse practitioner or physician assistant for three or more years. "Unsuccessful" is defined as a community that has been unsuccessful in recruiting a NP/P A during a three year period, or had recruited a health care professional who left in less than three years. The time period of 1991 to 1994 was specified; however, these dates had to be expanded to assure an adequate sample. Each community contact person was reached by telephone if possible or in writing if necessary. The purpose of the study was explained, and each person asked to identify nine other persons they would consider to be "community leaders," persons whose names came immediately to mind when a task needed to be accomplished in the community. Once the names and addresses of leaders from the identified communities were obtained, the survey instrument was mailed. The community contacts were asked 66

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permission to use their names in the cover letters that introduced the researcher and purpose of the study, indicating that they had been identified (for example) by "John Doe of the Frontier Health Center as a community leader who might be willing to assist in a study ... Each cover letter was individually addressed and further, indicated that their community had been identified by the person at the state level organization as a good place to study. (An example of the cover letter and survey instrument may be found at Appendix B.) A self-addressed stamped envelope was included for ease in response. The surveys were coded on both the return envelope and on the survey instrument to allow for response tracking. A follow up letter and second survey was sent to non-respondents approximately one month after the first. In a limited number of cases, a second follow up was sent one month later. Due to difficulties in identifying communities, the final study sample totaled five hundred "community leaders" rather than six hundred as initially anticipated ten community leaders from each of twenty-five "successful" and twenty-five "unsuccessful" communities. H2 Data Gatbering: The Providers The second research hypothesis based on Herzberg's Theory of Job Satisfaction required confirmation of provider characteristics identified through the literature review. Herzberg's Theory identifies two categories of factors that affect job satisfaction, "extrinsic" or environmental factors such as salary, supervision, and working conditions that contribute to job dissatisfaction, and "intrinsic" factors such as 67

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I achievement, responsibility, and advancement that influence job satisfaction (Herzberg 1966; Koelbel, Fuller, and Misener 1991). The dependent variable for H2 is retention of the health care provider for three years or longer, and is referred to as status, "'maintained'' or "'non-maintained.'' The independent variables include: o provider/spouse residence of origin (Rhodes and Day 1989; Ernst and Yett 1985) o rural experience during training (Fryer et al. 1994; Rhodes and Day 1989; Martini et al. 1994) o sense of autonomy/desire for independence of action (Tri 1991; Bard Lozecki 1977; Lawler and Valand 1988; Hanson, Jenkins, and Ryan 1990; Hupcey 1993;) o sense of responsibility and achievement (White and Maguire 1973; Perry 1976; Tri 1991; Bard-Lozecki 1977) o affinity for outdoor activities (Bigbee 1992) o age/years of experience (Benner 1984; Jenkins, and Ryan 1990; Tri 1991) o marital status (Hanson, Jenkins, and Ryan 1990; Pan et al 1995) o supportive medical community including consulting physician and provision for backup (Lawler and Valand 1988; Perry 1976; Rosenthal, Rosenthal, and Lucas 1992; Riley, Myers, and Schneeweiss, 1991; Hupcey 1993) Data collection for H2 was accomplished through interviews ofNPs and PAs using an interview instrument that consists of twenty-one standard questions addressing basic demographic data as weU as attitudes and opinions relating to the community and practice in general Two open-ended questions, consistent with the interview methodology used by Herzberg, were also included. The first question asks the respondents to describe a time when they felt "exceptionally good or bad" about the job. Following this account, the respondents are asked to describe a time when 68

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I they felt the opposite. Consistent with Herzberg's methodology, prompting questions were prepared to enhance the consistency of the responses. The responses to the open-ended questions were recorded and transcribed to facilitate analysis of the information. The initial sampling frame for the testing ofH2 was drawn from NP/P As who have practiced for three or more years in a target community contrasted with a similar group that had tried practicing in a frontier community, but left in less than three years. Assistance in identifYing these groups of providers was obtained through the state Offices of Rural Health or another organization that works with recruitment and retention ofhealth care personnel in each surveyed state. The names of five NP/PAs who have been maintained in frontier communities and five who have left such areas were requested from each state representative, for a total of sixty NP/P As to be interviewed for the study. This sample size proved to be overly ambitious from two perspectives. First, the state representatives had a very difficult time identifying providers who had left targeted communities and second, the time necessary to contact these very busy providers, schedule an appointment, and conduct the interview became prohibitive. As a result, the sample size was reduced to thirty NP/PAs, fifteen of whom were maintained, and fifteen of whom had left frontier communities. Again, several existing survey instruments were examined for possible use including the Index of Job Satisfaction (Brayfield and Rothe 1951) and the Minnesota Satisfaction QuestionnaireShort Form (Weiss 1967), and the National Medical 69

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. i i Provider Survey (Tourangeau and Ward 1992). The final interview instrument was a composite based largely on a MEDEX Graduate Survey conducted by the University ofWashington in 1990 (Larson, Hart, and Hummed 1992}, and a physician retention study conducted in Gadsden County Florida (Conte, Imershein, and Magill 1992). These two surveys contain questions that address the intrinsic and extrinsic factors of Herzberg's model, plus other factors identified in the literature as influencing provider recruitment/retention (An example of the interview instrument may be found at Appendix C.) As indicated previously, reliability and validity are difficult to measure in survey research, but are essential concepts to be addressed. Reliability can be enhanced by asking people only the things they are likely to know, by asking the same information more than once (test-retest), by randomly assigning items to two sets and comparing responses (split-halfmethod), and by using measures known for their reliability (Wagemaar and Babbie 1989). This interview instrument was based on previously used instruments, one an interview instrument (Conte, Imershein, and Magill1992), and the other a self-administered questionnaire (Larson, Hart, and Hummed 1992). The self-administered questionnaire was developed at the W AMI Rural Health Research Center and was carefully pre-tested and adjustments made prior to administration. Further, the instrument was designed to ask only the things the respondents were likely to know, a technique designed to enhance the reliability of the instrument (Wagenaar and Babbie 1989) 70

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Validity was checked by examining the various instruments to determine agreement with the concepts that appear to be inherent in retention of providers, job satisfaction, satisfaction with the community, supportive environment for example. This examination revealed that both instruments addressed similar measures identified in the literature as relating to job satisfaction, demonstrating face validity. Both instruments also included a range of meanings generally associated with job satisfaction, demonstrating content validity (Babbie 1989). Based on this agreement between the content of the previously used instruments, it is reasonable to believe that the degree of validity in the study instrument is acceptable. As with the community survey, the interview instrument was field tested on a group ofNP/P As who have been maintained at a frontier site as well as several who have not been maintained. Based on the results of the test interviews, some modifications were made in the instrument, primarily in the questions relating to the providers, as the original instrument was designed for interviews with providers who had been maintained. Given the geographic distances involved, it was planned that approximately one-half of the interviews would be conducted on site, with the remainder completed by telephone. Based on the field test of the interview instrument, forty-five minutes to one hour were allowed per interview. Time and travel constraints resulted in only ten interviews being conducted on site, with the remaining twenty conducted by telephone. All interviews were conducted by the researcher. The open-ended 71

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I : I I questions were recorded and transcribed by the researcher as well to reduce the possibility bias. In summary, the data gathering aspect ofH2 resulted in a study N of thirty Treatment ofthe Data As stated previously, the purpose of the study is to examine characteristics of both communities and health care providers, comparing these characteristics in successful/unsuccessful communities and health care providers Because both groups communities and providers were nonexperimental, the primary research method used to test both H1 and H2 was correlational-predictive. The data obtained through the community surveys and the provider interviews were used to examine relationships between and among the various identified variables. While there are many statistical applications that will summarize and test hypotheses, including regression analysis and analysis-of-variance, few are appropriate for categorical data where observations are from populations that do not demonstrate a normal distribution nor a constant variance (Norusis 1994; Aldrich and Nelson 1984) Since the study population for H1-the communities-was specifically identified by a local contact as being "community leaders," a normal distribution for this sample cannot be assumed The study population for H2-the providers-was selected based on criteria identifying the length of time they had remained in a frontier community. Further, the participants were recommended by the state representatives. Thus, 72

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neither sample can be expected to demonstrate a normal distribution. It is essential to link the statistical method to the kind of research questions being asked. This study is looking for relationships primarily among categorical variables. Therefore, an extension of multiway frequency analysis (MFA), the purpose of which is to discover associations among categorical qualitative variables (Tabachnick and Fidell 1989), was used to analyze the data from the community survey (H1). The MFA extension used is loglinear analysis, which is useful in uncovering potentially complex relationships among variables in a multiway crosstabulation. Loglinear models are similar to multiple regression models. However, in loglinear models, all variables used for classification are independent, and the dependent variable is the number of cases in a cell of the crosstabulation (Norusis 1994; Knoke and Burke 1980). In the community section of this study, one dependent variable has been identified-status of the community, successful or unsuccessfuL Therefore, a multiple regression-like application of MFA called logit analysis was used. In this application, questions about associations are translated into tests of main effects, or associations between the dependent variable and each independent variable. Further, the interactions or associations between the dependent variable and the joint effects of two or more independent variables can be determined (Tabachnick and Fidell 1989; Knoke and Burke 1980). For example, does size of community have a greater effect than community leadership skills? Or does proximity to a large community have a greater effect than the availability of health insurance? 73

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The community survey produced a plethora of infonnation, resulting in the need to perform data reduction activities ranging from simple aggregation of data to factor analysis of questions dealing with community leadership. The factor analysis procedure began with a total of eleven variables addressing aspects of community leadership reflected in questions nineteen through twenty-nine in the Community Survey instrument found in Appendix B. These were: residents voice opinions on medical care issues, elected officials support changes that enhance medical care, community boards and commissions are representative of the residents, leaders champion medical care issues, leaders plan for the long-tenn health care needs of the community, an effective network of volunteer organizations works on health care issues, there is support for students entering health professions education, merchants foster volunteerism, all groups have access to primary care services, an organization convenes for community problem-solving, and our community enters into cooperative agreements with other communities to solve health care problems. The outcome of the analysis was two factors, labeled "community leadership" and "community cooperation" that could then be used in the logit analysis. The model was based on the associations between the dependent variable, status of the community, and eight independent variables addressing proximity, economic base, availability of health insurance, critical mass of people, effective leadership, and use oflocal resources. Before any analysis can be performed, the data must be screened to identifY inaccurate data, missing data, and outliers or cases that are extreme and could distort findings. The most common procedure for screening or cleaning data is to generate a 74

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'I frequency table that will allow identification of missing data and obvious errors in data entry. The frequency distributions revealed a fair amount of missing data, but a review of the data, cross-checked against the source documents indicated six survey questionnaires that had not been fully completed. As a result, these six cases were deleted from the sample, leaving a total of 432 cases in the study. The data collection for H2-the providersincluded standardized questions designed to produce data that can be analyzed through traditional elementary statistical methods such as frequency distnbutions, crosstabulations, and measures of dispersion. To identify associations between the dependent variable, retention of the provider, and the independent variables, logistic regression analysis was used rather than logit analysis because the sample size was insufficient to allow for logit analysis. In logistic regression, the probability of an event occurring compared to the probability that the event will not occur is estimated using log odds ratios (Agresti I 996). The analysis included the identification of associations between the dependent variable, retention of the provider-maintained or non-maintained-with ten independent variables. In logistic regression, as in all other statistical procedures, the codes for the independent variables must be meaningful. One cannot simply take a nominal variable and assign arbitrary numeric codes and expect them to be useful. When using a two-category variable such as experience of a rural rotation during training, yes or no, each case can be coded 0 or I to indicate participation or not. However, if there is a variable with more than two categories, new variables must be created to represent the categories. The number of new variables, referred to as 75

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"dummy" variables, required to represent a categorical variable is one less than the number of categories (Norusis 1994; Chatteljee and Price 1991 ) In this study, dummy variables were created for three categorical variables, autonomy, responsibility, achievement and recognition. In addition to the standardized questions examined through logistic regression, the two open-ended questions that gathered information based on Herzberg's Dual Factor Theory were analyzed using a content analysis of the transcribed responses with identification and classification of key terms to determine consistency with Herzberg's theory. Matrices displaying responses of the maintained/non-maintained providers categorized by the researcher as "intrinsic" and "extrinsic" factors formed the basis for the inductive analysis of the qualitative data. This approach to inductive analysis has been referred to as logical analysis where classification schemes are crossed with one another to generate new insights or allow further exploration of the data set (Marshall and Rossman 1989, 116). The findings from this analysis were used to confirm or refute Herzberg's Theory, and linked with the quantitative data in formulating recommendations for future study or action. Basic descriptive statistics are used to provide comparative information regarding the characteristics ofNP/P As who were maintained versus non-maintained. As with the data from the community survey, screening procedures were completed on the standardized data to enhance accuracy. Because these data are from interviews where the interviewer directed the discussion, no missing data were identified and all cases were usable 76

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CHAPTER4 FINDINGS H1 The Communities Data collection for the community survey portion of this study began in February 1995 and was completed in May 1996. In all, a total of 672 initial and follow up surveys were sent to 500 persons living in frontier communities located in the six state area. Four hundred thirty-eight surveys were returned for a response rate of nearly 88 percent. Of these, six had to be discarded due to missing information, for a final response rate of86 percent. According to Babbie (1989), a response rate of70 percent is considered very good. The high response rate is attnouted to several things. First, the sample was not technically random; rather the participants had been identified as "community leaders," and as such, were likely to be somewhat more responsive than participants identified through a truly random sample Second, in the subjective view of the researcher, health care is important to people living in these areas, and it is only infrequently that they are asked to express an opinion. The survey instrument invited the respondents to provide any additional conunents they might wish to make, and many of them wrote notes ranging from a few sentences to several pages Some went so far as to send back studies that had previously been conducted of the health care needs in their areas. A high percentage requested copies of the final study 77

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Table 4. I shows the characteristics of the study communities in tenns of size, per capita income, and persons per square mile in the county or minor civil division displayed as "successful" or "unsuccessful" in maintaining a NP/P A Success-fu1 oessful Total N-50 Size of Community Table 4.1 Description of Communities Per Capita Income 0-1.500 1,500>2.500 5,0008,501> 2,500 8,500 10,000 10,000 15 7 3 5 15 9 12 11 2 2 10 9 27 18 5 7 25 18 Persons Per Square Mile .3-1 1.1-3 3.1-5.7 6 10 8 1 15 10 7 25 18 The communities ranged in size from a small mountain community of 223 people (in the winter2,000 in the summer) to a fairly large community of8,500. Although the selection criteria specified frontier communities of 2,500 or fewer people, the state representatives included a total of five communities that exceeded this level, two with populations of approximately 3,000, one of 4,000, one of 5,000, and the largest of8,500. These communities were maintained in the study because they had all struggled with recruitment and retention of health care professionals for the past several years, and the state representatives were interested in having them included. Fully 90 percent of the communities met the criteria of2,500 or fewer population. All, including the five communities with populations exceeding 2,500, were located in frontier counties with populations of six or fewer persons per square 78

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'i I mile. The persons per square mile ranged from a low of0.3 persons per square mile in a Montana community to a high of 5. 7 in South Dakota. The per capita income of the study communities, based on county census data, shows that the greatest number of communities-both "successful'' and "unsuccessful"-have per capita incomes in the mid-range, between $8,501 and $10,000. In all, a total of eight communities were surveyed in Colorado, ten in Montana, six in North Dakota, ten in South Dakota, eight in Utah, and eight in Wyoming. Maps with the names and locations of these communities are located in Appendix D. survey. 2340 92 < 15,000 ll Table 4.2 shows some of the demographic characteristics obtained through the Table 4.2 Demographics of Survey Participants Age by Group Sex Ethnicity* Size of Household 4151>60 F M w H NA NP 1-2 34 5&> 50 60 162 97 78 158 274 410 10 7 I 197 141 94 W=wbitc, H-Hisplllic, NA=NllliVc American. NP=Asim/Pacific Islmder Household Income Length of Time in Community 15,00135,00150,001> 1-10 ll-20 21-30 31-40 41-50 >50 35,000 50,000 75,000 75,000 Yrs Yrs Yrs Yrs Yrs Yrs 104 118 126 61 100 99 77 54 59 42 N=432 The participants varied in age, ranging from twenty-three to eighty-three, with the average age just under fifty. The greatest number (162) fell in the forty-one to fifty 79

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year old category, while seventy-eight of the respondents were over age sixty. One hundred fifty-eight (37 percent) of the respondents were female, while two hundred seventy-four (63 percent) were male. Family size varied from one-person families to nine-member families, with the greatest number (163, or 38 percent) living in twomember households. Annual household income was requested in categories, with eleven respondents (2.5 percent) reporting less than $15,000, while the greatest number, one hundred twenty-six (29 percent) reported household income in the $50,000 to $74,999 range. Sixty-one households (14 percent) reported incomes in excess of$75,000. There was considerably less diversity in the ethnic makeup of the participants. Four hundred ten respondents (94.9 percent) classified themselves as white, ten (2.3 percent) self-identified as Hispanic, seven (1.6 percent) as Native American, and one ( 2 percent) as Asian/Pacific Islander. Four persons (.9 percent) declined to provide this information. The length of time respondents had lived in their communities varied from one year to seventy-three years, with the greatest number ( 100 people or 23 percent) having lived in their communities from one to ten years. The next highest category was eleven to twenty years, with ninety-nine people reporting this length of time. Forty-two persons had lived in their communities over fifty years. Respondents were asked to select from a list of thirteen health care services ranging from ambulance service to x-ray the top five most important services to have available in their communities, and rank these services in priority order from one 80

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:I i to five. The top five services as defined by all respondents in order of priority, included: 1. primary care provider (physician, nurse practitioner, physician assistant), 2. ambulance service, 3. emergency room, 4. pharmacy, and 5. x-ray. A comparison of these priorities in the successful and unsuccessful communities revealed virtually no differences. See Figure 4. 1. 4 3 2 "' I o Figure4.1 Most Important Services by Community Successful and Unsuccessful AlltllarDISIIMCe Emrgerc( R)om Rl....,.cn provicl Rw!racvliE!x-RirfThe analysis of the associations between the dependent and independent variables began with an initial screening of the data to identify whether there were 81

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; actually any effects to be investigated. This was accomplished by running a hierarchicalloglinear analysis that provided the expected frequency for each effect compared to the observed frequency, goodness-of-fit statistics for the model, and tests of partial associations for each effect. A saturated model that included all possible effects was produced in which the expected and observed frequencies were identical, and the goodness-of-fit statistic, Likelihood Ratio Chi-Square, was .000 with a significance of 1 000, reflecting a perfectly fitting model. This was to be expected, since all effects were included in the initial screening When a saturated model is used, the value of the chi-square statistic is always 0 (Norusis 1994, 159). When screening is carried out in the testing of overall fit of a model, both Pearson Chi-Square and the Likelihood Ratio Chi-Square are generally available. The Likelihood Ratio Chi-Square is preferred because it allows for consistency in testing overall fit, screening, and testing for differences among hierarchical models. Inadequate expected frequencies may increase a Type I error rate when the Pearson Chi-Square is used. The Likelihood Ratio also has the property of additivity of effects, and thus is useful when examining three and four-way associations of several variables such as those included in H1 (Tabachnick and Fidell 1989) The hierarchicalloglinear analysis produced tests of partial association that examined all dependent and independent variables individually and in combination at each level (i.e all combinations of two variables, three variables, and so on until all combinations had been examined). The results suggested that only three-way 82

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I I i I associations (e.g., status of community, use oflocal resources, and community leadership, or other combinations of three variables) are significant based on tests that K-way effects are zero using both Likelihood Ratio Chi-Square and Pearson ChiSquare. These results are included as Table 4.3. Table 4.3 Tests that K-way Effects are Zero K DF L.R.CHISQ PROB PEARSON PROB ITERATION CHISQ 1 12 607.013 .0000 1237.959 .0000 0 2 62 427.106 .0000 675.434 .0000 0 3 180 261.739 .0001 971.231 .0000 0 4 321 296.m .1306 341.661 .204S 0 s 360 18.918 1.0000 12083 1.0000 0 6 241 2896 1.0000 1.S19 1.0000 0 7 96 .219 1.0000 .112 1.0000 0 8 16 .000 1.0000 .000 1.0000 0 The row labeled 3 in Table 4.3 evaluates the 3-way associations of the eight variables included in the community study, and shows statistical significance using the Likelihood ratio (262) and the Pearson chi-square criteria (971). Both show a probability of .000, indicating that the hypothesis that the three-way effects are independent should be rejected. However, the tests of four-way and higher-order effects (rows four through eight) show probability levels greater than 05 indicating that the associations of four or more variables are independent. This is important to this study, given the number of variables and the relatively small sample size compared to the number of variables. This test provides information relating only to the number 83

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: I of variables that are significantly associated, thus providing direction for further analysis. Since one variable has been identified as a dependent variable, only those effects containing "status," the dependent variable, are of interest in this study. The challenge then, is to determine which of the three-way effects, or associations of variables, should remain in the model. The purpose of modeling is to find the unsaturated model with the fewest effects that still closely mimics the observed frequencies. Screening helps to reduce the need to examine all possible unsaturated models by allowing effects that are less predictive to be removed during the screening process (Tabachnick and Fidell 1989, 2S 1 ). A model should fit the data, be interpretable, and as simple or parsimonious as possible. As mentioned previously, one step in reducing the number of effects to be considered is to identifY only those effects that include the dependent variable, "status." The next step is to review the partial Chi-square scores that are a result of tests of partial associations to identifY those combinations that contain "status," and are significant at the OS level. A partial chi-square score is the difference between the likelihood-ratio chi-square values of combinations of variables with and without the effect in question When examining the partial chi-square scores, one is seeking significant effects identified by having the largest values of chi-square with probabilities less than .OS. In other words, when seeking effects to be included in the best model, one looks for the highest chi-square values and lowest probability scores, while in assessing goodness-of-fit for a model, one looks for statistical nonsignificance, or low chi-square values with probabilities exceeding 05 {Tabachnick and Fidell 84

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I : 1989). The desired outcome in model selection is to reject the independence as we are seeking relationships among the various effects. As indicated by the K-way tests, no associations of variables greater than three-way proved to be significant, therefore, further analysis focused on combinations of three or fewer variables meeting the criteria identified above, i.e contains "status," and have likelihood chi-square significance levels of less than .OS. An examination of the data revealed eight combinations of three or fewer effects that were statistically significant p <.OS) and included the dependent variable "status." These effects may be found in Table 4.4 below. Table4.4 Combinations ofVariables Statistically Significant at p<.OS I Effect Name I Partial xz I Prob I comled2*critmas*status 7.691 .0214 comcop2*locres*status 6.892 0319 comled2*locres*status 7.236 .0268 comled2*percap3*status 10.741 .0296 miles30*percap3*status 6.788 .0336 ecoperc2*status 8.605 .0135 miles30*status 5.124 .0236 percap3 *status 57.529 0000 8S

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'l These labels relate to the following variables and their levels: Lab.d Comcop2 Comled2 Critmass Ecoperc2 Locres Miles30 Percap3 Status variable Description Community Cooperationpoor/medium/high Community Critical Miss greater 1500 yes/no ofEconomic base -poor/fair/good Use of Local Resources y_eslno 30 Miles to Community of 1 OK or greater Pee Capita Income Grouped -5000-8500 850 1 10,000 1 o.oo 1 and greater Status of Community successfullunsuccessful At this point in the analysis, only one variable, health insurance, dropped out of the model. This was not surprising, as only 15 of 432 people (about 3 percent) reported having no insurance. Therefore, while this variable has been highly correlated with utilization of health care services, given this sample of community leaders, it did not serve to discriminate between communities that have been successful or unsuccessful in maintaining services. The screening and model selection resulted in the following effects being retained in the model for further analysis of H1 Status = f (comcop2 *comled2*critmass*ecoperc2 *percap3 *locres*miles30) Before proceeding further with the analysis of the interactions of the variables, an examination for multicollinearity was conducted because several of these variables appeared on the surface to be highly correlated, e.g., community cooperation and community leadership; perception of economic strength and per capita income; and possibly use of local resources and per capita income. When variables are highly correlated, it is difficult to separate the effects of the individual variables. Using the Collinearity Diagnostics in the SPSS multiple regression program, the variables were examined by inspecting eigenvalues and condition indexes of the independent 86

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variables. These findings are in Table 4.5 below. The eigenvalue redistnoutes the variance in the variables, consolidating it into a few composite variables, rather than in many (Tabachnick and Fidell 1989). The columns identified by variable labels in Table 4.5 show the coefficients of variance of the study variables. The columns with high proportions of variance in two or more coefficients for the same eigenvalue would indicate evidence of near -dependency between or among the variables. Table 4.5 Multicollinearity Measures of Independent Variables-Community # Eigen Cond Cons COM COM CRIT ECOP LOC PERC Value Index tant COP2 LED2 MASS ERC2 RES 30 AP3 I 6.182 1.00 .0006 .0023 0026 .0067 .0024 0031 .0086 .3674 2 .8715 2 66 .0001 0005 .0005 .0021 .0013 0000 .9646 .0004 3 .4441 3.73 0005 .0146 0128 .6490 .0198 0180 .0003 0009 4 .2045 5.50 .0030 .0478 .0388 .3129 .0115 .3927 .0142 .0157 5 .1067 7.61 .0030 .1663 0871 .0124 .0507 .2242 .0086 .3674 6 .0947 8 08 .0001 .0125 .0932 0160 .6580 0182 .0063 .1622 7 .0772 8.95 .0055 .5740 .6651 0000 .0470 0073 .0000 .0167 8 0191 18. 0 9872 .1821 .0000 .()()10 .2095 .3366 .0026 .4348 In Table 4.5 higher scores have been denoted in bold print. Notice that higher scores appear for critmass and locres in eigenvalue 4, for locres and percap3 in eigenvalue 5, for comcop2 and comled2 in eigenvalue 7, and for ecoperc2, locres, and percap3 on 87

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eigenvalue 8. Therefore, there appears to be relationship between critical mass of a community and use of local resources; use of local resources and per capita income; community cooperation and community leadership; and perception of economic strength, use of local resources and per capita income, although the differences in scores on eigenvalue 8 would suggest a greater relationship between local resources and per capita income than with perception of economic strength. An examination of correlation coefficients also showed relationship between and among comcop2, comled2, ecoperc2, and locres. The range of scores was from 0000 to 43 81 with the highest being for the relationship between comled2 and comcop2. The next highest, 3 00, was the relationship between ecoperc2 and Iocres. The remaining relationships were all less than 3.00 Although neither the scores related to the eigenvalues nor the correlation coefficients were above 7, the score where multicollinearity becomes a potential problem Sweeney, and Williams 1981 ), the measures of multicollinearity supported the need for caution in the use of several combinations of variables. At this point in the analysis of H., seven independent variables plus the dependent variable remained in the model. Because the tests of partial associations had revealed that only three-way associations were significant, additional analysis was necessary to identifY which three had the strongest association Crosstabulations of the data were used, testing status against each of the other seven variables to further reduce the number of variables in the model. The complete tables of the 88

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I I I I I I crosstabulations displaying the relationships of all variables compared to "status" may be found in Appendix E. Three statistics are included that are helpful in determining the association between dependent and independent variables. These are the Likelihood Ratio Chi-square, Cramer's V, and Lambda. Again, since Chi-square is a test of independence, a probability ofless than .05 would indicate that the hypothesis of independence should be rejected. Both Cramer's V and Lambda range between 0, when there is absolutely no relationship, to I where the independent variable perfectly predicts the dependent variable. These tests revealed that only community leadership ( comled2), per capita income (percap3) and perception of economic stability ( ecoperc2) were highly associated with status. With the exception of per capita income and perception of economic strength, other variables demonstrating possible multicollinearity problems were deleted from further analysis. Logit analysis was utilized to examine both the main effects and the interactions among the four remaining variables status, community leadership, perception of economic status, and per capita income. Goodness-of-fit statistics indicated good fit of the model to the data with a non-significant Likelihood ChiSquare of 22.94 with 20 degrees of freedom, and significance of .292, well above the .OS level. When using a logit model, the dispersion, or spread, in the dependent variable can also be examined. The statistics used to measure the spread are entropy and 89

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, I I I concentration.2 In this study, neither the score for entropy nor concentration proved to be significant at the .OS leveL The scores were .116 and .153 respectively, showing that the model could be expected to exhibit this good a fit by chance 12 percent or 15 percent of the time, depending on the measure used The measures of dispersion suggested that although the overall model fit adequately, it was marginal in explaining the source of the dispersion. This was not considered a major concern as the Goodness-of-Fit statistics supported the modeL Both hierarchical and nonhierarchicalloglinear models were utilized in further analysis of the data to determine both the strongest combination of variables, and the independent variable having the greatest effect on the dependent variable. The hierarchical approach was used to identify the best model through a backward step elimination process. This resulted in the following variables showing the greatest degree of relationship: status, percap3, and comled2 (e.g., status of community, successful or unsuccessful; per capita income; and community leadership). The nonhierarchical approach is used when one is interested in the highest order interaction or main effects. Parameter estimates are provided for each effect and combination of effects. The strength and direction of the relationship can be determined from these estimates through the use of log odds ratios or logits Although the tests of association included in the hierarchical approach indicated that 2 Entropy and concentration subdivide the total dispersion of the dependent variable into that explained by the model and the residual or unexplained dispersion (Norusis 1994). A statistically significant result is desirable as this indicates that the model fits the observed frequencies better than expected by chance (Tabachnick and Fidell 1989). 90

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only three-way associations were significant, and further identified status, comled2, and percap3 as being the best model for interactions, ecoperc2 was also identified as significant when combined only with status. Therefore, ecoperc2 was included with the other three variables in an attempt to determine the strongest relationship or main effect of the three variables, community leadership, perception of economic base, and per capita income on the dependent variable, status of community. The values in Table 4.6 for each of the four variables are the parameter coefficients or log odds ratios produced by loglinear models. Since it is somewhat easier to think in terms of odds rather than log odds, the log odds were converted to odds by calculating the natural antilogarithm of the parameter estimate ( e raised to the power of the estimate). The scores have also been placed in rank order for greater ease in determining the relative importance or strength of each. Table4.6 Log Odds and Odds Ratios Parameter Log Odds Odds 95% Confidence Ratio Ratio Interval Unsuccessful .5701 1.77* 1.04-3.00 Ecoperc poor .7184 2.05* 1.16-3.63 Comled poor .3422 1.41 .82-2.41 Comled fair .2380 1.27 .77-2.08 Ecoperc fair -.0248 .98 .58-1.63 Percap medium -1.4394 .24* .15-.38 Percap -low -1.9860 .14* .07-.27 P
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Notice that the reference variable is "unsuccessful." Thus, the odds of the coefficients may be interpreted as the probability that a community will be unsuccessful in maintaining a health care provider given the defined characteristic, (e.g., poor community leadership). It must also be pointed out that when using categorical variables, specific conclusions about the impact of a variable are not possible. Rather, the results have meaning only in relation to one another. For example, notice that only two levels of the three level variables are included, poor and tair, or low and medium. These have meaning only when compared to the third level, good or high. Given this situation, row two shows that the odds are about two times greater (odds ratio of 2. 05) that the community will be unsuccessful if the perception of the economic base is poor compared to a community whose perception of their economic base is good. Data in row three suggest that the odds of a community being unsuccessful in maintaining the services of a NP or PA when the community leadership is poor compared to a community where the leadership is good, are nearly one and one-halftimes as great (odds ratio of 1.41). Odds can also be thought of as the ratio of the probability that an outcome will happen (community will be unsuccessful) to the probability that it will not happen (community will be successful). Odds that are close to 1 indicate that the two probabilities are nearly equal. Odds greater than one indicate that the event is more likely to occur, and oddS less than one indicate that the event is less likely to occur. An odds of 1 corresponds to a log odds ratio ofO (Norusis 1994), and indicates that 92

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the effects are not related. Confidence intervals for the odds have also been computed. For example, row two shows the 95 percent confidence interval for the odds of a community with poor perception of the economic base compared to a good perception as 1.16 3. 63. If there were no association between perception of economic strength and status of community, this odds ratio would be close to one. This interval does not contain one, therefore perception of economic strength and status can safely be accepted as related. Similarly, the confidence intervals of medium and low per capita income do not contain the figure one, indicating a relationship between status and per capita income. Given the data in Table 4.6, it is suggested that the perception of the community leaders regarding the strength of the economic base of the community is highly important in determining the level of success the community will have in maintaining a NP or P A to provide primary health care services. This is followed closely by demonstrated community leadership, which when considered poor, increases the odds that the community will be unsuccessfuL The odds ratio of. 98 for perception of economic base as "fair" in row five suggests that the odds are nearly equal that the community will be either successful or unsuccessful. Perhaps the most interesting and potentially confusing finding is that of per capita income. The log odds ratio of -1.9860 and odds ratio of .14 indicate that a community with "low" (between $5,000-$8,500) per capita income is much less likely to be "unsuccessful" when compared to a community where the per capita 93

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income is "high" (greater than $10,000). This is further supported by a log odds ratio of -1.4394 and odds ratio of .24 for communities having "medium" per capita income ($8,50 1-$1 0,000) compared to communities having "high" per capita incomes. These findings of the main effects of the independent variables (perception of economic strength, community leadership, and per capita income) on the dependent variable (status of the community) may all be considered significant, although in different ways. Poor perception of economic base and poor leadership suggest a greater likelihood of a community being unsuccessful in maintaining a non-physician health care provider, while low per capita income suggests a reduced likelihood of the community being unsuccessful. Or, in other words, low per capita incomes appears related to a community's being successful in maintaining a NP or P A. The analysis of the interactions of the variables is less clear and interpretation is more complex. Recall that the best fitting model showed the interactions of status, comled2, and percap3 significant at the three-way level of interaction, and status and ecoperc2 significant at the two-way level. A logit analysis of the interactions of the three effects, status, comled2, and percap3, revealed the data shown in Table 4. 7 displayed in rank order. 94

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:I I I I I Table 4.7 Logit Analysis of Interactions ofThree Effects Loll Odds Oddst
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similar to those in the main effects analysis shown in Table 4.6 appear. The log odds of-. 0044 and odds of. 99 for comled/fair indicate that the odds are nearly equal that the community will be successful or unsuccessful when community leadership is considered fair. The remaining values indicate that the communities will be less likely to be unsuccessful. The percapllow effect is interesting and consistent with the main effects analysis displayed in Table 4.6. A log odds of -2.7840 and odds ratio of .06, suggests that the odds are over 90 percent that the community will run be unsuccessful when the per capita income is low. The 95 percent confidence interval is from .02 to .23. Because the number one does not fall in the interval, the null hypothesis of independence can be rejected. Again, per capita income is significantly related to status, but the relationship is in the opposite direction from community leadership when viewed as a single effect. A review of the crosstabulations of status with comled2 and percap3 in Appendix E, confirm this finding, showing that in communities having "good" leadership, 60 percent were successful in maintaining a NP or PA, while in unsuccessful communities, leadership was classified as "good" in only 40 percent of the cases. Similar statistics are displayed for perception of economic strength, 56 percent reflecting a good perception in successful communities compared to 44 percent with good perception in unsuccessful communities. The per capita income findings seem contrary to these In communities of "low" income ($5,000 to 96

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$8,500), 30 percent were classified as "unsuccessful" while 70 percent were successful On the opposite end of the income scale, communities with "high" per capita income ($10,000 and greater) showed 72 percent as unsuccessful and 28 percent as successful. While the findings reveal no reason for this paradoxical situation, some speculations can be shared. The interaction between low per capita income and poor community leadership resulting in lack of success in maintaining a NP/P A was expected. With neither the income to support a practice nor the leadership to successfully recruit and advocate for the provider, the chances of being successful are very low. The perception of the economic base, revealed as the most important "main effect," and the relationship between low per capita income and successful communities was not expected. In examining the combinations of the three independent variables-percap, ecoperc, and comled-while controlling for status successful or unsuccessful-a strong and significant relationship (p<.OS) was found between ecoperc and comled. In both "successful" and ''unsuccessful" communities, the greatest percentage of scores showed combinations of poor ecoperc/poor comled and good ecoperc/good comled. These two variables, both based on the opinions of the respondents, seem to suggest that the attitudes of the community leaders toward the economic strength and the quality ofleadership have a strong effect on the status of the community. 97

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The relationship between percap and comled in "unsuccessful" communities was significant (p<.OS), and showed, as expected, the greatest percentage of scores clustered in the low percap/poor comled category. The paradox was most apparent in "successful" communities where the greatest percentage of scores clustered in the low percap/good comled category. Further, the relationship between the variables was not significant (p>.OS) .. It is suggested again that the attitudes of the community leaders may have a strong effect on the status of the community, and that, in fact, good community leadership may counteract the negative effect of low per capita income. Without good leadership, low per capita income communities have very low odds of being successful in maintaining a NPIPA It may also be that the leaders in these low percap communities have accepted the fact that the income is not adequate to support a physician-based practice, but may have formed alliances with neighboring communities to provide the support necessary for the maintenance of a NP/P A-based system of care. Further, the community leaders may have additional knowledge, appreciation, and acceptance ofthe skills and abilities ofNP/PAs. This acceptance may be supported by a positive attitude toward NP/PAs on the part of the supervising/consulting physician. If these suggestions of the impact of the perceptions of the leaders toward economic strength and quality of leadership could be further examined and confirmed, greater emphasis could be focused on the improvement of community leadership and education regarding the skills and contributions ofNP/P As 98

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I i as important factors in maintaining access to primary care services through the use of NPIPAs. This analysis ofH1 began with an examination of eight independent variables and their relationship, separately and in combination, on the dependent variable, status of the community, either successful or unsuccessful in maintaining the services of a nurse practitioner or physician assistant. Of these eight variables, only three proved to be significantly related to the dependent variable-community leadership, perception of economic strength, and per capita income. The optimal model contained the interactions of community leadership and per capita income on status, while the main effects showed perception of economic strength as the major variable in whether a community is successful or unsuccessful. Viewed separately, having low per capita income seemed to be more predictive of a "successful" community. It should be pointed out, however, that combined interactions are considered stronger than individual effects. Therefore, communities with good leadership and a higher per capita income are much more likely to be successful in maintaining a nurse practitioner or physician assistant. This study revealed that these three variables are much more influential than are such hypothesized variables as proximity to a community of 10,000 or greater, having a critical mass of residents greater than 1,500, having health insurance, utilizing local resources, or even having a community that cooperates with surrounding communities. A suggested explanation of the paradoxical finding of the 99

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relationship between low per capita income and successful communities rests on the fact that the greatest percentage of the low percap communities also demonstrated good community leadership. Thus it is posited that good community leadership can counteract the negative effect oflow income, and is of significant importance in the maintenance of access to health care in these small frontier communities. H2 The Providers The interviews with the nurse practitioners and physician assistants began in June 1995 and were completed on May 1, 1996. Eleven nurse practitioners (37 percent) and nineteen physician assistants (63 percent) were included in the study for a total sample of thirty providers. The selection criteria specified that "successfully maintained" meant that the NPIP A had remained in a frontier community three or more years. A non-maintained NPIP A was one who had gone to a frontier community, but left in three years or less. In fact, the range of years for the maintained providers was from four to seventeen years, with an average length of practice in the frontier community of ten years. In the non-maintained cohort, twelve had remained from less than one year to three years. Three providers had stayed slightly over three years. The average length of time at the site for the non-maintained NPIP As was just under two years five months. Demographic information describing the providers is included in Table 4.8. 100

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Maintained Non-Maintained Total N=30 Maintained 0 -Non-Maintained Total N=30 Maintained Non-Maintained Total N=30 r''Pt! Table 4.8 Demographics of the Providers NP PA F M Satisfied Neutral Dissatisfied 1-3 7 8 5 10 12 0 3 0 4 11 6 9 5 2 8 12 11 19 11 19 17 2 11 12 Aae at cntl 11 on ooamw 26-30 31-35 36-40 >40 M s 4 3 4 4 14 1 2 3 6 4 13 2 6 6 10 8 27 3 Provider Resid ----fOri <2500 2,500-10,001-50,001>100,000 <2,500 10,000 50,000 10,0000 7 4 2 0 2 6 3 6 2 1 3 7 10 10 4 1 5 13 N=27 LCill(\11 Ul 1 UIIC IU .;:)llC Ul 1 CCU :1 3.1-5 5.1-10 10.1-15 > 15 4 5 3 3 3 0 0 0 I I 7 5 3 3 l'.IUW l'.UWUUII ueJU= y N AD BS MS 9 6 5 7 3 6 9 1 8 6 15 15 6 15 9 s Resid' ---fOri 2,500-10,001-50,001>100,000 10,000 50,000 100,000 2 2 1 3 1 1 1 3 3 3 2 6

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Eight of nineteen physician assistants (42 percent) were in the "maintained" category while seven of eleven nurse practitioners (67 percent) were maintained. This should not be considered meaningful in terms of whether one type of provider is more likely to be maintained, as many of the providers are double certified as both NP and P A They use the designation of the license or certification most advantageous in their state of practice. Eleven of the NPIPAs were female (37 percent) and nineteen (63 percent) were male. The gender breakout showed that five of eleven ( 45 percent) of the female providers were maintained while ten of nineteen (53 percent) of the male providers were maintained. The ages of the providers at the time of the interviews ranged from twenty-eight to fifty-six. with three providers being forty-five years of age and three being forty-nine. The ages of the providers when they first went to the frontier site ranged from twenty-six to forty-nine, with the greatest number (ten) going to the site between the ages of thirty-six and forty. Table 4.8 displays this age distribution by maintained and non-maintained provider, showing a fairly even age distribution across all categories for both cohorts Twenty-seven of the providers (90 percent) were married and three (10 percent) were single. Fifteen had participated in a rural rotation or experience as a part of their training program, and fifteen had not. One-half or fifteen of the providers had baccalaureate degrees, while nine held master's degrees. Five reported an 102

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I I : I I I associate degree, and one indicated a certificate of completion of a training program. Only nine of the providers reported a linkage with an educational institution that provided contact with health professions faculty and students One-third or ten of the NP/PAs grew up in a community of2,500 people or less while an additional ten providers grew up in communities between 2,500 and 10,000. Only five had grown up in communities greater than 100,000 population. Thirteen of twenty-seven spouses (48 percent) grew up in communities of2,500 or fewer people. Six grew up in communities of 100,000 or greater, and the remaining eight grew up in communities ranging from 2,500 to 100,000. Five providers were "very satisfied" with their salary, while twelve were "somewhat satisfied," for a total of nearly 57 percent being in the "satisfied" category Two reported being "neutral" about their salary and eleven reported being either "somewhat dissatisfied" (eight) or "very dissatisfied" (three) The foUowing descriptive infonnation is included to provide a snap-shot of the environment in which these providers practiced. Twenty-two of the providers (73 percent) worked in communities where there was no hospital, while eight (27 percent) worked in communities where there was a small hospital. The number of beds in these hospitals ranged from thirteen to twenty-five. For those providers who lived and worked in communities without a hospital, the distance to the closest hospital ranged from ten miles to one hundred four miles. Eight of these hospitals (thirty-six percent) 103

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. i were within thirty miles of the home community. An additional ten hospitals (total of 82 percent) were reported as being within sixty miles. The remaining four hospitals ( 18 percent) were eighty or more miles from the community. NP/P As work in collaboration with or under the supervision of a physician. Therefore, the location of the physician was also requested. For those NP/P As in communities without a hospital, the distances were nearly the same as the distances to the hospitals since the physicians were generally located in these communities. One-half or fifteen of the providers were employed by a non-profit communitybased board of directors, while eleven or 37 percent were employed by hospitals and four or 13 percent were employed by private physicians. The majority of the providers (43 percent) felt their work hours per week were "about right," while eight (27 percent) felt the hours were "somewhat too many." Seven (23 percent) reported their hours per week as "much too many." Similarly, the number of patients seen in a week was considered by sixteen providers (53 percent) as "about right," while ten (33 percent) felt the number of patients was either "much too few" or "somewhat too few." Only four ( 13 percent) suggested that there were "somewhat too many" patients in a typical week. Several providers commented that there were not too many patients, but that they were just spread over too many hours throughout the day and week. The average number of patients seen in a typical week ranged from a very low twelve to a high of one hundred fifty, with the most frequently reported number being one hundred, followed by one hundred twenty patients. 104

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When asked about the satisfaction of the professional needs of their spouses, nine providers (30 percent) responded that their spouse was "very satisfied." Eight (27 percent) reported "somewhat satisfied," two were "neutral," and the remaining eight (27 percent) were either "somewhat dissatisfied" (three) or "very dissatisfied" (five). Just as an attempt was made to include connnunities from the six states in the study, similarly, NP/PAs were sought from the six states, with varying degrees of success The final cohorts are displayed in Table 4.9. Table 4.9 Geographic Distnoution of Providers co MT ND so ur WY Total Maintained 2 4 2 5 2 0 15 Non-6 2 1 1 2 3 15 Total 8 6 3 6 4 3 30 Although the provider interviews produced a great deal of descriptive data, the purpose of the study was to identify associations between the dependent variable, retention of the provider, and the independent variables. Based on H:z, retention of a nurse practitioner or physician assistant in a frontier community is a function of the provider/spouse residence of origin, rural experience during training, sense of autonomy/desire for independence of action, a sense of responsibility and achievement, an affinity for outdoor activities, age/years of experience, marital status, and a 105

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. i : : I I I I I I i I i I supportive medical community. From this a total often independent variables had been created. Given the sample size of it was apparent that the number of variables must be reduced if meaningful results were to be possible mostly due to a degrees of freedom problem. Both correlation coefficients and crosstabulations of the data were conducted to assist in this process. Because twenty-seven of thirty providers were married, and the three who were were in both the "maintained" and "non-maintained" categories, marital status was removed as a study variable. Further, the correlation coefficients showed a moderately strong relationship between the location where the provider grew up and "spouse residence of origin." Therefore, the "spouse" variable was eliminated. A second reason for elimination of"spouse" was the reduction of cases in the analysis due to three single providers having missing data in this variable. The interview instrument had addressed "level of responsibility" and "recognition & acknowledgment" as two separate items; H2 addressed responsibility and achievement in the same variable. Therefore, the two variables were consolidated using mean scores, but when considered separately in the correlation coefficients, there was low correlation between acknowledgment & recognition and responsibility. There was, however, a fairly high correlation between responsibility and autonomy. As a acknowledgment & recognition was retained as a separate variable and responsibility and autonomy were consolidated. The correlation coefficients upon which these decisions were based can be found in Table 4.10. 106

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ACKREO At.ITONOMY ACKREO 1.0000 .JS%6 (30) (30) p .. P...056 At.ITONOMY .JS%6 1.000 (30) (30) pa,056 p .. OREWUP .1580 .2SSO (30) (30) P...404 P...174 -MEDCM2 -.2403 -.3388 0 -...l (30) (30) pa,201 P...067 OUTDOOR .3420 .1196 (30} (30) P=.064 P...S29 RESP .2918 .!938 (30) (30} P=.ll8 P.. 001 RURROT -.1466 .2791 (30) (30} Pz,44Q P...13S STATIJS -.1954 -.1196 (30) (30) P=.301 P...S29 SPOUSE -.0749 0643 (28) (28) P=.70S P...74S -------------------------------------------------------------. OREWUP .1580 (30) P=.404 .2550 (30} pa,174 1.0000 (30) P -.1382 (30) P...466 .1189 (30) P=.S32 .2957 (30) P.. .ll3 .2615 (30} P...l63 -.2140 (30) P...2S6 4496 (28) P=.016 Table 4.10 Correlation Coefficients MEDCM1 Ot.ITDOOR -.2403 .3420 (30) (30) P...201 P...064 -.3388 .1196 (30} (30) P...067 P=.529 -.1382 .1189 (30} (30) P...466 P...S32 1.0000 .0894 (30) (30) p .. P=.638 .0894 1.0000 (30} (30} P=.638 P... -.2928 .0546 (30} (30} P.. .ll6 P.. 775 .2683 .0667 (30} (30} P...152 P=.726 .0894 .2000 (30) (30) Pc.638 P=.289 .3175 0656 (28) (28) p:JOO P= 740 RESP .2918 (30) p .. ,064 .!538 (30) P...OOl .29S7 (30} P...113 .0546 (30) P=.166 .0546 (30) P=.77S 1.0000 (30) P-. .2182 (30} pa,362 -.1637 (30) p .. ,362 1790 (28) p .. ,362 Status Spouse Rwrot -.1954 -.0749 .1466 (30) (28) (30) p .. ,301 P-.705 P=.440 -.1196 .0643 .2791 (30) (28) (30) P5,529 P-.745 P.l35 -.2140 .4496 .2615 (30) (28) (30} P= .. 256 P...016 P=.163 .0894 .3175 2683 (30) (28) (30) P=.638 P-.100 P=.l52 .2000 .0656 .0667 (30) (28) (30) P=.289 Pm,740 P=.726 -.1637 .1790 .2182 (30) (28) (30} P=.387 P...362 p .. 247 .2000 .0000 1.0000 (30} (28) (30} P.289 Pl.OOO P-. 1 0000 .0000 .2000 (30) (28) (30) P= P5l.OOO p .. ,289 .0000 1.0000 .0000 (28) (28) (30) P..l.OOO p .. P..l.OOOO

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Finally age when the provider first went to the site was eliminated in an attempt to reduce the number of variables so the sample size was no smaller than five times the number of variables (6 x's 5 = 30). The following variables were identified for inclusion in the logistic regression procedure: Dependent Variable"Status" of the provider, maintained or non-maintained Independent Variables -"Grewup"-size of provider's community of origin "Rurrot" -rural rotation during training "Outdoor" -affinity for outdoor activities "Autoresp"autonomy and responsibility "Medcm2" supportive medical community "Ackreg" acknowledgment & recognition Although the correlation coefficients bad revealed some moderate relationships among several variables, and some transformations of variables had been completed, it was considered prudent to complete diagnostic tests to identifY multicollinearity problems before conducting the logistic regression analysis. The results of these tests are displayed in Table 4.11 below. Table 4.11 Multicollinearity Measures of Provider Data Num Eigc Cond ems ACK AUro MED our RESP SPOUSE RURR.OT ber nval Jndex taal REG NONY CM2 DOOR I 7.309 1.000 .00067 .00294 00166 .00107 00431 .00295 .00234 .00107 2 .523 3.738 .00060 .01796 .00683 .00018 .60619 02449 .00618 .00107 3 .412 4.214 .00010 .05325 .01144 00471 .00078 .16002 16212 .00000 4 .242 5.495 .00234 .29972 01756 .04298 .01753 .00294 02156 .04112 5 .217 5 .798 .00534 .28124 .01807 .01176 .17568 .22118 01219 .00077 6 .144 7.134 .00829 .03728 .09222 .01206 .06140 .16819 .35449 07689 7 .088 9.123 00251 .01612 .55748 .16329 .05925 .38863 .04313 01435 8 .037 14.056 .07987 14256 .16601 29734 .00153 02906 .36951 .8S785 9 .029 15 .867 .90028 .14894 12874 .46661 .07333 00254 .02848 .00596 108

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Values greater than .350 have been placed in bold to help identify any higher scores related to the same eigenvalue. In this case, eigenvalue 7 shows higher scores for autonomy and responsibility. These are the same variables showing higher values in Table 4.10, providing support for the consolidation of autonomy and responsibility into one variable, "autoresp." An additional run of correlation coefficients using the consolidated variable "autoresp" showed no values higher than .3420, reducing concern for multicollinearity. 3 In preparation for the logistic regression procedure, transformed or "dummy" variables (Chatteijee and Price 1991) were created for "autoresp" and "ackreg." "Rurrot," "outdoor," and "medcm2" were dichotomous and coded 0/I, making it posSible to enter them directly in the analysis. "Grewup" was based on interval data that descnbed the size of the community where the provider had grown up Backward stepwise selection based on the likelihood ratio was used to estimate the model. In this method, all of the variables are included initially. At each step, variables are evaluated for entry into or removal from the model (Norusis 1994). Only the first and last steps of the process are reflected in Table 4. 12, showing that all six variables were initially entered into the model (Variables in the Equation), and eventually, all six variables were eliminated from the model (Variables Not in the Equation). Of particular importance is the residual chi-square included immediately 3 According to Anderson. Sweeney. and Williams ( 1981 ) multicollinearity is a potential problem when the value of the sample correlation coefficient exceeds 7 for any two of the independent variables 109

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I before the list of the variables not in the equation. The residual chi-square tests the null hypothesis that the coefficients for all variables not in the model are 0. If the significance level for this value is small, i.e., significant at the .05 or .01 levels, there is reason to reject the null hypothesis that the coefficients for the variables are 0, or independent, and proceed with the analysis. If the residual chi-square is large and the null hypotheses cannot be rejected, further attempts at building a model would be unwise as the resulting model would not be useful (Norusis 1994, 16) VARIABLE AuroRESP AUIORESP( 1) AuroRESP(2) AtrrORESP(3) AtrrORESP( 4) ACKR.EG ACKREo(1) ACKR.EG(2) ACKREG(J) ACKREG(4) GREWUP MEDCM2 QUI'JX)()R RURROT CONSTANI' Table 4.12 Logistic Regression Analysis on Status of Provider -Variables in the Equation-B S.E. WAID df SIG .6865 4 .9530 4.0916 20.9638 .0381 I .8453 4.2520 20.9701 .0411 I .8393 5.4693 20.9701 .0679 l 7944 -2.7036 51.3029 .0028 I .9580 2.3612 4 .6697 -.3032 12.1183 .0006 1 9800 -1.15ll 12.1260 .0090 I .9244 -1.8717 12.1614 .0237 I .8m -2.2801 12.1298 .0353 I .8509 -.2025 .3464 .3417 I .5589 -.6211 1.8227 .1161 I .7333 1.7791 1.1639 2.3365 I .1264 -1.0571 1.2746 6879 I .4069 -1.3516 17.2022 .0062 l .9374 110 R 0000 .0000 .0000 .0000 .0000 0000 .0000 0000 .0000 .0000 .0000 .0000 .0899 0000 ExP(B) 59.8372 70.2492 237.2881 .0670 .7385 .3163 .8167 .1023 .8167 .5374 5.9248 .3475

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Table 4.12 (Con't) Variables not in the Equation Residual Chi "' 8.062with 12 df Si2 .7802 I VARIABLE I ScORE I df I SIG I R I AuroRESP 2.3922 4 .6640 .0000 AUTORESP( 1) .4225 1 .5151 .0000 AuroRESP(2) .1357 1 .7125 .0000 AUTORESP(3) 1.0345 1 .3091 .0000 AUTORESP( 4) .0000 1 1.0000 .0000 ACKREG 16923 4 .7921 .0000 ACKREG(1) .8207 1 .3650 .0000 ACKREG(2) .0000 1 1.0000 .0000 ACKREG(3) 2013 1 .6537 .0000 ACKREG{4) .5357 1 .4642 .0000 GREWUP 1.3737 1 .2412 .0000 MEDCM2 .2400 1 .6242 .0000 OUI'DOOR 12000 1 .. 2733 .0000 RURROT 1200 1 2733 .0000 No more variables c:an be deleted or added. The significance level of the residual chi-square for these variables is .780. Therefore, the null hypothesis could not be rejected and further attempts to build a model using these data were not carried out. Further examination of the data confinns that there are no statistically significant relationships between or among the independent variables and the dependent variable, status of the provider. The section of Table 4.12labeled "Variables in the Equation" shows the starting point of the statistical procedure. Ill I

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. i Column B displays the coefficients of the variables. Also included are the standard errors, a statistic referred to as the Wald statistic, which has a chi-square distnbution, the degrees of freedom, the significance level of the W aid statistic, and the R statistic, used to examine the partial correlation between the dependent variable and each of the independent variables. R ranges in value from -1 to +1. IfR has a small value, it indicates that the variable contnbutes very little to the model. A review of the significance levels for the coefficients shows that none is significant at the .05 and the R statistic shows that none of the variables, with the exception of"outdoor" contributes to the model. Therefore, based on this sample population, none of the identified variables proved to be significantly related to the maintenance of a NPIP A. SPSS also produced histograms of the estimated probabilities of a provider being maintained or not maintained given certain combinations of variables. While there appeared to be some clustering of maintained and non-maintained symbols at either end of some of the plots, the results were certainly not conclusive. Because the sample size was small, all independent variables were examined in pairs and individually against "status" with the same result, i.e., little evidence of correlation. Some scores improved, but none was significant, nor did the combined variables contribute to the model. It is suggested that the reason for this is related to sample size, but may also be related to other sample characteristics that were identified through the crosstabulations of the data such as a very homogeneous sample group. Crosstabulations had been run on the data as part of the early screening 112

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. process. Therefore those results were reviewed in an attempt to learn something more about this sample ofNPIP As that might contribute to expanding the knowledge base of how to maintain providers in frontier areas. These crosstabulations may be found in Appendix F. In examining the crosstabulations for associations, three statistics were considered: Likelihood ratio chi-square, Cramer's V, and Lambda. The likelihood ratio chi-square was used because it is based on maximum-likelihood theory and is more appropriate for use with categorical data. Cramer's V is a variant of chi-square that takes the range of 0, when there is no association between the variables, to I when there is perfect association. Likewise, Lambda ranges from 0 to I, with 0 meaning the independent variable is of no help in predicting the dependent variable, while I means a perfect association. Lambda is based on the reduction of error when values of one variable are used to predict values of the other (Norusis 1993). The crosstabulations for the study variables confirmed the lack of association between the independent variables and the dependent variable. None of the likelihood ratio chi-square scores was significant, nor did either Cramer's V or Lambda approach 5 on the scale ranging from 0 to I. These scores also are affected by sample size, as the measures are based on comparisons of observed events to expected events. Small cell counts will negatively influence these results. In looking beyond the defined study variables, four other variables did show significance-salary, distance to a hospital, distance to a physician, and a variable 113

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I referred to as "cultural/social opportunities." Salary showed a level of significance of .02 on the likelihood ratio chi-square, and scores of .576 and .533 on Cramer's V and Lambda respectively. Distance to a physician showed a likelihood ratio chi-square of .03 with Cramer's V and Lambda of .856 and .800. Distance to the hospital had a likelihood ratio chi-square of .05, with Cramer's V and Lambda showing scores of .803 and .733. The third variable, "culsoc," showed an even stronger association with a significance level of .004 and Cramer's V and Lambda of .637 and .533 respectively. Although many other combinations of variables were examined, no others showed significant association. It was interesting to note, however, that the spread of responses to many of the questions was very narrow, and may have contributed to the lack of significance as well, since the responses were frequently skewed in one direction. For example, twenty-five respondents (83 percent) indicated that the medical community was supportive, twelve who had left the community, and thirteen who had remained. Twenty-five (83 percent) reported being either very satisfied or somewhat satisfied with the level of responsibility and autonomy, twelve who left the community, and thirteen who remained. Nmeteen providers (63 percent) reported being either very satisfied or somewhat satisfied with the degree of acknowledgment and recognition that they received, while eight (27 percent) were somewhat dissatisfied or very dissatisfied. The breakout of those who remained was eleven satisfied compared to eight who reported being satisfied, but who left the community. Of the eight who were dissatisfied with acknowledgment and recognition, three 114

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remained in the community and five left. A rural rotation during training is often identified as having a significant impact on successful placement in a rural area. These findings were somewhat mixed. Fifteen providers (50 percent) had a rural experience during training, and fifteen did not. Of the fifteen who had the rural experience, nine ( 60 percent) remained in the frontier community while six (40 percent) left. Conversely, of those who did not have this experience, six ( 40 percent) remained, and nine ( 60 percent) left. Based on this sample, however, the finding was not statistically significant. In this sample, 5 S percent of the female providers left the community compared to 48 percent of the male providers, but, like the others, these results are far from being significant. Linkage with a health professions educational institution that will provide professional stimulation through contact with faculty and students has also been identified as a factor in retaining providers. In this sample, only nine (30 percent) had such a linkage while twenty-one (70 percent) did not. Of the nine with the linkage-usually serving as a preceptor for students-four left their practice while five remained. The split between those without a linkage experience was eleven who left (52 percent) and ten (48 percent) who remained in the community. Having a hospital in the community might have been significant had there been more communities with hospitals. The findings showed that of the providers in the eight communities having hospitals, six (75 percent) were retained while two left. Conversely, in the communities without hospitals, nine providers (41 percent) 115

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I I I I remained while thirteen (59 percent) left. The significance of the likelihood ratio chisquare score for this association was .093, not significant at the .05 leveL but certainly closer than many of the other scores. In brief: the logistic regression analysis of the independent study variables against the dependent variable produced no significant associations. Three posSible explanations for this finding are suggested. First, there simply may be no apparent association, although other studies have indicated that the independent variables may be related to retention of a provider in an area. This study looked specifically at nurse practitioners and physician assistants in very sparsely populated areas, a group rarely studied. It is possible that previous findings cannot be generalized to this population. Second, the sample size (N=30) was small for this type of analysis. The sample population was initially identified for use with the qualitative interview process testing Herzberg's theory of job satisfaction. Collecting and analyzing quantitative data from this sample may have been a methodological error since many of the ceU counts were fewer than five, the recommended number for contingency and regression type analyzes. And third, although studies ofNP/P A practices in the northwest indicated that it takes two to four years for a practice in an isolated area to stabilize economically, using three years as the cut off limit for the non-maintained providers may have been too long. Findings may have been different ifthe cut-off date had been less than two years. The similarities between the maintained and non-maintained cohorts may have been so great that it was not possible to discriminate between the groups on the identified variables. 116

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, I I I i Herzberg's Dual Factor Theory Applied to the Providers In addition to the standardized questions examined through logistic regression, the interview process resulted in an additional data resource. Consistent with the methodology used by Herzberg, the respondents had been asked to talk about a time when they felt exceptionally good or exceptionally bad about their work as a nurse practitioner or physician assistant. Following this response, they were asked to tell about a time when they felt the opposite about their job. Just as data reduction-is necessary in quantitative research, so also is it necessary in a qualitative approach. The responses must be organized and categorized into themes or patterns, hypotheses must be tested against the data, alternative explanations of the data examined, and finally, an interpretation made (Marshall and Rossman 1989). In qualitative research, as in quantitative, raw data have no meaning. Only through interpretation can meaning be brought to the quantity of data that has been produced through the study. The approach used in this aspect of the study was logical analysis, an inductive method that attempts to cross various classifications to generate new insights or concepts (Marshall and Rossman 1989). This approach was also used to confinn or refute Herzberg's dual factor theory of job satisfaction. Unlike some approaches to qualitative research where the categories are formed from the organization of the data, and hypotheses built upon emerging patterns, this analysis used a matrix format based 117

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on the "intrinsic" and "extrinsic" factors previously identified by Herzberg. These factors were: Intrinsic achievement recognition the work itself responsibility advancement possibility for growth Extrinsic supervision company policy & administration salary working conditions effect on personal life status job security interpersonal relations The transcripts of the responses to the two open-ended questions were reviewed, and using content analysis, key phrases were entered into two matrices, one for each combination of factors -intrinsic: maintained versus non-maintained, and extrinsic: maintained versus non-maintained. Each key phrase was designated by a plus ( +) or minus (-) to indicate whether this related to a positive or negative experience as described by the provider. In addition to the factors identified by Herzberg, an additional column for "other" was included in each matrix for recording of categories that might emerge during the analysis. The matrices may be found in Appendix G. The use of the matrices with plus and minus notations created a visual representation of the data obtained through the interviews. A preliminary examination of the data seemed to confirm Herzberg's theory that factors that contributed to job 118

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satisfaction were "intrinsic" while those that contributed to dissatisfaction tended to be "extrinsic." By far, the matrices with the "intrinsic" factors or "satisfiers" were filled with pluses for both maintained and non-maintained providers. Conversely, the matrices of the "extrinsic" factors or "dissatisfiers" were filled with minuses for both. On closer examination, several other trends were noticeable. First, there were no comments in the "advancement" column (intrinsic factor) for either maintained or non-maintained providers Career advancement was not a topic that was included in any of the responses to the questions. It is suggested that this may be due to the fact that the respondents are all health care professionals who are working in direct patient care. This is where most of them have chosen to work, and the career advancement track is relatively flat in patient care once one has attained the desired level of training. Similarly, the "job security" (extrinsic factor) column was blank for the maintained providers, but contained several comments, all coded as negative, for the non-maintained providers. All of the comments related to the financial difficulties of maintaining a clinic-loss of revenue, and pressure to see enough patients to maintain the clinic and provide employment for other people in the community. One provider expressed it this way, "Trying to keep the clinic open and prosperous, not prosperousjust together to make sure I had job security, and staff had some security. And you have to provide for the people who help you too. And we're taking things away all the time instead of adding to. It doesn't add job satisfaction for the people who work with or for you. It didn't add to mine either." Intrinsic Factors. The greatest number of comments defined as "intrinsic" from 119

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both the maintained and non-maintained NP/PAs related to "the work itsel(" or with factors that arise from within the work, in this study, that is patient care. With the exception of two comments that referred to the death of a patient, all were positive in the extreme. One PA related the story of the "Christmas baby" in these words, "I guess delivering a baby on Christmas morning at 2:00a.m. Yeah! It was a snow storm, a blinding snow storm. You couldn't get in and you couldn't get out. And it was at the recreation -well the basement of one of the ranchers -in their rec room. There was myself and a neighbor lady and we delivered the baby. Gee whiz, was that ever neat. But over all, it's just the appreciativeness of being allowed to take care of these people and see them grow over the years, their family, their children, their grandparents, following them along in their medical care. It's a great reward." Another provider related the story of a rancher who refused to seek any medical care. Through a personal relationship between the rancher's family and the PA's family, the rancher finally agreed to let the P A examine him. A serious problem was discovered and appropriate specialty care arranged. In the words of the P A, ... and essentially it saved his life, which is very satisfying. That's the best part of the job. But it's part of the job that's very satisfying when you know that you have helped someone to live a longer better life just by picking up on little things like that." The second most frequently occurring comments for both maintained and non-maintained providers were in the category of "recognition." Twenty-six of thirty-two comments identified such things as expressions of appreciation from patients, trust of the patients, community acceptance and appreciation, and being recognized as providing a needed service. One provider specifically mentioned a call from a referral 120

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physician, commending her for a good job. A non-maintained provider stated, "I think it was part of the community and I was recognized as an entity, someone who was there serving a function that they really needed. So it sort of melds together in these small rural communities, not only you as a professional, but it's you as a person. It's acceptance and reliance on you for your skills." The category of"recognition," however, also had a small number of negative responses (six out of a total of thirty-two) that referred to lack of recognition being related to a time when the providers felt bad. Half of these times were related to lack of recognition of skills on the part of physicians. A NP in North Dakota had this comment, "Well, there are the times you get fiustrated I suppose, tear your hair out trying to get someone to cooperate in trying to get a patient cared for. Let's see, trying to talk to doctors that you want to consult with or refer to or to even listen to what you're saying. There are always those times that make you feel like -what the heck am I doing here?" A non-maintained NP had these comments, .. .it was difficult to get past that barrier sometimes of I) why was I even trying to take care of these patients, I couldn't possibly know what I was doing, and 2) isn't there a doctor out there that I can talk with rather than you? That's tough. That was hard." All of the comments in the "achievement" category were positive for the maintained providers. The non-maintained cohort actually had a greater number of comments in this area, but included two that identified a lack of appreciation for accomplishments. For the most part, however, comments related to topics such as early diagnosis and treatment of serious disease, making a real difference in people's 121

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I ' [ 0 i lives, being able to handle difficult patients successfully. One was successful in raising money to get defibrillators for the emergency medical technicians in the community, and another was successful in raising money for a new clinic, while a third felt very good about starting a walking competition event between neighboring communities that continued after she left. Several providers, those who were maintained as well as those who were not, discussed the extent to which their experiences had helped develop confidence in their abilities to provide health care, especially emergency care. A non-maintained P A, reflecting on the experiences in dealing with trauma in her frontier site compared it with her current site in the city in these words, .. .I've even seen my doctors function in an emergency situation, and I do better than they do now. All they do is call911 !" Another provider who works in two small clinics was more specific in her comments. "I think it probably makes me a stronger provider. It makes me more well versed in every aspect of medical care versus the PA who's in a clinic with five docs and they handle the kids with the ear aches and sore throats and the diarrhea and anything of much magnitude gets shipped off to the internist. (Here) You do the lacerations, you do the traumas, you do the emergency car accidents, you do the lady in labor, ready to deliver. In rural areas, you have to be the generalist. There's no specialization to it because you have to know everything. And I think that makes me a much better PA for it. Not to sound boastful, you just have to be to survive. n Even a NP who had a very unpleasant experience and stayed in a frontier community only eighteen months had these comments, "I learned an awful lot about myself I learned a lot, I really honed my skills a lot while I was up there. Very very 122

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challenging experience." All of the comments of the maintained providers in the category of "responsibility" were positive, and many emphasized the autonomy that one is able to exercise. The ability to follow patients over time and utilize a full range of skills was also cited as positive. A provider in Utah discussing the "outlying" clinics that he serves had these words, "We're in a place where I follow a number of people and since we're out there regularly, they became essentially our patients, versus the "group's" patients so to speak. And there's a lot of autonomy out there because you have to use autonomy. And it is a very small community, and therefore you can really follow these people. I mean you can really truly be in family practice. I mean, you know what's going on in their lives outside the clinic. That allows you to really get involved and forge a practice that is really going to be positive based on their family situation." It was interesting to note that the base or main clinic for this provider was located in a community of about 1,500 people. The "outlying" clinics were in much smaller surrounding areas. The responses from the non-maintained providers showed a slightly less positive outcome in the "responsibility" category. Forty percent of the comments (four often) were negative, and emphasized that there was too much responsibility at the frontier site. A provider who had been involved in two traumatic deaths related his feelings in this way, "The outcome would not have been different anywhere we were. And I don't blame myself for the outcome, and again I talked with numerous 123

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physicians and trauma surgeons regarding the outcome and it would have been the same no matter where we might have been. But it's that kind of responsibility that prompted me to leave [the site}." There were fewer comments relating to the "possibility for growth," only five for each group of providers. One provider emphasized the need to study continuously to know enough to handle the broad array of situations with which she was faced. Several mentioned the growth and development in their skills at handling trauma cases and dealing with ambulance services. One PA in South Dakota, who has been at his site for fifteen years and has become recognized as an "expert" in providing primary health care in isolated underserved areas, talked about the rewards received from participating on national committees to develop guidelines for processes that will have positive outcomes on patient care, trying to ensure that the needs and concerns of the frontier areas are addressed in such guidelines. These opportunities provide both personal and professional growth for this individual. Both the non-maintained and maintained groups had negative comments related to the absence of opportunities for growth. One non-maintained NP indicated that she left the area due to a lack of personal and professional growth. She expressed her feelings this way, "I think that for me that's really the reason that I left. It was a matter of being the person that knew the most somewhere for a long time, and realizing that there was a whole bunch that I didn't know. I really needed to get out and move and learn some other kinds of things." That NP has completed a master's degree and is working in a large suburban health 124

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. i care system dedicated to serving underserved and vulnerable populations. In brief: the examination of the "intrinsic" factors revealed few differences between maintained and non-maintained providers. The kinds of things that were satisfYing for one group were satisfYing for the other. A minor area of difference occurred in the "responsibility" factor, where the non-maintained providers tended to feel that there was a higher level of responsibility imposed on them than was appropriate, or with which they were comfortable. Extrinsic Factors. It was anticipated that greater differences would appear with the "extrinsic" factors, since those things that are related to dissatisfaction are more likely to result in departure from a job, than are those factors that result in satisfaction In fact, this did appear to be the case, but not to the extent initially anticipated. Again, a quick review of the pluses and minuses showed many minus signs, indicating that the negative experiences related by the providers, both maintained and non-maintained, were identified with the "extrinsic" factors. This finding also confirms Herzberg's theory that those factors resulting in dissatisfaction tend to be "extrinsic" in nature. The most apparent difference between the maintained and non-maintained providers was in the area of "supervision." "Relationship with physician" was placed in this category rather than in the "interpersonal relationships" category because of the unique relationship between the NP/P A and the physician. In the case of a P A, the relationship is clearly supervisory, while in the case of the NP, the relationship is more consultative. Nonetheless, there is a necessary relationship, thus supervision was the 125

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: i I I i I : I category selected Comments relating to physician relationships occurred nine times for the non-maintained providers, and seven times for the maintained. The type of comments varied considerably. Eight of nine comments (89 percent) from the nonmaintained providers reflected very poor relationships with the physicians, while only one comment reflected a positive relationship. For the maintained providers, four of seven responses (57 percent) expressed positive to very positive relationships with the physician while three (43 percent) expressed a poor relationship. One non-maintained P A expressed her situation is these terms: "I think that I felt the most awful in (the site) when I realized that the physicians were not in agreement in 1) hiring PAs, or 2) how we would be utilized. And so they were really fighting over the fact that we were even there. By this time, I had moved across the country and bought a house. I felt quite awful about that." That provider remained less than one year at the location. Other comments included such topics as "personality conflicts," or disagreements over the appropriate treatment for a patient. "Working conditions" produced the greatest number of comments from both the maintained and the non-maintained providers. Of sixteen comments from nonmaintained providers only one was considered to be positive, and that was from a P A who was in a clinic that was experiencing a growth period. He stated, "During that period of time, the number of hours worked, scheduling, amount of work that had to be done between seeing patients and other things really didn't matter. There was a goal to achieve, there was a spirit of team work. Everybody was contributing a little bit more to meet certain objectives." 126

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I i I The on-call demands topped the list of negative "working conditions" for both maintained and non-maintained providers. Ten of the providers, six who left and four who remained in their communities essentially had no back up for call and were, therefore, on-call twenty-four hours a day, seven days a week when they were in the community. They felt they could leave only when they had arranged for some type of coverage. The stress of this situation was reflected in several comments For example, "The one day I think the worst I felt was-it was an extremely busy day ... we used to get a lot of trauma patients. I had a patient come in who had a laceration. I was exhausted, I had been up most of the night before with on-call stuff: I was very tired. You're trying to handle all this stress and all this stuff with little sleep and you're scared to death." Another PA related an incident that occurred when he left the community for an afternoon. "And there was a little boy who had got run over and everybody was looking for me. I felt like I had let everybody down because I wasn't there, and the more I talked with different people and stuff. . I can't be there all the time, twenty-four hours a day for everybody and for everybodys needs. I have to have some of my own needs And I felt bad that I had gotten to the point where I felt like everybody came before I did and everybody came before my family did ..... people always let you know that you weren't there. I tried to get in touch with you yesterday or, where were you ... they just didn't let you have five minutes." The inadequacy of support staff was also a frequent comment. Nursing staff in many communities was in very short supply, and many NPIP As were fortunate to have the help of a medical assistant Others had to rely on minimally trained staff, both for 127

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medical support and administrative support. A PA who left a community in Wyoming had this to say about his experience, "When you come out ofPA you know a little bit. Almost everything I've learned, I've learned in practice .. .! was my own x-ray technician. I had to do all my own lab work, I was my own pharmacist. And I don't think any P A school is training a P A to do all that." Other providers talked about the difficulties in getting support staff who could or would file Medicaid and Medicare reports appropriately. In many of these areas, this was very important to the revenue of the clinic. A NP who left a Colorado community had these comments, "It was my first rural experience also-and I had to learn how to write budgets and spreadsheets and all this other junk. And I thought, hey, what's the deal here??" The effect on the "personal life" ofthe provider also seemed to be significant. A total of twenty-four comments had been entered into the matrices, with thirteen of fourteen being negative comments from non-maintained providers. Of those who had remained in frontier communities, ten comments were split five positive and five negative. For the most part, the comments addressed the lack of any personal time or time to spend with family. A South Dakota PA had these comments when describing some of the effects of her practice: "One day out of a couple of weeks, we all deal with it, but as I find that with flu season, or call (schedule) that goes crazy, it's a chain reaction that continues for a couple of weeks, then some of the negative aspects in terms of the time I have available, even for just myself: is none, and what I can give back to my family is diminished. That's a very negative part ofit." 128

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And another simply stated, 11 At times the family suffered because I felt like I couldn't leave town, that sort of thing. Not see the kids participate in some activities that in some bigger towns they would be able to do. 11 The isolation of some communities had a negative effect on both providers and families. One described that effect in this way, ... the weekend would come and we'd just look at each other and say, OK, what shall we do??? We'd already visited the desert, and pretty much-as tar as all the other social opportunities-we couldn't see any ofthose ... So we'd head up over the mountain-three hours-to go to the mall. So with little kids, that made it hard." This perspective was countered by a PA who had remained in a frontier community for seventeen years who said, "Well, one of the things that people talk about is, there's not much education for your kids when they're growing up. To a certain degree education in a small town like this is not likely to be as advanced as in a big city, but the difference is that in a small town, the kids have to do everything. Our kids have to be involved in fourteen different activities just to keep the school running And that gives them experiences that they could get no where else, and that people in big schools don't get .... Education is not books and facts and knowledge It's actually a process of learning how to learn. n "Interpersonal relations" crimments related primarily to relationships with other staff. For the maintained providers, four reported positive experiences and three reported negative. The non-maintained group reported similar results with three positive comments and five negative. The negative comments were generally related to philosophical disagreements among provider staff regarding patient treatment. One NP commented, "I felt like my ideas were not welcome, and certainly the people did 129

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, I ; '' I not accept me. So philosophically we had big differences. So that created a real turmoil in the setting." Several of the positive comments mentioned working as a team, while the negative referred more to lack of communication among colleagues, or more need for physicians to listen to the NP/P A A PA who had not remained in the frontier community, when thinking back over his experience had these comments, "Sort of gives me a warm feeling as I think back now, and the relationships that I developed with people both personally and professionally over that time frame. And their familiarity and comfort with me as a provider as well as a friend and a person there in that rural community." Another PA who had left a frontier community described the positive aspects of his current practice this way, "So I actually have some social interaction at work as well as professional interaction. In the situation where I am now, rm actually working with someone that you can call a friend and you actually get together with and have dinner with and play golf with and so on." Comments relating to "company policy and administration" were almost totally negative regardless of whether the provider was maintained or non-maintained. Only two positive comments were recorded and they were both from the maintained group. One comment identified a governing board that had "bought into modem management" techniques, making the clinic a much nicer place in which to work. The other mentioned a "positive and supportive administration." The negative responses included such comments as, "administration undermines the team approach," or "the 130

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. I I administration was not considerate of hours or call schedule." Two providers made very specific comments about the administration being very "physician-oriented," and did not understand or try to learn about the effective utilization ofNP/P As. ill-defined expectations for the position were also identified as causing problems. One provider reported what he termed "intermittent harassment" from the administration who he reported as saying to him, "you don't work hard enough to have back office staff. What's the big deal about having to give a shot from time to time. Why can't you do a temperature, pulse, and respiration? Why does it have to be a nurse or assistant or whatever?" The difficulty with an administration that was keeping an eye on the bottom line and, thus, unwilling or unable to ensure adequate physician coverage was described by one maintained provider in these words, ... there was a period of time when our administration was not very thoughtful of or respectful of what we were going through the load we were carrying and the difficulty it was. In filet it was probably a legal liability to them as well, but they appeared not to really be trying to solve the problem of getting people as best they could. In other words, shall I say it this way, there was kind of an attitude that well, we can get somebody -beat the bushes and get somebody in here. And the attitude that a wann body is as good as somebody who's been here a while -a locum tenums is as good as somebody who's been here a while. Obviously, I think they found out. It's not true, but it's kind of a concept they bad." "Status" seemed to discriminate between maintained and non-maintained providers as well. The comments on the maintained side of the scale were phrases such as, "helps my image," or being greeted as, "hi, doc." One provider stated that it 131

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felt good to "be right up there with the bankers and lawyers." One provider's positive comments included: "I need those wann fuzzies, everybody needs warm fuzzies. But I think it's even more so in a small town like this, because it helps my image. Because you know darn well those people aren't just saying it to me. They're setting down here at the coffee shop saying, 'Hey, if it wasn't for that clinic down there I wouldn't be here today."' In the community where the P A was instrumental in getting defibrillators for EMTs, the following comment was made, ... had it not been for me as a health care provider, they probably wouldn't have gotten them. And the EMTs know that, and it probably wouldn't have been done without me." Two non-maintained providers talked about being accepted as the primary care provider for the community and recognized as someone who could serve the community's needs. On the negative side were comments relating to lack of acknowledgment by community and physician and a lack of awareness of what a NP/P A could offer the community. The following comment describes this situation. "The hospital is a small town hospital that had not had any PAs on staff: There were some physicians that weren't at all sure that we were educated to do what we were doing. You'd call a surgeon with someone with a tender belly, and he would want to know if the supervising physician had seen them They wouldn't even want to know what I had done first. So in that way it was kind of hard to deal with in a small community where you had to have rapport with people to do referrals. n The last extrinsic factor identified by Herzberg was "salary." While "salary" did not appear frequently in the responses, it did appear a total of six times, three each 132

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for the maintained and non-maintained providers. Interestingly, in one case, a negative comment was made relating to a salary that was too high-higher than anyone else's in the community. The provider's comment was, "I think it was hard for me to fit in because I made more money than almost everybody living there. It was like, well, we can't trust you because you make too much money. And you can't be on the same level as we are." All other comments regarding "salary" were negative. For example, "Unfortunately, I'm one of the lowest paid PAs in the state, and unfortunately also, I'm one of the most experienced. I'm coming up with almost twenty-five years as a P A. I also know that because of the economic condition of this clinic, I'll probably continue to be one of the lowest paid PAs in the state." Another P A had this to say about "salary," "I don't think that my supervising physician, who is also the owner of the clinics, and therefore the employer, has a very clear idea of what physician assistants are being paid. I don't know what the other physician assistant is being paid. I know that I am currently being paid less than the national average for new graduates, and I think that my job description goes way beyond the average." In reviewing the transcripts and identifying key phrases, three additional themes seemed to emerge. These are referred to as: training and preparation; physician quality of care; and community support. Turning first to "training and preparation," all of the comments were from non-maintained providers and included such phrases as: "I don't think I was really prepared for what I got into out there. I hadn't done a lot of emergency medicine, and rd been out of intensive care for years." 133

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These comments were from a thirty-eight year-old NP with several years of previous nursing experience. Another PA stated, ... in a lot of rural situations you're by yourself a lot of the time, because there's nobody else that's around, and sometimes you don't think you know enough to help the person. That's a very stressful situation and sometimes you wonder if you did the right thing, or if more could have been done." A PA who serves as a preceptor for PA students shared the advice he gives students who are interested in a rural practice. "One thing I really try to stress to them, that when they get out ofPA school, they have no business going to a rural area. They need to spend time where they have close supervision for the first year or two so they can get everything that they have learned beat into them. .. you need that couple of years of family practice with three or four other providers just to kind of imprint what you learned in PA school." And yet another provider who left his site had these comments, "I think, looking back at my time, had I been a more seasoned PA maybe I would have been a little better. I don't know that for a fact, but I think a very mature person who has some clinical experience will go in and initially be a better provider than someone straight out of school." Lack of preparation for the expectations of the site can be summed up in these comments of a provider who struggled to remain at his site one year. This is his reaction to being the loan provider on-call for the emergency room. "I felt kind of panicky. You just admit that you don't know exactly what to do for every situation and so you just draw upon the knowledge that you do have and do the best you can. The outcome was good, but it just made a strong impression that if this continued to happen, the outcome may not be so good. Eventually it would have forced me out of medicine. It just wasn't my-it left a bad taste in my 134

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mouth. It wasn't the type of medicine I wanted to practice. I'd just as soon refer that urgent stuff to somebody else who deals with it every day and likes it." Similarly, another PA who was relating the frustrations of being on-call and having to cover the emergency room shared the following: "I guess coming out of school immediately, I guess I thought that I should be prepared for this. I should know how to deal with all trauma and should be able to deal with it. And at the time, I didn't feel like I was capable of doing that. And now that I'm out of that situation, I realize that was a lot to expect of someone anyway. And now I've kind of dealt with that a little bit. While I was there, I always had the feeling that I wasn't quite good enough in that situation. And I guess it kind of hurts your self esteem after a while." And another stated, "I just think it's too much for someone without the background in trauma I just don't think someone should be put in that position for the benefit of the person and the patients." Although the comments above relate to emergency and trauma situations for which providers felt ill-prepared, it should be noted that several positive experiences included life-saving actions associated with emergency situations These were, for the most part, positive comments related by the maintained providers, and were included in the matrix as part of "the work itself" In addition to the emergency and trauma situations, there were also comments about the need to know more about the business aspects of running a practice, budget preparation, third party billing, completing government forms, and marketing your services to keep the clinic operational These were all aspects of the practice for 135

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which the providers felt inadequately prepared, and/or did not realize they would be a part of the expectations of the job. The second theme that emerged from the data was "physician quality of care." While this could have been categorized in "working conditions," it seemed sufficiently important to be included separately. There were eight comments from different providers relating to poor care on the part of the supervising or consulting physician, or in some cases to a referring physician or group who did not provide adequate follow up from the perspective of the NPIP A. One provider's comments were, ... and so here I was in a rural area with not a good physician as a backup and seeing very high risk patients, and it was just really frightening." Another related the negative outcome of a traumatic injury situation in this way: "Myself and the EMTs, I think, did a really good job of managing him acutely and got him to the hospital in (town about 45 minutes away), and watched as he was fairly badly mismanaged there. He may have had a bad outcome in any case, but he was flown to [another hospital] and he died there. That was a difficult time of watching not as good a care go on in the hospital as went on before he got to the hospital." Other comments related to physicians who worked beyond their capabilities and refused to refer patients for specialty care that might have resulted in more positive patient outcomes. It was interesting to note, however, that of these eight comments referring to poor quality of physician care, six of them were comments of maintained providers Only two non-maintained providers mentioned this as a negative issue. It may be that for the non-maintained providers, there were so many 136

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: i 'I I other factors contributing to their dissatisfaction, that quality of physician care did not rise to the top. For the maintained providers, however, who were more satisfied in their practices and planned to remain in them, poor quality of care was a greater concern. It could also be that the maintained providers, because they had been in the practice longer, were in a position to see more instances of poor quality care than were those who were not maintained. The third theme that emerged from the interviews was "community support." This factor was raised by maintained and non-maintained providers alike, but more often by the non-maintained. This factor took the form of community residents bypassing the clinic and going to another town for medical care. One maintained provider explained that when he arrived in the community, the practice was primarily a Medicare practice made up of people who had difficulty with transportation or with emergencies. His comments were, "The younger people, pediatrics, OB/GYN, the healthy people went down the road. That left a big big hole in the practice They [the patients] didn't understand that I was flattered that they brought their life-threatening situations to me and took all their mundane things to [another town]. But what I wanted was a general practice. I wanted preventive medicine, things that I didn't have to worry about so much. I like kids and healthy people. That's a whole different type of practice. How do you get across to the community that they really have to use us-that they have to use us for everything. Just your routine bread and butter medicine-that's what keeps us in business, not the emergencies?" Another provider commented, "The population had grown reliant on commuting for the greater 137

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portion of their needs both medically and groceries, etc. The community was largely supportive of my being there, however, they were somewhat reluctant due to their previous experience with more or less short time providers. Unfortunately, they never fully accepted me as a primary provider, but more ot: we'll use you when we absolutely need you. Otherwise, we'll go some place else. And this provided my greatest fiustration with the provision of professional services in [the site]." Another non-maintained provider expressed the fiustration that if he had remained in the community for twenty years, there would still be people waiting to see if he would stay another year before they started going to see him. He summed it up in these words: "even the members of our Board did not choose to use the clinic as their primary source of care. By and large the Board members are the more aftluent members of the community and they're going to go somewhere else. Or at least that's how it seemed during the time I was at [the site]. Although each of these additional categories might have been combined with Herzberg's original factors, they seemed sufficiently dissimilar to be identified separately. It is suggested that all three are "extrinsic" factors that contribute to the dissatisfaction of the provider. This review of the data from the open-ended questions confirms Herzberg's dual factor theory for this sample ofNPIP As. The descriptions of the events or times when the providers felt exceptionally good about their jobs were filled with comments that are descnbed as "intrinsic" to the job. The factors that were included in the stories of times when the providers felt exceptionally bad about their jobs were filled 138

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: I I i with descriptions of "extrinsic" factors The three emerging themes from this study training and preparation, physician quality of care, and community support received negative comment, and are all considered to be "extrinsic" to the work itself. Using Herzberg's factors, the "work itself" and the "recognition" received from this work were the major factors in job satisfaction as described by both cohorts of providers For the "extrinsic" factors or "dissatisfiers" the major influences were "personal life" and "working conditions." Remembering that Herzberg's dual factor theory descn'bes a unipolar situation where satisfaction and dissatisfaction are not opposite ends of the same continuum, but rather are separate traits that arise individually from the content of the work itself ( satisfiers) and from the context in which the work is performed ( dissatisfiers ), it is suggested that attempts to increase the recognition extended to a provider will not decrease the dissatisfaction that person is experiencing because of the working conditions or stress on personal life. If maintenance ofNP/PAs is to be increased in isolated frontier areas, emphasis must be placed on decreasing the negative aspects of the working conditions and their effect on the personal life of the provider. 139

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CHAPTERS CONCLUSIONS AND RECOMMENDATIONS While the concern of the nation seems to be focused on issues surrounding managed care or whether Medicare will be able to meet the health care needs of the "baby boomers" as that group approaches their sixties, the issues of equity of health care from both a public and an economic perspective continue. The public view is that health care is a right, and a basic level of care should be available to alL What this basic level should be and how it is to be made available to all points to the major economic issues in health care-efficiency in the supply of health services and equity in their distribution (Sharp, Register, and Leftwich 1992). Whether health care is considered a "right" rather than a privilege as described by Marmor (1973) and others, or as a "merit good" to be distnouted according to need rather than ability to pay (Detsky 1978), the challenges of equity of distnoution are of greater magnitude in frontier areas of this country where residents face shortages of nearly everything except distance This relationship between supply (the providers) and demand (the communities) and the unique characteristics of this relationship in health care is the basis of this study. Discussion of Findings The demand side of the equation is characterized by the community, in this 140

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' I I I case, frontier communities having a population base of six or fewer persons per square mile. The supply side focuses on a group of health care providers, nurse practitioners/physician assistants (NP!PAs), who were originally created in the 1970s as a response to the perceived shortage or maldistnbution of providers of primary health care to these remote areas. Characteristics of both communities and providers were examined to determine whether distinguishing factors that enhance the ability of communities to maintain a health care provider, or that contribute to the likelihood that a NPIPA will remain in such an area, could be identified. Based on the literature review, independent variables that suggested an effect on the ability of a community to maintain access to health care were identified. Similarly, variables identified as contributing to retention from the perspective of the health care provider were selected. These variables were tested against the dependent variable for each group, status of the community-successful or unsuccessful-and status of the provider-maintained or non-maintained. Both dependent variables were measured over a three-year period of time. The Communities For the community portion of the study, the independent variables were: proximity to a larger community of 10,000 or greater, socio-economic status, availability of health insurance, "critical mass" equal to or greater than 1,500 potential patients, effective leadership at the local level, and utilization of local resources. Using a logit analysis that tested for both main effects of variables and interactions among variables, only two were found to be significantly related to success in maintaining a 141

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health care provider-socio-economic status and effective community leadership. Two proxy measures were used to determine socio-economic status. The first was per capita income and the second was a factor based on a series of responses that, when aggregated, resulted in a measurement of the perception of economic strength. The combination of these two significant factors-a relatively low per capita income and a high degree of community leadership-seemed to be the greatest predictor of success in maintaining a health care provider. When only one factor was used, the perception of economic strength was strongest. The finding that low per capita income was more predictive of success than was high income, when viewed as a main effect, seemed inconsistent with the other findings. Therefore, an attempt was made to identifY why this might be the case. In reviewing the seven communities having the lowest per capita income ($5,000$8,500), it was determined that four of seven (57 percent) of those communities were receiving a direct federal subsidy in the form of a community health center grant. There were fourteen of twenty-five communities (56 percent) in the medium per capita range ($8,50 l $1 0,000) receiving a direct subsidy in the form of a community health center grant or support through a federally-salaried health care provider placed in the community. Of the eighteen communities at the highest end of the income scale (greater than $10,000), only four communities (22 percent) were receiving such a subsidy. Strikingly, one of these was part of a three-community network where the other locations were in the lower per capita income category. A 142

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second community received support specifically to provide services to migrant and seasonal fann workers, not to the community as a whole. The last two communities received support in the form of a federally-salaried health care provider. It is suggested that the magnitude of federal intervention in the lower per capita income communities may have resulted in these communities being more successful in maintaining a NPIP A, for it reflects a clear commitment by the federal government to the support of access to care in these areas. If this were the case, it seems to reflect a degree of success of these federal programs in maintaining access to primary health care in lower income, sparsely populated areas. It may also reflect community leadership that accepts the skills and contn"butions ofNP/PAs and is assertive in pursuing assistance for the community, i.e., demonstrates good community leadership. A second posSible explanation for this finding is that higher per capita income communities may be more intent on recruiting a physician than a NP/P A. In addition, these communities may have greater financial resources that make traveling longer distances for care more feasible. If this were the case, the support structure and attitude in the community may be less conducive to the recruitment and retention of NPIPAs. Given that further analysis revealed a significant relationship between the perception of economic strength and community leadership, both variables based on the opinion of the respondents, an additional explanation may be that good community leadership may counteract the negative effect oflow per capita income. This leadership may be reflected in communities that seek outside assistance and collaborate 143

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with neighboring communities. Although the low per capita income association with "successful" communities is interesting, greater attention should be given to the combination of poor community leadership and low per capita income as a combination of variables that tends to predict success or failure in the maintenance of a NP/PA-based system of primary health care. The logit analysis indicated that a community with low per capita income and poor community leadership is ten times more likely to be unsuccessful in maintaining a health care provider when compared to a community with high per capita income and good leadership. A community with poor community leadership and medium per capita income is nearly three times more likely to be unsuccessful. Therefore, it is suggested that the maintenance of access to primary health is both a community leadership and an economic issue The need for strong community leadership is consistent with the propositions put forth by Amundson ( 1993) in his article on "Myth and reality in the rural health service crisis: Facing up to community responsibility .'' It is also consistent with the efforts supported by the Colorado Healthy Communities Initiative that challenge individuals and communities to recognize that they are both the source and the beneficiaries of the actions they take (Norris 1993). Projects funded by the Northwest Area Foundation (NRHA 1994a) designed to increase community participation in addressing the problems of health care in rural areas further support the need for increased community leadership and participation. 144

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Less attention appears to have been given to the second of this combination of variables-low per capita income, and the influence this overall economic strength, or lack thereof. has on the ability of a community to maintain a health care provider. The literature contains numerous studies that attempt to quantify the "critical mass" of people necessary to "support a physician" and to a lesser extent, other health care providers (Pathman 1991; Hicks and Glenn 1991; Rosenblatt and Moscovice 1978; NRHA 1992). However, these studies are generally either provider-to-populationbased, needs-based, or demand-based and focus on the number of health care providers necessary to serve a given population, or the number of patients necessary to produce "a competitive compensation package" for the provider. Tilden and Tilden (1995) in their book, Ensuring Access to Primacy Health Services in Rural Areas: A Guide to Recruitment and Retention of Physicians, Nurse Practitioners. Physician Assistants and Certified Nurse Midwiyes, identify eight ''fundamental ingredients of successful community-based recruitment." These include such things as school system, housing, churches, recreation, social and cultural opportunities; pride; enthusiasm and unity of purpose; a recruitment plan; demonstration of need for medical personnel; presence of sufficient numbers of medical personnel to provide support and call coverage; adequate office and hospital facilities; and "presence of sufficient financial resources to provide new medical professionals with a competitive compensation package, (Tilden and Tilden 1995, 18-19). It does not appear that the overall economic strength of the community necessary to support the provider is 145

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examined with the same intensity used when business or industry is interested in locating in an area. Perhaps this is because we, as a people, are hesitant to place our health care in the same category as access to a Walmart or a Pizza Hut. It is suggested, however, that additional attention should be focused specifically on the relationship between the overall economic development and stability of an area, and the benefits to be realized by the community as a whole through the availability of access to primary health care. This attention should be directed toward not only the benefit of being able to maintain a health care provider in the community, but also toward the more general economic benefits to be derived through additional employment opportunities and revenue generated by people who remain in the area for care and to purchase other goods and services. The second strong indicator, when looking at main effects only, is a positive perception of economic strength among community leaders. This finding seems to combine some aspects of both the economic and the leadership functions as it places importance on the perceptions of the community leaders that the economic strength of their community is good. In many cases, those communities with a high per capita income are the same communities where the leaders perceive a strong economy, but this was not a consistent finding. There are communities where the per capita income is low, but the perception of the leaders is one of a strong economy-and several of these communities are among those categorized as "successful" in maintaining access to primary health care (e.g., thirteen of forty-two respondents from successful 146

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communities with the lowest per capita income (3 1 percent] reported a good perception of economic strength). For the "unsuccessful'' communities, thirty-seven respondents from the lowest per capita income category (30 percent) reported a good perception. These findings suggest that greater emphasis needs to be placed on the community as a whole, especially on improving the leadership capacity and focusing on overall economic development activities, rather than on health care in isolation. Several of the studies cited in the literature review (Hicks and Glenn 1991; Moscovice and Rosenblatt 1979) discuss the need to have an adequate population base or 11critical mass11 to support a health care provider, primarily a physician. While these studies examine the need for the generation of revenue to support the provider, they fail to consider the overall economic well-being that must be present in the community to generate that revenue. Moreover, these studies overlook the contribution to the economy through the number of jobs created or the revenue retained in the community when people obtain health care and other services there. While some studies addressed clinics being by-passed in favor of obtaining services in other communities, the reference is generally to lack of support of the local hospital, and is not phrased in terms of the economic effect of such actions, but rather to the difficulty of maintaining a hospital when the daily census is very low. The hypothesis for the community portion of the study stated that the long term maintenance of a NPIPA-based system of primary health care is a function of six community characteristics-proximity to a larger community of 10,000 or greater, 147

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. ' i : l I I I socio-economic status; availability of health insurance; "critical mass" of population equal to or greater than I ,500; effective leadership at the local level; and utilization of local resources Of these six, two were found to significantly influence the maintenance of a health care provider. The findings that socio-economic status and community leadership are the major contributing factors to the maintenance of a health care provider in frontier communities seems to support the efforts of such programs as the Colorado Healthy Communities Initiative sponsored by the National Civil League and the projects funded by the Northwest Area Foundation designed to increase community participation in addressing the problems of health care. On the other hand, the Community Health Services Development Model produced by the University of Washington addresses community development, but is more narrowly focused on medical care rather than on the broader issues of health and the relationship between health of a population and the economic health of a community. The Providers For the provider portion of the study, the independent variables included: provider/spouse residence of origin, rural experience during training, sense of autonomy/desire for independence of action, sense of responsibility and achievement, affinity for outdoor activities, age/years of experience, marital status, and supportive medical community Those variables that were ultimately included in a logistic regression analysis were factors that addressed autonomy and responsibility, acknowledgment and recognition, residence of origin, supportive medical community, 148

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affinity for outdoor activities, and rural rotation during training As reported in the findings, contrary to other studies using similar variables (Rhodes and Day 1989; Hanson, Jenkins, and Ryan 1990; Pan et al. 1995; Lawler and Valand 1988), none of these factors was found to be significantly related to maintenance of a NPIP A in a frontier area. Although there have been many studies examining health care providers' decisions to move to rural areas, there have been few that look specifically at factors affecting the providers' retention over time, and, in general, these studies have been based on the belief: not strong empirical evidence, that certain factors (e.g., inadequate income, professional isolation, family needs, marital status, job satisfaction) are important in decisions to remain in rural areas (Pathman, Konrad, and Agnew 1994; Pan et al. 1995). No other studies were found that examined the maintenance of NP/PAs in small isolated communities; therefore, it may be that the characteristics of providers who go to such areas are so similar initially that an attempt to identifY statistically significant differences is difficult at best. This conclusion seems supported by the very similar response patterns of the maintained and non-maintained providers as reflected in the crosstabulations in Appendix F. A review of the data revealed that three of the thirty NPIPAs in the study (10 percent) stood out as having different response patterns from the others. These three related negative experiences across the board, but did mention the improvement in skills and confidence level. The backgrounds of these three were examined more closely to determine any commonalities, especially in the areas of residence of origin, 149

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. I previous experience, and rural rotation Although not statistically significant, it was interesting to note that two of the three grew up in cities of greater than 100,000 population, and the third was raised in a town of between 50,000 and 100,000 (twenty of the sample NP/PAs had grown up in towns of 10,000 or less). Two of the three had not had a rural rotation during their training program, and all three expressed that they were right out of school with no experience in emergency or trauma medicine. In response to a question about the three most important factors considered when choosing the site, one answered that she was "looking for something different-a fantasy." The crosstabulation procedure did show association between the dependent variable, status-maintained or non-maintained-with four other variables not included in the logistic regression analysis. These were: salary, distance to a hospital, distance to a physician, and cultural/social opportunities. Using Herzberg's dual factor theory of job satisfaction, all of these factors would be considered "dissatisfiers" or extrinsic to the content of the work itself. These tactors, combined with those identified from the qualitative analysis of the interviews would seem to indicate that the challenges of increasing the level of satisfaction, and more importantly, reducing the "dissatisfiers" in the environment are both crucial and immense In most of these areas, reducing the distance to a hospital or physician is unlikely. In fact, as small rural hospitals close, this distance may literally increase. In this sample, only eight of the thirty providers lived in a community with a hospital. ISO

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I I I I I i I The greatest number of comments addressing "extrinsic" factors was in the category of "working conditions," with on-call schedule leading the list. The long hours required and inadequate time to spend with family are difficult issues, and cannot be addressed in isolation. Linking the quantitative finding of an association between cultural/social opportunities and status, with the qualitative comments relating to personal life and interpersonal relations (such as, "no collegial interaction" or "nothing for the family to do") presents either a difficult burden for frontier communities lacking adequate health care or a tremendous opportunity for creative problem solving in the areas of isolation and scarce resource allocation. In addition to the isolation filctor, there is the issue oflack of competent nursing and administrative support staff. Very positive comments were made in several situations where there was a good working relationship or teamwork among the staff Negative comments related to not having enough staff, staff who were poorly qualified, and administrators who did not understand the practice of a NP/P A or who were inconsiderate of the demands placed on the provider. This is consistent with the study by Baldwin et al. (1995) that descn'bed reduced support staff: both health care and administrative, significantly more time spent on-call, and more emergency room contacts in rural areas than in urban. On the other side ofthe issue, the intrinsic rewards from the work itself are repeatedly expressed to be great, as is the recognition received. Add to this the very positive feelings of achievement and appreciation that were expressed by both 151

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. i maintained and non-maintained providers, and there are strengths that can be built upon. While they may not, by themselves, reduce the level of they may add enough satisfaction to maintain a provider long enough that some other activities can be identified that will reduce the "dissatisfiers Several of the non-maintained providers commented that their current urban-based position was not as fulfilling as their frontier experience had been. One stated, it's not been as rewarding. In fact, sometimes I wonder if I might at some point go back to a rural practice again. Working in a big clinic and just pumping the patients through isn't as rewarding." Of particular concern are the comments made about the supervising or consulting physicians. Of the seventeen comments about relationships with the twelve (71 percent) were negative. Add to this the seven comments about poor quality of care provided by the and the issue becomes one not only of scarce resources, but of poor quality resources as well. One must however, if the poor working relationship between NPIP A and physician might have influenced the perception of quality of care. One of the quantitative variables in the study was "supportive medical community." Although it did not prove to be statistically significant in its relationship to retention status, the fact that eight of fifteen nonmaintained providers (53 percent) when relating their bad poor relationships with physicians would tend to support the importance of a positive and supportive relationship between NP/P A and physician or community in 152

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I I I I the maintenance of the NP/PA. This is an area that has received little study as it relates to the maintenance ofNPIP As in practice settings of any and certainly not in frontier areas. In brief: although the quantitative portion of this study of the providers did not reveal statistically significant associations between the independent variables and the dependent variable, it has effectively raised serious questions regarding the conventional wisdom pertaining to factors that contnoute to the maintenance of NPIP As. Furthermore, the qualitative portion did reveal very strong factors relating to satisfaction and dissatisfaction in the work experiences of the NPIPAs Given the findings of the community portion of the study, that socio-economic status and effective community leadership are the most important factors in a community's ability to retain a health care provider, combined with the findings that poor working conditions and the negative effect on personal life are the greatest sources of dissatisfaction, some recommendations for possible improvement can be made. Recommendations The recommendations for improving the ability of communities to maintain the services of a NPIP A are simultaneously easy to state and very difficult to achieve. Assuming a preference for health care professionals exists, then efforts on the part of state and local organizations, local, state and federal governments, educational 153

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I i i j I I institutions, agricultural and recreational organizations, and other stakeholders with an interest in maintaining access to health care in these areas need to be put into enhancing the leadership capability and improving the socio-economic status of communities. To increase the likelihood that a NP/PA will remain in a community, the factors that contribute to the greatest job dissatisfaction need to be reduced. These factors primarily have to do with working conditions, especially the on-call schedule, and the negative effect of the practice on personal and family time. How to address these challenges is more difficult. Because these factors are environmental in nature, that is, not under the control of any individual who can make adjustments to alter the situation, but rather the result of the complex influences of the economy, the geography, and the personal tastes and culture of the people living in these areas, no simple catchall solution is possible. To address the policy issue of maintaining access to primary care services in frontier areas, all aspects must be considered collectively. Efforts to maintain access to primary health care in the form of maintaining a NP/PA must be a part of the larger economic development activities of the community. Community leaders must take advantage of opportunities to improve their leadership skills and must look beyond their borders with a view toward strengthening their community though vertical and horizontal integration for both health care and economic development with surrounding communities both near and far. This means that formal and positive vertical relationships must be developed with communities having hospitals or other resources that can be strengthened through 154

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increased utilization. The relationships must be beneficial to both parties, i.e., one community receives coverage and support for their NP/PA while the other receives the hospital referrals necessary for survival of that institution. Vertical integration also includes the development of relationships with health professions educational institutions and other professional organizations that can provide professional information and bring collegial interaction to the frontier. Horizontal integration addresses the sharing and working together among communities to reduce the burden of the "on-call" schedule and the development of formal and regular opportunities for backup relief for the providers in these areas. Through the development of positive vertical relationships, such as with a local hospital in a neighboring community, the horizontal relationships may be easier to accomplish. Although the distances involved may be great, the knowledge that consistent and dependable relief is available on a regular basis will be a major factor in reducing provider dissatisfaction. Thus, it is the dual integration of existing resources, combined with a focus on improving community leadership and socio-economic status while working to reduce the "dissatisfiers" of working conditions and effect on personal life that will enhance the odds of maintaining health care services in frontier areas. Implications for Policy Makers The last twenty-five years have seen policies at both the federal and state levels 155

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move from an emphasis on diffusion theory based on increasing the numbers of health care providers-hoping that additional numbers would result in some locating in rural and other underserved parts of the country-to one of retention of providers by trying to increase job satisfaction. The findings of this study support a further move from a theory of"retention" to one of"development and maintenance" ofthe community infrastructure. The change in concept is important as one definition of"retain" is, "to keep in a fixed place or position." "Maintain," however, means, "to continue or carry on, to provide for." Given the complexities of the current health care environment, it is not possible "to keep in a fixed place or position.'' It is essential that communities and health care providers "continue to carry on and provide for." A development and maintenance theory is consistent with and supportive of the definition of primary care adopted by the Institute of Medicine committee on the Future of Primary Care, which states: Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (Institute ofMedicine 1994). This definition should serve as the groundwork for the development of a system of care that emphasizes the maintenance of health care providers resulting in a "sustained partnership with patients" and a practice that will be conducted "in the context offamily and community." The continuity of care element that can be provided by a NP/P A who has remained in the same community for ten years 156

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compared to the fragmentation in care when a series of providers treats the same patients is hard to overestimate. The trust relationship that develops through a "sustained partnership with patients'' has been shown to improve patient outcomes (Institute of Medicine 1994), and the "knowledge of the context of family and community" enhances the ability of the health care provider to see beyond the condition of the patient at the moment and to understand the context in which this condition exists. Thus, the ability to provide effective treatment is also enhanced (Institute of Medicine 1994). A "development and maintenance theory" consistent with the above definition should enhance access to primary health care not only in frontier areas, but also other underserved areas of this country. To address this issue, policy makers must be more comprehensive in their thinking, assuring that sources of assistance are coordinated and directed toward improvement of the total community over the long term, not directed toward individual projects such as the recruitment of a health care provider or the building of a clinic. Special emphasis needs to be placed on support of the community infrastructure through the efforts of the Chamber of Commerce to attract business and industry to the area, or the School Board in recruiting quality teachers for the schools, or the Farm Bureau in striving to stabilize agricultural income in the area. From the perspective of public administration, a description of how any state or federal health care funds that go into a community will enhance the overall economic development of the community should be required as a part of any 157

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application for support Policy makers should ensure that policies from differing organizational components are complementary and designed to work together to improve the whole One way to accomplish this is to require the review of sources of assistance currently available and modifY requirements to allow for greater integration and coordination of supported activities. Assistance to support broad-based community development activities should be made available as a component of categorical programs in addition to the support of the specific project. Policy makers should adopt a ""theory of development and maintenance" that will support and enhance the leadership at the community leveL Clearly, any attempt to bring together the disparate policies that address both health care and community development will be plagued with difficulties inherent in any policy process-differing ideologies, the ethics of equity of distnoution of scarce resources, the politics of the situation, and certainly the economics of the area (Brewer and deLeon 1983). Nonetheless, in times of government reductions, it is of greater importance that the variety of duplicative sources of funding available to support community development activities, service integration activities, health care activities, construction projects, social service projects, and numerous other special interest projects be brought together at both the state and federal levels. This will enable funds to be targeted toward more comprehensive goals and provide support for the enhancement of the community infrastructure including economic development and community leadership. Both policy makers and the officials responsible for 158

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. I implementation of the policy should be charged with investigating and bringing together sources of support that will enhance community infrastructure and lead to improved access to health care. Implications for Communities At the same time, it must be clear that communities have the major responstbility for their own well-being. Communities must adopt the "development and maintenance theory." They must continue to carry on and provide for, not remain in a fixed position. Improvement in socio-economic status (or at least its perception) and effective leadership are key to developing a community that is able to maintain a health care provider. This requires hard work and cooperation. Recruitment of health care providers goes hand in hand with recruitment of new businesses to the area, or the development of a recreational area that will enhance tourist travel and possibly draw more residents to the area. But before this recruitment can occur, the ground work in terms of development of a solid community infrastructure must be completed. Communities must broaden their perspective of "community" from the town where one lives to the surrounding area, drawing on the strengths of the total area. Communities vary in their resources; leaders should be willing to share both their strengths and the areas where assistance is needed. For instance, although not without struggles and tension, consolidated school districts have been in existence for many years, bringing together the necessary "critical mass" of students to support a better 159

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educational system than could exist in each small community Even district health departments that cover several rural counties are common. The difference seems to be that these are considered to be public goods, available to all and supported by all. Personal health care, however, continues to be very individual, and more difficult to conceive of as a "public good" until it is no longer there. This perception makes the cooperation and collaboration necessary for communities to form alliances even more difficult. Isolation, long hours, on-call schedule, and negative effects on family life are the primary causes of dissatisfaction among NPIP As in frontier communities. The community, with its leaders, is largely responsible for reducing these "dissatisfiers." The community leaders should be instrumental in working with neighboring communities and other organizations to assure that there is adequate relief for the provider, and that supportive back up is available. The community leaders should assure that the provider has time off, that the time is taken, and that adequate coverage is arranged so the provider does not feel "guilty" about leaving the community. This could be accomplished through the pooling of available resources among communities Making arrangements for emergency coverage, for example, might be easier and more cost effective if a group of communities contracted together with an emergency coverage group to provide service every week, thus ensuring some continuity for both the communities involved and for the group providing the coverage. Relationships are built on mutually beneficial outcomes. The continuity and accountability that can be 160

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developed between a group of communities and an outside group that provides will be beneficial to both groups. Communities can also build on their strengths. Arrangements for relief for health care providers can be packaged as opportunities for a working vacation for a family on a ranch or fann-maybe a local ski resort or a fishing vacation. a mutually beneficial relationship has been created. A family receives a break from their normal and a community obtains much needed relief for their health care provider. Frontier communities must develop all aspects of their environment as they work toward the creation of a system of care that will enhance the overall well-beingphysical and economic-of the total area Community leaders must take the lead in visibly utilizing the services of the local provider. If the leaders are known to "go down the road" or "to the city'' for their routine primary and preventive health care, this example will speak volumes to the other community residents Community leaders must conversely help the community residents understand the need to respect the time of the provider and family, by encouraging residents to make and keep appointments., not delaying routine care until the situation worsens into an emergency, helping to educate the residents about true emergencies when the provider should be called out, and those situations that, while irritating, are not emergencies. Leaders working with the providers, can help to establish and support a kind of triage system that assures necessary care, but protects the provider's time as well. 161

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Finally, community leaders should work with universities and other educational and state institutions to assure that the community has access to distance learning technologies This technology, which is developing rapidly, can bring the world to the frontier. It should be used to enhance not just health care through telemedicine techniques, but overall community and economic development, from training the front office staff how to maximize revenues through improved third party billing; to informing community leaders of the multitude of resources available; to providing the base for telemedicine that will open the world of speciality consultation to the community. In return, the community can provide a living laboratory that will assist in meeting the university's mission of education, research and service, receiving quality services as a benefit. A telemedicine linkage to a university teaching hospital or a specialty group can enable the NPIPA to arrange specialty consultation in the community. This capability accomplishes several things. First, the vital link between the primary care provider-the NPIP A-is maintained so explanations can be enhanced if necessary, and recommended treatments discussed. Second, the patient can be diagnosed and possibly treated in the community, saving travel and other financial costs to the patient, as well as keeping revenues in the community. Third, such an arrangement can also provide a source of continuing education and consultation to the provider, thus reducing the professional isolation of the provider. And fourth, if hospitalization and further specialty care is needed, the relationships and mechanism to manage the 162

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transfer of the patient will be firmly in place, allowing for increased continuity of care. Implications for Health Care Providers NPs and PAs who are considering a practice location in a rural or frontier area need to take extra time to consider their own personal needs as well as those of their family. How important are the opportunities that might be available for a family in a larger community compared with the different kinds of learning experiences that will be available in a small community? If a provider has spent limited or no time in a frontier community, arrangements should be made for a pilot "immersion" of at least a month's experience, complete with on-call and emergency responsibility before a final decision is made. Based on the findings of the qualitative portion of the study, several non-maintained and even some maintained providers felt ill-prepared by their training for emergency and trauma situations. For some, these were the overriding reasons that they left the area. Arrangements should be made for additional training in emergency medicine and the handJing of trauma situations for providers going to frontier areas. Additional knowledge may be necessary in how to work effectively with volunteer emergency medical technicians and other ambulance personnel. Many rural ambulance services are county-based, and the political realities of crossing county lines gives additional support for regionalization of systems and sharing across county lines. The NP/PA should thoroughly discuss the business management of the practice and be aware of the expectations of the provider as it relates to this aspect. Additional assistance in the business management aspects of a practice should also be encouraged 163

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for providers going to small practices with limited support staff When a NP/PA is considering any practice location, an on-site visit is essential. It is even more important for those considering a frontier location. An on-site visit of several days, if possible, should be scheduled so all aspects of the community can be explored. The costs involved in such a visit may be supported by the community as an investment in their community development activities, by a hospital that is recruiting for health care providers, shared with the provider, or supported by other organizations or agencies (e.g., the National Health Service Corps or State Loan Repayment programs) whose mission is to improve access to primary health care. Based on the qualitative findings that a poor relationship with the physician was a major factor leading to "dissatisfaction," NP/PAs should become as well acquainted as possible with the supervising/consulting physician before accepting a position at a remote site. Practice protocols should be discussed with the supervising/consulting physician to assure compatibility in practice philosophy. Also, since the working conditions-in particular, excessive time "on-call'' -are a serious source of dissatisfaction, arrangement for relief and backup coverage should be specified, and the NP/PA should meet the providers who will be providing the coverage. A discussion should be held with community leaders regarding the need for personal and family time, and respect for both the provider and the members of the community should be demonstrated. Because disagreements in treatment protocol and business management contributed highly to dissatisfaction among providers, guidelines for conflict or dispute resolution should be discussed upon acceptance of the position, 164

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if not before. Such guidelines should be made part of recruitment materials available to both communities and providers. If there is an administrator of the clinic, the relationship between provider and administrator must be clearly understood by all involved, and the roles and responsibilities clearly defined. Positive opportunities for team activities in practice were identified in the qualitative findings as a source of satisfaction with the job, and the lack of opportunities for professional growth and development were included as sources of dissatista.ction. Therefore, provisions for continuing education and professional growth and development for both the provider and the office team should be discussed, and if the position is accepted, team building activities focusing on continuous quality improvement for both administrator and provider should be a normal part of the improvement process for the clinic. Emphasis on continuous quality improvement can be supported through distance learning technologies that enable the staff to work together on solving any emerging issues. Providers should actively press for community support for such activities. Implications for Health Professions Educational Institutions Just as communities must accept a broader role and perspective if they are to enhance their socio-economic status and leadership capability, so must health professions educational institutions take a broader look at their role in the overall picture of health, particularly access to primary health care. First, educational institutions must ensure that their students are, in fact, well trained through the 165

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provision of a broad base of experiential activities. Although the present study of NPIPAs did not confirm the effect of a rural rotation during training on status of the provider, there are other studies (e.g., Fryer et al. 1994; Rhodes and Day 1989; Martini et al. 1994) that have indicated a positive effect. The fact that two of the three most dissatisfied providers had no rural rotation (i.e., experience) may support the observation that such an experience is helpful-indeed essential-to the decision making process of the provider. Schools should work more comprehensively with communities, not just physicians and other health care providers, in the design of educational experiences in frontier communities, so that the experience can be broader than just spending time in a rural clinic. Because one of the "dissatisfiers" is lack of or poor quality support stati: special modules designed for providers going into remote areas should be developed and made available through a variety of media, compressed video, interactive video, video tapes, and audio tapes, all accompanied by written materials. These modules should address a variety of business management topics including front desk responsibilities of scheduling, revenue maximization, and simply how to greet a patient, and might be accomplished through a relationship with a local community college, an Area Health Education Center, or a technical institution. Training videos for both the provider and the entire staff on how to deal with emergency situations would be an important part of a module on emergency medicine that focused on the most frequently occurring emergencies in the particular area (e.g., 166

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motor vehicle accidents, farming accidents, recreation accidents). This might be accomplished through a collaborative relationship between a group of emergency physicians and those health professions educators who are preparing students for primary care in rural areas. Another recommendation for health professions educational institutions is to develop a program of rotations of four to six weeks in the emergency room of a busy hospital for rural providers who are faced with emergencies on a fairly regular basis, but do not have the opportunity to work with emergency medicine physicians, nor to see the volume of cases that spending some time in an emergency room would provide. Coverage through the use of residents, faculty, or members of professional organizations would be provided to enable the frontier provider to be absent from the practice. Liaisons should be developed with the NP organization and the PA association in the state, using these groups as a vehicle to reach the rural and frontier providers who might otherwise be missed. The isolation factor and the lack of opportunity for professional growth and development have been identified as "dissatisfiers" in previous studies (e.g., Tri 1991; Hanson, Jenkins, and Ryan 1990), and were confinned in this study. Educational institutions should move rapidly to increase their distance learning and telemedicine capabilities as one technique in reducing the isolation factor and bringing possibilities for professional growth and development to the frontier NP/P As. A video conference or interactive computer training program would reduce the isolation considerably, 167

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, I ; i I i : I : allowing the frontier provider the opportunity to "chat" with other providers, sharing cases and unique aspects of their practices. Enhanced telemedicine should enable greater specialty consultation to be provided to remote sites, reducing the number of patients who have to travel to the city for evaluation. This maintains not only the patient in the community, but also the revenue that is generated by the visit, further strengthening the economic base. The relationship between provider and administrator was found to be a major source of dissatisfaction for both maintained and non-maintained providers. Educational institutions could address this issue through the development of educational programs focusing on these relationships using continuous quality improvement techniques that involve the entire staff and emphasize the team responsibilities of provider, administrator, and support staff in assuring that quality services are available to the residents of the area. Further, dispute resolution should be included in seminars designed for students who are nearing graduation or preparing to move to their practice sites. The educational institution could arrange for conflict management/dispute resolution training organizations to provide trainers or seminars on such topics as: understanding the causes of disputes, analyzing the causes of healthcare conflicts, privileging battles, bioethical disputes, support staff/physician/NP/P A conflicts This inclusion of conflict management/dispute resolution might result not only in a reduction of the "dissatisfiers" in a practice, but might also have a positive influence on the number and type of malpractice claims filed 168

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against providers. The relationship between the health professions educational institution and the community should extend beyond the walls of the clinic. The combined expertise and resources of the schools themselves, the departments of continuing education, and Area Health Education Centers should come together with rural development councils to address the overall issues of economic development and community leadership and the vital role they play in maintaining access to primary health care in frontier areas. In return, the health professions educational institution will be able to develop an on going relationship with a living laboratory that can support the institutions primary goals of education, research, and service. Conclusion The issues of maintaining access to primary health care in frontier areas remain complex and difficult to address. Nonetheless, this dissertation has provided some direction in terms of important elements within the comiDlmity that deserve attention. First, there must be an adoption on the part of all frontier community stakeholders of a "theory of development and maintenance" that will continue to move communities forward, rather than letting them remain stagnant while change takes place around them. Second, there must be emphasis placed on the total community and the development of a solid infrastructure based on economic development. Third, community leaders must work cooperatively with a broad variety of other state, local, 169

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. i and educational representatives in an attempt to reduce the "dissatisfiers" that are present within a community, and which negatively effect the maintenance potential of health care providers. Health care providers interested in locating in frontier areas must conduct a realistic appraisal of the needs and resources of the community, and attempt to match those needs with the needs of self and family. Health professions educational institutions should reflect this movement and become more community-based, not just in developing community-based educational experiences, but in being in a service relationship with communities in the broader sense, working to assure that support mechanisms are in place that will reduce the "dissa.tisfiers" related to the business management and coverage aspects of the practice. Curricular enhancements such as greater emphasis on team approaches to health care and the inclusion of dispute resolution techniques should be considered to increase the likelihood of success for all graduates. Emphasis should continue to be placed on recruitment of students from rural areas, but even greater emphasis must be placed on the development and enhancement of educational techniques that will allow students to receive the major portion of their training in their home or nearby community, providing for career advancement without spending long periods of time away from their home community. Finally, policy makers should assure that a comprehensive approach is applied to the concept of community infrastructure building. By reducing the number of special projects, and increasing the emphasis on systems that blend the resources of the entire community, the support structure necessary to maintain access to primary health 170

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' I care in frontier areas will be enhanced. Too often complex social problems are examined through the use of only one research technique with the result being a conclusion that may be applicable to only one segment of the problem. In the case of access to primary health care in frontier the issues include the characteristics of the the characteristics of the providers, the geography, the culture of the area and of the providers, and the very personal and private aspects of the delivery of health care services. This study bas combined quantitative and qualitative techniques in examining the characteristics of both the communities and the providers. The quantitative findings of the community section showed that socio-economic status (per capita income and perception of economic strength) and community leadership were the most important factors in determining whether a community would be successful in maintaining a health care provider. Although the quantitative findings of the provider component did not serve to confirm previous studies, the qualitative section was more useful in identifying factors that lead to job satisfaction or dissatisfaction. From these recommendations for improving the community leadership and socio-economic status can be made. Further, ways to reduce the in a practice or community and enhance the maintenance ofNP/P As have been suggested. The findings clearly indicate that access to primary health care is not the province of one group. Rather, it requires the full commitment of all stakeholders. This includes organizations at state, and local levels who are working to recruit health care providers, community organizations who are working to bring 171

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business or industry to an state and national governmental agencies whose mission is to improve access to primary health care7 but primarily7 the responsibility rests with the community and its leaders to identifY the and exercise the leadership necessary to obtain assistance in achieving their goal of maintaining access to primary health care. By focusing on strengthening the infrastructure of the community and concentrating on the development of systems of care that can sustain providers in frontier areas, perhaps there will be more providers who will descn"be their experiences in words such as these: ... part of this rural practice-what makes it worth staying-you run the full gamut-I've delivered two babies in the middle of the night. I've helped, or sat with some people over a hundred years of age when they died and with their families. It's the whole gamut in between. Everything from the little babies, taking care of their ear infections to their snotty noses and sore throats on up to putting the young ladies on birth control pills so they don't start having babies too soon, to taking care of folks and getting them referred to the right areas if they need surgery, up through the ages and taking care of grandmas and great grandchildren. It's just that whole gamut of medicine that makes it worth staying. These are the words of a PA who has been in his community for twelve years. The challenge is to develop the support system and find the person who will go to another frontier community, and twelve years later, demonstrate a continuing commitment to the community by making a similar comment. Anything less would be to sentence frontier areas to a loss of access to primary health care. 172

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APPENDIX A State Representatives Who Assisted in the Study COLORAQO Lindy Nelson, Director Denise Denton, Director MONTANA Frank Newman, Ph.D. Director Jennifer A. Kreuger, PA-C President, Montana Academy of Physician Assistants NQRlliDAI(QTA Mary Amundson Coordinator SOUTH DAJ(OIA Rebekah Craddock, Assistant Director liTAH Abby Grayzel Acting Coordinator WYOMING Nancy Bender Caiola Executive Director Jane Cassel, PA-C Assistant Lecturer NEBRASKA Tom Rauner Research Analyst Office of Rural & Primary Health Policy and Planning Colorado Dept. of Public Health and Environment Colorado Rural Health Center Montana .Area Health Education Center (Now retired) University of Montana, School of Phannacy and Allied Health University of North Dakota Center for Rural Health, Primary Care Office Dakota Association of Conummity Health Centers Bureau of Primary Care and Rural Health Systems State of Utah Dept. of Health (currently with the Utah AHEC) Wyoming Health Resources Network, Inc. University of Wyoming Family Practice Residency Program Nebraska Office of Rural Health (Identified pilot communities) 173

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. I APPENDIXB Example of the cover letter and copy of the Community Survey 174

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I i I I ; I i i i I I FIELIX2) Dear FIELD(3) BARBARA E. BAILEY, RDH, MA 10477 EAST WEAVER CIRCLE ENGLEWOOD, CO 80111 December 29, 1995 I always approach unsolicited mail from unknown persons with extreme reserve, so let me quickly introduce myself. My name is Barbara Bailey and you were identified by John Mengeohausen as a community leader who might be willing to assist me in a research study that is a part of my doctoral dissertation at the University of Colorado. When I'm not engaged in dissertation research, I work for the U.S. Public Health Service where one of my responsibilities is to try to assist communities, such as Howard, in maintaining health care in their areas. My particular area of interest is the "frontier," those sparsely populated areas that have to struggle a little harder to maintain services. I am engaged in a study of frontier areas that have been successful in maintaining heahh care services compared with similar communities that have been less successful in maintaining such care. The second aspect of the study is to complete interviews with health care professionals who have remained in frontier areas for three or more years compared with those who tried working in such a community, but left in less than three years. The intent is to identify characteristics that would be of assistance to both communities and health care professionals in their attempts to match people and places in a way that will insure that health care services continue to be available to the most wlnerable of our rural areas. This study is being conducted in frontier areas in the states of CO, MT, ND, SD, UT, and WY, and your community was identified by Rebekah Cradduck of the State Primary Care Association as a good place to include. Enclosed is a Community Survey that should take less than 30 minutes, probably 15 to 20 minutes, to complete. Please be aware that the findings will be applicable to all frontier commimities, and I will be happy to share them with you upon completion of the study. Your responses will be kept confidential, and your name should not be included unless you wish me to respond to some question you might have. Again, thank you for your assistance. If you could take a few minutes to complete the survey and return it in the enclosed envelope by lanuaiY 12. I would appreciate it very much. Sincerely, Barbara E. Bailey, RDH, MA 175

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COMMUNITY SURVEY I This survey is being conducted as a part of a study to determine the characteristics of communities in low population areas that enable them to maintain health care services. Your answers will be kept in confikt nee and will not be traceable to you. Your candid responses will be beneficial, not only to your nity, but to other small areas facing loss of health care sen:ices. Your participation is greatly appre iated. I NOlJ : Your "community" for purposes of this survey. means the town in which you live a d the immediately sunounding area. "Household" includes family members and any othf living in your home for whom you have responsibility. I 1. I I I I I I I I I 2. i 3. i List the age and circle the sex of the members of your household including yourself. M = male F = female AGE First, yourself SEX M F M F M F M F AGE SEX M F M F M F M F How many people do you estimate live in your community? AGE SEX M F M F M F M F Approximately how far do you live from the next larger town. and how long does it take you to get there 7 ___ miles minutes ---4. What is your household's primary source for the following goods and services (please check the most frequently used location) 7 local means located in your community as defined above. OK= Don't Know and NA =Not Available. NON GOOD OR SERVICE LOCAL LOCAL OK NA gasoline groceries clothing shoes medical care hospital services county health office restaurant fast-food franchise ambulance long term carelnursing home pharmacy physician nurse practitioner/ physician assistant public library college courses 176

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: I i 5. Please rank the five services you think are most important to have available in your community. Give a 1 to the most important item, 2 to the next most important, and so on until you have selected five. Ambulance service Emergency Room Health Education (for prevention of disease) Laboratory Long Term Care (nursing home) Pharmacy Physical Therapy Primary Care Provider (Physician, nurse practitioner, physician assistant) Obstetrical care Overnight hospital beds Specialty physicians Surgery X-ray 6. Do you have health insurance? Circle one answer. 1 ) YES Complete questions 7 & B. 2) NO Skip to question 9 below. 7. If yes. please name your coverage. Circle one answer. 1 ) Medicare (includes supplemental policy) 2) Medicaid 3) Private Insurance (please name:. _____ 4) Otheri.e . VA: __________ 8. If you have private insurance. who pays the premium? Circle one answer. 1) Employer pays 2) You or your family pays 3) Employer and family share the premium cost 9. Approximately how many medical care visits have members of your household made during the past year to physicians or nurse practitioners/physician assistants? Do not count visits occurring before you lived in this community. Please indicate whether the visit was LOCAL or NON-LOCAL. Local Non Local PHYSICIAN VISITS 177 NURSE PRACTITIONER/PHYSICIAN ASSISTANT VISITS Page 2

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10. Did household members visit primary care providers (physicians, nurse practitioners, physician assistants) outside your community during the past two years? 1 ) YES: Please complete questions 11 and 12. 2) NO: Skip to question 13 below. 11. Why did household members seek health care outside the community? a) Services/specialty is not provided locally b) Quality of services is better elsewhere c) Services are cheaper elsewhere d) Referred by local provider e) Referred by non-local provider f) Takes too long to get appointment with local provider g) Insurance requires it h) More privacy with non-local providers i) Wait in office to see local provider too long j) Don't like personality or style of care of local provider k) Told by someone not to use local provider (poor reputation) For each reason, circle 1 or 2: Yes, a Reason 1 1 1 1 1 1 1 1 1 1 1 Nota reason 2 2 2 2 2 2 2 2 2 2 2 I) Other-Why? _______________ 12. Please list the physician specialties seen outside your community, e.g., cardiologist, gynecologist, oncologist, etc. --------------13. Do you have a personal primary care provider whom you expect to care for most of your medical care needs? Circle one answer. 1) YES 2) NO -! If yes, where do you see your personal primary care provider? Please place an "X" in the appropriate box. Physician NP or PA Local Non-Local Page 3 178

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; I I i 1 How would you rate each of the following aspects of the overall medical care provided in your community? Circle one answer in each row. OK = Don't Know and NA = Not J Available. EXCELLENT GOOD FAIR POOR Quality of medical treatment 1 2 3 4 OK NA Concern/compassion for patient 1 2 3 4 OK NA Reasonableness of charges 1 2 3 4 OK NA Night and weekend availability 1 2 3 4 OK NA e) Ability to get appointment quickly 1 2 3 4 OK NA Ability to see provider promptly i at scheduled hour 1 2 3 4 OK NA g; Friendliness of office staff 1 2 3 4 OK NA h) Attractiveness of clinic space I and waiting room 1 2 3 4 OK NA ., i I i bility to see my choice of i provider 1 2 3 4 OK NA I i 1p How satisfied are you with each of the following kinds of healthcare in your I community? Circle one answer in each row. DK = Don't Know and NA = Not I Available. i I I Very Scmewhet Indifferent Somewhat Very I Satldied Satlofled Diaetl.tled DinWdled I all Local Clinic 1 2 3 4 5 OK NA Dentists 1 2 3 4 5 OK NA c)! Pharmacy Services 1 2 3 4 5 OK NA d): Ambulance Service 1 2 3 4 5 OK NA ell Counseling 1 2 3 4 5 OK NA I f) lcoholism Treatment 1 2 3 4 5 OK NA g)i Hospice Care 1 2 3 4 5 OK NA hll Home Health Care 1 2 3 4 5 OK NA i) i bstetrical Care 1 2 3 4 5 OK NA j)i utrition Counseling 1 2 3 4 5 OK NA i i I I 16. How satisfied are you with these services for the elderly in your community? Circle I one answer in each row. OK = Don't Know and NA = Not A vailab/e. i Very Somewhat Indifferent Scmewhet Very I Seti.fied Setldied Dinatldied Diaatldled I a)! enior Center (s) 1 2 3 4 5 OK NA b) l eals on Wheels 1 2 3 4 5 OK NA c) enior Housing 1 2 3 4 5 OK NA d) i ursing Home 1 2 3 4 5 OK NA I 179 Pege 4

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17. Where would you seek care for each of the following health care needs? Place an "X" in the appropriate blank. LOCAL PROVIDER NON-LOCAL PROVIDER a) ken arm b) f! gnancyldelivery c) eumonia hospitalization d) A pendix surgery e) ntal health counseling f) lE neral physical exam I 1 8. 1 Please use the following scale to evaluate your community as you see it today as a i place to ... Circle the appropriate response in each row. l i I a) se children b) rn a living c) op d) est your savmgs e) ild a new house f) st rt a business g) g t an education h) rr ire 1 Very Good 1 1 1 1 1 1 1 1 Good Fair Poor 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 No Opinion 5 5 5 5 5 5 5 5 The j oil owing questions address factors that have been found to be helpful in examining ove'l II community issues. Please indicate, by circling one number in each row whether you agrB, or disagree with the following statements using a scale of 1 to 5 with 1 meaning that you ; trongly agree and 5 meaning you strongly disagree. l i i 19. i I I 20.1 I I I 21. i 22. 23.1 STRONGLY AGREE Residents of our community voice opinions on medical care issues. Elected officials in our community support public policy changes that 1 will enhance medical care. 1 Members of community boards and commissions represent all community residents. 1 Our community leaders champion medical care issues. 1 Our local leaders are planning for the long-term health care needs of the community. 1 180 NEUTRAL 2 3 2 3 2 3 2 3 2 3 STRONGLY DISAGREE 4 5 4 5 4 5 4 5 4 5 Page 5

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I STRONGLY NEUTRAL STRONGLY AGREE DISAGREE I I There is an effective network 24., of volunteer organizations that I work together on health care issues. 1 2 3 4 5 I 25, I There is a community-sponsored I program to provide support for students entering health professions education. 1 2 3 4 5 i I 26. I Our local merchants foster a i spirit of volunteerism among I I their employees. 1 2 3 4 5 I All groups in our community 27. i I have access to primary care I services. 1 2 3 4 5 I If not, please identify those groups without access to care. e.g., children, elderly, i I I 28. 29. i i I I I I I low income. There is an organization within our community that plays a role in convening community problem-solving efforts. Our community actively enters into cooperative agreements with other communities to solve health care problems. 1 1 2 3 4 5 2 3 4 5 almost done! Just three more questions of a more personal nature; but they are y important to the survey (and will be kept strictly confidential). Please answer them and t en mail the survey today! 30, How long have you lived in this community? ___ years 31 Which of the following categories best describes your yearly total household income 7 Circle one answer. 1 l less than $1 5,000 4) $35,000-49,999 2) $15,000-24,999 5) $50,000-74,999 3) $25,000-34,999 6) more than $75,000 181 Page 6

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:I I I i I : I I 32. i ace I I I I I Which of the following best describes your racial or ethnic identification? Circle one answer. 1) Black 4) White 2) Hispanic 5) Asian/Pacific Islander 3) Native American 6) Other Please specify: _______ would like to provide additional comments on your community's ability to maintain to primary care services, please do so on the back of this form. Thank you for your helo. Please return your questionnaire in the enclosed envelope to: Barbara E. Bailey 10477 East Weaver Circle Englewood, Colorado 80111 182 Pege 7

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APPENDIXC Example of the Provider Interview Instrument 183

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' i I MAINTAINED PROVIDER INTERVIEW I Thank ypu for agreeing to talk with me about your experiences in ( name of community l. This interview is part of a study that tries to identify characteristics of frontier communities that enable them to in primary care services, and also, some of the characteristics of nurse practitioners and physiciah assistants who maintain practices in these areas. This interview will take 45 minutes to one I hour anc consists of a series of standardized questions designed to provide a basis for comparison among roviders followed by some very open-ended questions that ask you to describe some of your experien es. All of the information will be kept strictly confidential, and responses will be used only in the aggrrgate, with the exception of the use of some specific experience information. However, no informatlc n will be traceable to the source. I Name: NP or PA Age: ___ Marital Status: __ 1. did you receive your NP/PA training? ------------------1 2. When did you begin practicing in ________________ ? Date: ____ i 3. Are were) you there as part of a scholarship or loan repayment obligation? I If yes, was your obligation NHSC? Yes No How long? If no, describe---------------Yes No i 4. Is you employer 1) a private physician; 2) a hospital; 3) a community board; 4) other ? l I I 5. 'd like to learn about the population of where you grew up and where you are currently g. I will give you some ranges, so we don't have to be exact. l i a) vou grew up b) your spouse grew til c) size current location d) size smallest town you e ever lived in e) size or largest town you ha' e ever lived in provide specific number I Less than *2,500 2,500 to 10,000 10,000 to 50,000 50,000 to 100,000 Greater then 100,000 6. your NP/PA training, did you have a rural rotation or rural experience? Yes No OK OK OK OK OK ltes, describe:-----------------------------! 184 Page 1

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you chose to practice in _____ what were the three most important factors you ? a First: b Second: ____________________________________________________________ ___ c Third: 8. How ould you characterize your present workload in terms of both hours and patients per hour? I al ours per week: Much too Somewhat About Somewhat Much too few too few right too many many I I I bi Patients per hour: Much too Somewhat About Somewhat Much too i few too few right too many many I i 9. ing to list several characteristics of communities, and I'd like you to tell me how you would describe! our level of satisfaction with each. The categories for response are: l Satisfied Dissatisfied Popuj Vea somewhat Neutral Somewhat Very a) tion of community 1 2 3 4 5 OK NA b) Recre tional opportunities 1 2 3 4 5 OK NA c) Com unity Church 1 2 3 4 5 OK NA d) ment for Children 1 2 3 4 5 OK NA e) ance of Spouse 1 2 3 4 5 OK NA n Spous 's professional needs 1 2 3 4 5 OK NA J of schools 1 2 3 g) 4 5 OK NA h) Cult r 1/social opportunities 1 2 3 4 5 OK NA i) r of peers available to relate, o intellectually 1 2 3 4 5 OK NA j) Econd ic base of community 1 2 3 4 5 OK NA k) Locati n near family/friends 1 2 3 4 5 OK NA I n Comm nity values 1 2 3 4 5 OK NA I i 10. Ov1 all, how satisfied are you with the community in which you currently live? 1 Very fied 2 Somewhat satisfied 3 Neutral 4 Somewhat dissatisfied 5 Very dissatisfied 11. rried, how satisfied would you say your spouse is with the community overall? NA 1 V'Y sjt ofied 2 Somewhat oet;ofied 3 Neutrol 4 Somewhat d;.,at;ofied 6 Ve"f d;ssat;sfoed 1 2. Abd t how many different health care providers would you say you interact with during an average weet on a professional basis? kinds of providers are these, e.g. other NPs or PAs, physicians, dentists, specialists, physical ists,etc.? ____________________________________________________________ __ i i i 185 Page 2

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i 13. NO Do your consulting physician live in the town in which you currently practice? YES If! ot, how far away is your consulting physician located? miles ___ minutes 14. Hot many consulting physicians have you had in your current professional position? 15. ximately how many hours per week is your consulting physician on-site at your practice loca ion? I Is ttl rea hospital in your community? If! es, how many beds? 16. YES NO If! o, how far away is the closest hospital? ____ miles ____ minutes i 17. ximately how many clinic hours do you spend in each of the following activities during a 18. typ cal week? aJ b) c) dJ eJ f)l gl I irect Inpatient care irect outpatient (ambulatory) care upervision of other providers dministration onsulting with physician n-call ther: ____ In al ypical week, how many patients do you see? I I I HOURS 19. Novv I'd like to ask you about some specific aspects of your practice-how satisfied or dissatisfied you mayj e with them. Again, I stress that your responses are strictly confidential. The responses are: I Satisfied Dissatisfied I Ve!J! somewhat Neutral Somewhat Ve!J! a) Relatj nship with consulting 1 2 3 4 5 OK NA physi ian b) Quali' of care provided by 1 2 3 4 5 OK NA i lting physician cons c) ility of physician 1 2 3 4 5 OK NA I d) r of other providers in 1 2 3 4 5 OK NA com unity I e) Salary 1 2 3 4 5 OK NA f) Levell f responsibility 1 2 3 4 5 OK NA g) of services you are 1 2 3 4 5 OK NA allo, d to provide h) f personal stress 1 2 3 4 5 OK NA i) Profe ional acknowledgement & rec nition 1 2 3 4 5 OK NA j) Workl1 d/available leisure time 1 2 3 4 5 OK NA k) Opp r unity for continuing 1 2 3 4 5 OK NA mecq al education I) Oegr : of autonomy you are 1 2 3 4 5 OK NA able\ o exercise 186 Page 3

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i I I I Satisfied 19. (co1' ) I m) On-q: II schedule 1 somewhat 2 n) OppQ tunity for professional 1 gro h and development o) Rela i nships with other staff 1 p) Man ement/Administration of 1 q) r) 1 1 2 2 2 2 2 Dissatisfied Neutral Somewhat Very 3 4 5 DK NA 3 4 5 DK NA 3 4 5 DK NA 3 4 5 DK NA 3 4 5 DK NA 3 4 5 DK NA 20. Do ou have a formal linkage with a health professions educational institution that allows regular eraction with faculty and students? YES NO es, is this a Faculty appointment? Serve as preceptor? Other: ___ YES NO YES NO 21 W t is the highest degree you currently hold? 1) None 2) Associate 3) Baccalaureate 187 4) Masters 5) Doctoral 6) Other: ____ Page 4

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I I We completed the standardized portion of the questions. Now it is time for you to have a chance to just k about your experience. I would like for you to think about a time when you felt exceptionally good or IE xceptionally bad about your current job. This can be either "long range" in that it occurred over several onths or years. Or it can be "short range", occurring as a single incident. Please tell me what happen that was either exceptionally good or bad. Prom t uestions: I 1. Ho1 ong ago did this happen? 2. Ho1 ong did the feeling last? 3. his typical of what was going on at the time? I I 4. Can I ou tell me more precisely why you felt the way you did at the time? I 5. WhJt did these events mean to you? I I 6. Did f ese feelings affect the way you did your job? How? How long did this go on? i 7. Can u give me a specific example of the way in which your performance on the job was affected? i 8. Did* at happened affect you personally in any way? For how long? Did it change the way in which u got along with people in general or your family? did it affect your sleep, appetite, digestion, I neral health? 9. Did : hat happened basically affect the way you felt about working at ---------..!...? hat happened change the way you felt about your practice? How? i Now you have described a time when you felt _____ about your job, please think of another time, on during which you felt exceptionally about your job, and tell me about that time. ! Use the i arne prompt questions. I I WE ARa INISHED. Thank you for participating in this survey. Would you like to receive a copy of the findings! pon completion? YES NO If yes, ase provide your current mailing address: I I 188 Page 5

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. i I Figure D.l .. : .:, ... . ::::: :::.:. ----. :i;2mEHHld APPENDIX D. COLORADO : . : ; .... : .. :::: . . :-' -------------r .. .... ..... Community Center Cheyenne Wells Dove Creek Fairplay Lake City Limon Las Animas Trinidad County Saguache Cheyenne Dolores Park Hinsdale Lincoln Bent Las Animas Population1 1963 1128 643 387 223 1834 2481 8580 3 From U.S. Census, General Population Characteristics, 1990 189 . l Pop Per Sg Mi1 1.5 1.3 1.4 3.3 .4 1.8 3.3 2.9

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. I i Figure D. 2 .. , I Community Broadus Chester Choteau Circle Ennis Jordan Malta Red Lodge Roundup Teny MONTANA County Population Powder River 572 Liberty 942 Teton 1741 McCone 805 Madison 773 Garfield 494 Phillips 2340 Carbon 1958 Musselshell 1808 Prairie 659 190 -. ---r------1 T., I Pop Per Sq Mi .6 1.6 2.8 .9 1.7 .3 1.0 3.9 2.2 .8

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Figure D. 3 I Community Cando Elgin Garrison Hettinger McVille Rugby County Towner Grant McLean Adams Nelson Pierce NORTH DAKOTA 191 Population 1564 765 1530 1574 559 2909 I Pop Per Sq Mi 3.5 2.1 5.0 3.2 4.5 5.0

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Community County Burke Gregory Faulkton Faulk Gettysburg Potter Howard Miner Isabel Dewey Murdo Jones Onida Sully Plankinton Aurora Redfield Spink Woonsocket Sanborn I SOUTH DAKOTA I Population 756 809 1510 1156 319 679 761 604 2270 766 192 ... ... :: ... :.: .. ;;.;;;: : .. : ';::;.::: ;; ; :: ;; ; ; . ;:.: . ; : . ::; ... (-::;:: ...... ; .. : -.; Pop Per Sq Mi 5.3 2.7 3.7 5.7 2.4 1.4 1.6 4.4 5.3 5.0

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Figure D. 5 UTAH -----........... ... ,.... .. ... ............................... ". . .... ., ... .. ... . .1,' . -, ... '.l ..l -----. I -J.: i ... -: ... . . Community County Population Pop Per Sq Mi Bicknell Wayne 327 .9 Enterprise Washington 936 1.7 Green River Emery 866 2 3 Milford Beaver 1107 1.8 Moab Grand 3971 1.8 Monument Valley SanJuan 345 1.6 Nephi Juab 3515 1.7 Panguitch Garfield 1444 .8 193

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Figu!e D. 6 WYOMING Community County Population Pop Per Sq Mi Glenrock Converse 2153 2.6 Greybull BigHorn 1789 3 4 Lovell BigHorn 2131 3.4 Lyman Umta 1896 5.4 Lusk Niobrara 1504 1.0 Medicine Bow Carbon 389 2.1 Saratoga Carbon 1969 2.1 Worland Washakie 5742 3.7 194

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: i I i I APPENDIX E. Table A. I Crosstabulations of Community Data STA TIJS Status of Commtmity by COMCOP2 community cooperation COMCOP2 Cotmt Col Pet StdRes STATIJS Unsuccessful Successful Column Total poor 1 75 56.8% 1.3 57 43.2% -1.2 132 30.6% medium 2 77 45.8% -.6 91 54.2% .6 168 38.9% good Row 3 Total 60 212 45.5% 49.1% -.6 72 220 54.5% 50.9% .6 132 432 30.6% 100.00/o Chi:guare Value DF Pearson 4 56554 2 .10200 Likelihood Ratio 4.57449 2 .10155 Minimum Expected Frequency-64.778 Statistic Value ASEI Val/ASEO Phi .10280 Cramer's V .10280 Lambda: symmetric .03782 .02358 I.57ll7 with STA1US dependent .08491 .05184 I.571l7 with COMCOP2 dependent 00000 00000 STA TIJS Status of Commtmity by COMLED2 commtmity leadership COMLED2 Count Col Pet StdRes STATIJS Unsuccessful Successful Column Total poor 1 67 54.9% .9 55 45.1% -.9 122 28.2% fair 2 85 53.1% 7 75 46.9% -.7 160 37.00/o good Row 3 Total 60 212 40.00/o 49.1% -1.6 90 220 60.00/o 50.9% 1.6 150 432 34 .7% 100 .0% 195 Approximate Significance 10200 .10200

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Table A. I (Coot) Value QF Significance Pearson 7.65981 2 .02171 Likelihood Ratio 7.70014 2 .02128 Minimum Expected Frequency59.870 Statistic Value ASEI Val/ASEO Phi .13316 CramersV .13316 Lambda: symmetric .07645 .04900 1.51834 with STATIJS dependent .10377 07499 1.31269 with COMLED2 dependent 05515 .04590 l.l6960 STATUS Status of Community by CRITMASS aitical mass> 1500 CRITMASS Count Col Pet StdRes STATUS Unsuccessful Successful Column Total Chi-Square Pearson Likelihood Ratio < 1500 0 86 44.6% 9 107 55.4% .9 193 44.7% > 1500 126 52.7% .8 ll3 47.3% -.8 239 55.3% Value 2.84491 2.84881 PF Row Total 212 49.1% 220 50.90AI 432 100.0% Significance .09166 .09144 Minimum Expected Frequency94.713 Statistic Phi Cramer's V Lambda: symmetric with STATUS dependent with CRITMASS dependent Value -.08115 .08115 .03210 .061 .000 ASEI .03757 07065 .00000 196 Val/ASEO .84159 .84159 Approximate .02171 02171 Approximate Significance .09166 .09166

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: i I I Table A I (Cont.) STATUS Status of Coomnmity by ECOPERC2 perception of economic base ECOPERC2 Cowtt Col Pet StdRes STATUS unsuccessful successful Column Total Chi-Square Pearson Likelihood Ratio poor l 79 59.8% 1.8 53 40.2% -1.7 132 30.6% Minimum Expected Frequency -Statistic Phi Cramer's V Lambda: symmetric with STATIJS dependent with ECOPERC2 dependent fair good 2 3 80 53 44.4% 44.2% -.9 -.8 100 67 55.6% 55.8010 .9 .8 180 120 41.7"A. 27.8% Value 8.83165 8.87057 58.889 Value ASEI .14298 .1429 .056 .02386 .122 .05076 .000 .00000 STATUS Status of Community by INS health insurance INS Cowtt Col Pet StdRcs STATUS unsuccessful successful Column Total no 0 7 46.7% -.1 8 53.3% .1 15 3.5% yes 205 49.2% .0 212 50.8% .0 417 96.5% Row Total 212 49.1% 220 50.9% 432 100.0% 197 Row Total 212 49.1% 220 50.9% 432 100.0% DF Significance 2 .01208 2 .01185 Approximate Val/ASEO Simificance .01208 .01208 2.27654 2.27654

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. I i Table A 1 (Cont.) Chi::guare Value QF Significance Pear.;on .03604 .84944 Likelihood Ratio .03607 .84937 Minimwn Expected Frequency7.361 Statistic Value ASEI Val/ASEO Phi -.00913 CI'8JDCI"s V .00913 Lambda: symmetric .000 .00000 with STA rus dependent .0000 .00000 with INS dependent .000 00000 STATUS Status of Community by LOCRES use of local resources LOCRES Count ColPct StdRes STATUS unsuccessful successful Colwnn Total Chi-Sauare Pearson Likelihood Ratio no 0 42 54.5% .7 35 45 5% -.7 77 17.8% Minimwn Expected Frequency Statistic Phi Cnuner'sV Lambda: symmetric with STA TIJS dependent with LOCRES dependent yes Row 1 Total 170 212 47.90/o 49.1% -.3 185 220 52.1% 50.90/o 3 355 432 82.2% 100.0% Value Qf Simifigmce 1.12240 .28940 1.12308 .28926 37.787 Value ASEI Val/ASEO .0509 .05097 .02422 .02994 .79831 .03302 04070 .79831 .00000 00000 198 Approximate Significance .84944 .84944 Approximate Significance .28940 .28940

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I I I Table A I (Cont.) STA rus Status of Community by MILES30 30 miles to comm of 10000 or> MILES30 Cotmt Col Pet no yes StdRes Row 0 Total STATIJS 193 19 212 uosuccessful 50.5% 38.0% 49.1% 4 -1.1 189 31 220 successful 49.5% 62.0% 50.9% -.4 l.l Colwnn 382 50 432 Total 88.4% 11.6% 100 .00AI Value DE ignifigmce Pearson 2.n469 1 .o9sn Likelihood Ratio 2 80203 1 .09414 Minimum Expected Frequency24 537 Statistic Value ASEI VaVASEO Approximate Significance Phi .08014 .o9sn Cramer'sV .08014 .09sn Lambda : symmetric .01527 .07403 .20467 with STA TIJS dependent .01887 09132 20461 with MILES30 dependent .00000 00000 STATIJS Stanis of Community by PERCAP3 pee capita income grouped PERCAP3 Page 1 of I Count Col Pet 5000850110001 StdRes 8500 10000 &> Row STATIJS 1 2 3 Total Ill Rn ll.d '>I'> unsuccessful 30 .00;{, 37.4% 72 .2% 49. 1% -2 1 -2.4 4.1 42 134 44 220 successful 70 .0% 62.6% 27.8% 50 .94'/o 2 1 2.4 -4.1 Colwnn 60 214 158 432 Total 13.9% 49 .5% 36 .6'* IOO.Oo/t 199

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Table A. I (Cont.) Value DF Significance Pearson 54.10923 2 .00000 Lilcelihood Ratio 55.61679 2 .00000 Minimmn Expected Frequency 29.444 Approximate Statistic Value ASEI Val/ASEO Significance Phi .35391 .00000 Cramer's V .35391 .00000 Lambda: symmetric .24186 .04988 4.41470 with STA TIJS dependent .33019 .04853 5.78024 with PERCAP3 dependent .15596 .05870 2.45807 200

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STATIJS by GREWUP GREWUP Count Col Pet StdRes STATUS NonMaintained Maintained Column Total Chi-Souare Pearson Likelihood Ratio <2500 I 3 30 .00A! -.9 7 70.0% .9 10 33.3% Minimum Expected FrequencyAPPENDIXF TableA2 Crosstabulations of Provider Data 250010000 10,000-50000 50,000100000 > 100,000 ' 2 3 4 5 6 2 I 3 60.00.4 50 .00.4 100. 0% 60.00.4 .4 .0 7 .3 4 2 0 2 40.0% 50.0% .0% 40.0% -.4 .0 7 -.3 10 4 1 5 33.3% 13.3% 3.3% 16. 7% Value OF Sigoifi!d!!!ce 3.20000 4 .52493 3.63602 4 .45150 .500 Cells with Expected Frequency < 5 -6 of lO ( 60.00A!) Approximate Statistic Value ASEI Val/ASEO Significance Phi 32660 .52493 Cramer'sV .32660 .52493 Lambda : symmetric .20000 13352 44810 with STATUS dependent .26667 18053 1.30005 with GREWUP dependent .15000 13829 1.01710 201 Row Total 15 50 .00.4 15 SO.OOA! 30 lOO.OOA!

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Table A2 (Cont.) STATUS Status by MEOCM2 supportive medical comnumity MEDCM2 Count Col Pet StdRes STATUS N on-Maintained Maintained Colwnn Total C!--Pearson Likelihood Ratio no 0 3 60.00/o .3 2 40.00/o -.3 s I6.7% Minimmn Expected Frequencyyes I2 48.00/o -.I 13 S2.00/o .I 25 83.3% Value .24000 .24137 2.500 Cells with Expected Frequency < S 20F Statistic Phi Cramer'sV Lambda: symmetric with STATUS depelldent with MEDCM2 dependent STATUS by OUIDOOR OUIDOOR Cotmt Col Pet StdRes STATUS Non-Maintained Maintained Colwnn Total Chi-Square Pearson Likelihood Ratio no 0 9 60.00/o .s 6 40.00/o -.5 IS 50.00/o Value .08944 .08944 .OSOOO .06667 .00000 yes 1 6 40.00/o -.5 9 60.00/o .S I5 50.00/o Value 1.20000 1.20813 Minimum Expected Frequency7.500 DF Row Total IS 50.00/o IS 50.0% 30 IOO.OO/o 4( SO.O%) ASEI .24372 .32203 .00000 Row Total IS 50.00/o IS 50.00/o 30 IOO.OO/o D:f 202 Sicrnificance .6242I .62322 Approximate Val/ASEO .20013 .20013 Significance .27332 .27170 Sirnificance .6242I .6242I

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Table A. 2 (Cont) Statistic Value ASEI Phi .20000 CI'IIIDCI'sV .20000 Lambda : symmetric 20000 .2ll66 with STA lUS dependent .20000 .23094 with OUIDOOR dependent .20000 23094 STATIJS by Al.ITORESP ( autonomy/responstbility) Al.ITORESP Count Col Pet StdRes STATIJS Non-Maintained Maintained Colwnn Total Chi-Square Pearson Likelihood Ratio very satisfied 1 8 47.1% -.2 9 52.9% .2 17 56.7% Minimum Expected Frequencysomewhat neutral satisfied 2 3 4 I 50.00.41 33.3% .0 -.4 4 2 50.00.41 66.7%, 0 4 8 3 26.7% 10.00/t, Value DF 2.39216 4 3.I7l24 4 .500 CeUs with Expected Frequency< 5 80F 10 ( 80 0%) Statistic Value ASEI Phi .28238 CI'IIIDCI'sV .28238 Lambda : symmetric 07143 I5357 with STAlUS dependent .13333 .21756 with Al.ITORESP dependent .00000 .00000 203 Approximate VaYASEO 87706 .78246 .78246 somewhat d .sfied ISS8b 4 I IOO.O% .7 0 .OOA -.7 I 3 3% Significance .66405 .52959 Approximate VaYASEO .44871 .44871 Significance 27332 .27332 very dissatisfied 5 I 100.00/o .7 0 0% 7 1 3 3% Significance 66405 66405 R ow Total 15 50.00/o 15 50.0% 30 100.00/o

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I I Table A. 2 (Cont.) STATIJS by ACKREG (prof recognition & acknowledgement) ACKREG C01mt Col Pet StdRes very satisfied somewhat neutral satisfied STATIJS I 2 3 Non-5 3 2 Maintained 38.5% 50.0010 66 7% 6 .0 .4 Maintained 8 3 I 61.5% 50.0% 33. 3% 6 .0 -.4 Colmnn I3 6 3 Total 43.3% 20.0010 IO.OOAI Chi::Sguare Pearson 1.69231 4 Likelihood Ratio 1.71798 4 Minimmn Expected Frequency1.000 Cells with Expected Frequency < 5 80F 10 ( 80 0%) Statistic Value ASE1 Phi .23751 Cramer'sV .23751 Lambda: symmetric 09375 .10782 with STAlUS dependent .20000 .21499 with ACKREG dependent .00000 .00000 STATUS by RURROT (Rural Rotation) RURROT Count Col Pet yes no StdRes Row STAlUS 2 Total Non6 9 15 Maintained 40.0% 60.0% 50.00AI 5 .5 Maintained 9 6 15 60.0% 40.0% SO.OOAI 5 -.5 Column IS 15 30 Total 50. 0% 50.()% 100.00AI Value DF Pearson I 20000 Likelihood Ratio 1.20813 Minimum Expected Frequency7.500 204 somewhat dissatisfied 4 4 66.1'110 .6 2 33.3% 6 6 20.0010 Sii!Difigmce .79211 78745 Approximate Val/ASEO 84182 .84182 Sitmificance .27332 .27170 very dissatisfied 5 I 50.0010 .0 I 50 .0010 0 2 6 7% Significance .792ll 79211 Row Total I5 50. 0% 15 50.0010 30 IOO.O%

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. I Table A. 2 (Cont.) Statistic Phi Cramer'sV Lambda: symmetric with STA TIJS dependent with RURROT dependent STATUS by SALARY SALARY Count Col Pet very StdRes satisfied STATUS 1 Non-I Maintained 20.00AI -.9 Maintained 4 80.00/o .9 Column 5 Total 16.7% Pearson Likelihood Ratio Minim.tm1 Expected FrequencyValue -.20000 .20000 .20000 20000 .20000 Approximate ASE1 .20133 .23094 .23094 somewhat neutral satisfied 2 3 4 2 33.3% 100.0% -.8 1.0 8 0 66.7% .00/o .8 -1.0 12 2 40.()% 6.7% Value DF 9.96667 4 11.46106 4 1.000 Cells with Expected Frequency < 5 -80F 10( 80.0%) Approximate Statistic Value ASE1 Phi .57639 Cramer's V .57639 Lambda: symmetric .33333 .15907 with STA TIJS dependent .53333 .20367 with SALARY dependent 16667 .16820 205 Val/ASEO .93934 .78246 78246 somewhat dissatisfied 4 7 87.5% 1.5 1 12.5% -1.5 8 26.7% Sisnifi!d!!!ce .04099 .02184 Val/ASEO 1.86023 1 89264 .91713 Significance 27332 .27332 very dissatisfied s l 33.3% -.4 2 66.7% .4 3 10.0% Simificance .04099 040991 Row Total 15 50.00/o 15 50.0% 30 100.00/o

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. Table A 2 (Cont) STA TIJS Status by CULSOC CULSOC Count Col Pet StdRes STATIJS Non-Maintained Maintained Column Total Pearson Likelihood Ratio very satisfied 1 2 66 .7"/o 4 1 33 .3% 4 3 10.0% Minimum Expected Frequency somewhat neutral satisfied 2 3 1 1 12.5% 100.0% -1.5 7 7 0 87.5% .()% 1.5 -.7 8 1 26 7% 3 .3% Value m: 12.16667 4 15.44078 4 .500 Cells with Expected Frequency < 5 80F 10 ( 80.0%) Statistic Value ASEI Phi .63683 Cmmer'sV 63683 Lambda: symmetric .27273 19319 with STATUS dependent .53333 .20367 with CULSOC dependent .05556 .26995 206 somewhat dissatisfied 4 5 41.7"/o -.4 7 58.3% .4 12 40.0% SiKDiligmce .01615 .00387 Approximate Val/ASEO 1.24449 1.89264 .20013 very dissatisfied 5 6 100.0% 1.7 0 .0% -1.7 6 20.0% Significance 01615 .01615 Row Total 15 50.0% 15 50 .0% 30 100.0%

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Table A 2 (Cont) STAniS by DISHOSP (Distance to Hospital) DISHOSP Count Col Pet StdRes STAniS Non-Maintained Maintained Column Total Pearson Likelihood Ratio 0 miles 1 2 25.0% .4 6 15.0% -.4 8 26.7% Minimwn Expected FrequencyI to 30miles 2 5 62.5% -1.5 3 37.5% 1.5 8 26.7% Value 19.33333 25.99979 .500 Cells with Expected Frequency< 5 70F Statistic Value Phi .80277 Cramer's V .80277 Lambda: symmetric .29730 with STAniS dependent .73333 with CULSOC dependent .00000 31 to 60miles 3 6 60.0% .7 4 40.00/o -.7 10 33.3% QF 16 16 10 ( 80.0%) ASE1 .07630 .13333 .00000 207 6I to 100 miles 4 I 33.3% -.4 2 66.7% .4 3 10.00/o .25176 .05403 Approximate Val!ASEO 3.32166 3.32166 > lOOmiles Row 5 Total 1 15 100.0% 50.0% 1.7 0 I5 .0% 50.0% -1.7 1 30 3.3% 100.0% Significance .25176 .25176

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N 0 00 APPENDIXG HERZBERG'S FACTORS APPLIED TO MAINTAINED AND NON-MAINTAINED PROVIDERS Achievement Getting nn dafibrillatora for arra(+) Automobile wreckaaved livea(+) T-Worlt in the Clinic(+) Peedt>aelt fraa patienta and faa111ea(+) Able to aCCCIIpl1ah am.thing and Mite a cUUenonce(+) RaJ.aing .,.,Ill' for the cliDJ.o ( +) Hit 011 a diag11oaia that a d.t.fficlllt to identUy(+) Ability to help people ata:r ill their awn ..-DJ. tiea for cano(+) Advancement RecocpU.tion Bxpre .. iona Of appreciation(+) Walk down atzeet and be greeted "hi doc"(+) Workillg on national caBitt .. a (+) ec-nity acceptance(+) Appreciation(+) llecogn1tio11 and eppreciation frca patienta (+) &apport, 1Dvolv-t love of ;people ill the -uty baa .. .se--tt.d to the ..-DJ.ty(+) Volutaera to WOEk with oliDJ.o pzoj.ata(+) Recognhed aa CC!IIIp8tent and able to deal with aitutiona (+) Lack of acceptance() Laelt of J:8009Il1 tion on part of phyaiciana(-) Acceptance by ..-DJ.ty(+) .Apprec1ation (+) Truat of the patienta(+) INTRINSIC FACTORS Maintained Providers Work It8elf Di&gllcaed cancer and patient arranged appropriate care(+) Bvery t.u. l'a a!le to help a patient Mite rigllt deciaicna and averyth111g goea well(+) Heart attaelt, we
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__:___:__:::_::.:.:..:.:.-=--==-=== = ======-=-:.:::..::.:::..: = -= =-=--= -= ==:.:..::..:. .::..::..::. -= ::::._:_:::.:.::: = = -== = =--==::..: = --=-=-= -........ ------N 0 \0 Non-Maintained Providers Achievement Recopldon Work ltaelf Relponstwnty a.d 90il lor the cllliic and JiiilliiCilatlon lrca patlenta(+) Be1ng aJUe to cue tor patlenta(+) I waa contdllutlng in a aooCIIIpUaluod til-(+) I waa only peraon wllo collld do saving a patient/b:iead(+) way othera oollldn' t(+) o jol> ac.etbiag, or in the beat oct patient and lluabend atarted on weight Too -ell napona1.bility(-) o appreciation tbinga poaitioa to acCCIIIpliah control progr-(+) to be the done() ac.etbingl ) Bavea Uvea With ablllance aeniae(+) peraon to cover at night aegative patient oatcc.eaC-1 Raga frc. P,.tientaC+) li'rOYiaion of good quality patient are(+) an4 be tnated like a Three..,. al.ive and -11 dne to .llppZWaiatioa and e
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N 0 Supervision Relat1oJtahip with Relat1o11ah1p with R8lat1oaah1p with Relat1oaah1p with Relat1oaah1p with phyaici&Jt(+) Relat1o11ah1p with pllyaiciu C-) Re1at1onah1p with playaiciu(-) RelaUo11ah1p with phyaiciu(+) Job seaurity ---------------------EXTRINSIC FACTORS Maintained Providers coq,any-l'oliay And Adminiatration Prabl-with Clill1o/ hoapital Adld.J11atrat1o11 1Uiderllined appzoaola(-) Bu-t J::r:ca Adai.JIJ.atraUon(-) Relat1onah1p oJ: !lOud with Adld.JIJ.atra tar (-) !lOud that bougllt into --=-vat(+) Probl-with Adai.JIJ.atraUoJt C-l Poa1Uve aappcu:Uve Pr1glatell1ag witlloat good aapport ayat.a(-) Poor relatioaahip with Adld.JIJ.atraUoD/ Jlo a apport C-) Adld.JIJ.atratioD aot canaiderata oJ: Jaotra(-) o DJ:rtoa help to da&l witla 1(/)1(-) l'eraonal Li:fe Law Bait, aegat1ve t.paat oa !.ally(-) Iaauea oJ: wife worlt1Jtg(-) Roara aad Call bad on family() If year family lilt it(+) L1te orrara(+) Huaband hen-peaked(-) atreaa level(-) x-diata aaceptuce(+) Naat be !.ally oriented(+) Great Place to raiae lt1da(+) Workin9 Conditions Call Bolaedule (-) u oJ: :r.oo- uat.able practice) -1 Call achedaJ.a(-) Too -IIY pta(-) IJtaclaqaata aupport Bt.J!J: (-) Lo119 Jaoara/ JIJ.ght calla,_, OVerload(-) I'OorUIUUMqaata 110 aaraiag aapport atat!C-l Bbort-hudedC) BoarD too lOIIIJ(-) Uclt oJ: C01lt1aa1ty with :r.oo-() Call BolaedaJ.a 1-1 Call Bchedala(-) Salary salary(-) Salary(-) Salary(-) J:or BR calla(-) Salary() Salary(-) Salary(-) Inteii)ersona1 Relations Relat1onah1p with at.J!f at training acllool C-) Ckaat relat1onah1p ntla otlaar at.J!J: (+) Poai tiva at.J!f can really gat gat to ltn-people(+) to gat doca to llat.aa to you C-) -.ecS -cooperation !rca phyaiciua() T work(+) other Phyaiciaa aot provid1119 good .,..,. (-) l'hyaiciU DOt provid1DIJ good cano C-l By paaai119 CliJIJ.a(-) atreaa level too hiqh be-1119 elone(-) 1'00r pbyaicien roll-up(-) Deana 1n c-JIJ.ty Support() Poor quality care by phyaiciaa (-) 1'00r qllali ty care by pbyaician(-) 1'00r care by pbyaiaian 1'00r quality care by phyaician (-) status Ralpa 11!1 '--PC+) "hi doc"(+) rigllt ap tlaere Wi tJa banltara lawyera(+)

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. -----------------------------------------------------N ..... ..... Supervision RalaU.onahip With pllyaician () RalaU.oulaip Witb pbya1c.tan(-) RalaU.onahip Witb pbya1o1an(-) llbya1c.tana aot 1a lliriag l'Aa() RalaU.onahip with pllya1o1an() RalaU.onab1p Witb pbya1o1an() Have to prove onea.U to phya1e1aa () RalaU.onahip with pbya1o1an() RalaU.ouhip With phya1c1an (+) Job Security rinaacial difficulty mainta1D1ag a clinic r.c .. or Revenue(-) 'l!reaau:e to keep clinic opeD() llaapcnaible for joba of otllll!:a() source of revenue for othera joba () II...S to draw paU.enta to Jteep cllDic opea() Non-Maintained Providen Cclqlany l'olioy Administration lxpeotaU.ona for doing too ell poor/ not ulld to D/J!Aa () pbya1o1an OriaJltlld paid too -ell for aaparv1aion(l Tao ..ay DOJI-cl.1nical upeataU.oaa C-1 lxpeotlld to wod: bayoad .copa and trainiag() ER Lim.taU.oaa aitaaU.on aot eaoagll anythiag() lxpeotlld to work beyond capability Cl Personal Life 11o U... for peraoiUll. life() llothing to do WiU faa:U:r/klda () Boua upeataU.ona too Spirit t.-work(+) Other Statu llot Accepted() Lack of Aclalowled91ant akilla(-) Lack acceptance by otber pbya1c1ana() Acceptlld aa prt.ary care provider(+) Lill1tad IR uperiancaC-1 Tt.. ca.penaaU.cn() Salary too high() IaolaU.on/no 1ateracU.on with colleagaea() Ullpr.pered for rural uperieaca rigllt out aabool(-) Ullpr.pered for the a1taaU.on, not eaough ...Uo1ne tra1D1ng() IIJIP&Ctlld too -ab for one rigllt out of achool(l Didn't knew what I waa gett1n9 into(-) Iolat1on faaily/few act1vit1 for abildrea() ...tid to be auoned J!A-.ora -tara and uperianced() IaolaU.oa() ralt pallioky dida' t knew what to do() too -all for -e rigllt oat of acllool and Without a tra-bacqrolllld() r1.rt rural uperieaca-llad to learn hew to do badgeta(-1 J!eopla not aa1ag clinic() Peopla not willing to pay for aervicea of J!A() Uaing clinic only aa laat reaart()

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' i REFERENCE LIST Aday, Lu Ann, Charles E. Begley, David R. Larson, and Carl H. Slater. 1993. Evaluatins tbe Medical Care System: Effectiveness. Efficiency, and EQ.uity. Ann Arbor: Health Administration Press. Aday, Lu Ann. 1989. Designing and Conducting Health Surveys San Francisco: Jossey-Bass. Agresti, Alan. 1996. An Introduction to Categorical Pata Analysis. New York: John Wdey and Sons, Inc. Aldrich, John H. and Forrest D. Nelson. 1984. Linear Probability. Logit. and Probit Models. Newbury Park, CA: Sage Publications, Inc. American Academy ofFamily Physicians. 1993. Facts about Family Practice. Kansas City, MO: AAFP. Amundson, Bruce. 1993. Myth and reality in the rural health service crisis: Facing up to community responsibility. The Journal ofRural Health 9 (Summer): 176-187. Amundson, Bruce and R.A. Rosenblatt 1991. The W AMI rural hospital project part 6: Overview and conclusions The Journal of Rural Health 7 (Fall): 560-574. Amundson, Bruce A, Amy Hagopian, and Deborah G. Robertson. 1991 Implementing a Community-Based Approach to StreQ&thening Rural Health Services: The Community Health Services Development Model. Rural Health Working Paper Series, Working Paper #11. Seattle: W AMI Rural Health Research Center. Anderson, David R., Dennis J. Sweeney, and Thomas A. Williams 1987. Statistics for Business and Economics. St. Paul, MN: West Publishing Company. Babbie, Earl. 1989. The Practice of Social Research. Fifth Edition Belmont, CA: Wadsworth Publishing Co. Baldwin, DeWitt C., Jr., and Beverley D. Rowley. 1990. Alternative models for the delivery of rural health care: A case study of a western frontier state. Journal of Rural Health 6 (July): 256-272. 212

PAGE 222

. i : I I Baldwin, Laura-Mae, L. Gary Hart, Peter A West, Tom E. Norris, Edmond Gore, Ronald Schneeweeiss. 1995. Two decades of experimentation in the University of Washington Family Medicine Residency Network: Practice differences between graduates in rural and urban locations. The Journal of Rural Health II {Wmter): 60-72. Bard-Lozecki, I I977. Physician's Assistants Job Satisfilction. Pittsburgh: Pittsburgh Univ., Western Psychiatric Insts. Bashshur, Rashid L., Dena Puskin, and John Silva 1995. Second invitational consensus conference on telemedicine and the national information infrastructure. Telemedicine Journal. 1 (4): 366. Bell, James, Susan Oehme Raetzman, and Laura Aiuppa. I99I. On tbe Move: Innovations in Rural Health Care DeliyeJy. Kansas City, MO: National Rural Health Association. Benner, Patricia E. I984. From Novice to Expert Menlo Park: Addison Wesley Publishing Co. Berk, Marc L., Amy B. Bernstein, and Amy K. Taylor. I983. The use and availability of medical care in health manpower shortage areas. lnquity 20 {Wmter): 369380. Bernstein, James D., Fredrick P. Hege, and Christopher C. Farran. I979. Rw:ill Health Centers in the United States. Cambridge, MA: Ballinger Publishing Co. Bicknell, W.J., D.C., Walsh, and MM. Tanner. 1974. Substantial or decorative? Physicians' assistants and nurse practitioners in the United States. The Lancet, 2: 1241-1244. Bigbee, Jeri L. 1992. Frontier areas: Opportunities for NPs' primary care services. Nurse Practitioner 17 (September): 47-48, 50, 53-54, 57. Braden, Till J. and Karen Beauregard. 1994. Health Status and Access to Care of Rural and Urban Populations. (AHCPR Pub. # 94-0031 ). National Medical Expenditure Survey Research Findings 18, Agency for Health Care Policy and Research. Rockville, MD: Public Health Service. Brayfield, Arthur H and Harold F. Rothe. 1951. An index of job satisfaction Journal Psychology 35 (October): 307-31I. 213

PAGE 223

, I I Bream, Terry and Arthur Schapiro. 1989. Nurse-physician networks: A focus for retention. Nursin& Ma1Jaiement 20 (May): 74,76-77. Brewer, Gany D. and Peter deLeon. 1983. The foundations ofPolicy Analysis. Homewood, IL: The Dorsey Press. Brooks, Edward F. and Susan L. Johnson. 1986. Nurse practitioner and physician assistant satellite health centers: The pending demise of an organizational form? Medical 24 (October): 881-890. Bronstein, J. M. and M.A. Morrisey. 1991. Bypassing rural hospitals for obstetrics care. Journal ofHealtb Politics. Policy and Law 16 (Spring): 87-120. Burner, Sally T., Daniel R. Waldo, and David R. McKusick. 1992. National Health Expenditures through 2030. Health Care Financins Review 14 (Fall):1-31. Capan, Patrice, Margaret Beard, and Mindy Mashburn. 1993. Nurse-managed clinics provide access and improved health care. Nurse Practitioner 18 (May): SO, 53-55. Cawley, James F. 1986. The Cost-Effectiveness ofPhysician Assistants. A report of the combined research committee of the Education and Research Foundation and the American Academy ofPhysician Assistants. Chatterjee, Samprit and Bertram Price. 1991. Rejp"essjoo Analysis by Second Edition. New York: John Waley and Sons, Inc. Chaulk, C.P ., R.L. Bass, and P.M. Paulman 1987. Physicians' assessments of a rural preceptorship and its influence on career choice and practice site. Journal of Medical Education 62 {April): 349-51. Christianson, Jon and Ira Moscovice. 1993. Health care reform: Issues for rural areas. Paper prepared for invitational meeting on Health Care Reform in Rural Areas. Little Rock, Arkansas (March). Chubon, Sandra J. 1991. An ethnographic study of job satisfaction among home care workers. Carlos 10 (April): 52-54, 56. Clymer, Adam. 1994. Finding, not paying, doctors is top rural health concern. 1M New York Times. February 22, 1994 214

PAGE 224

! Coburn, Andrew, Sam M. Cordes, Robert A Crittenden, J. Patrick Hart, Keith J. Mueller, Wayne W. Myers, and Thomas R. Ricketts 1994. An expert panel approach to assessing the rural implications of health care reform: The case of the Health Security Act. The Journal ofRural Health. 10 {Wmter) : 6-15. Connor, Robert A, John E. Kralewski, and Steven D. Hillson. I994 Measuring geographic access to health care in rural areas. Medical Care Review 51 (Fall): 337-377. Conte, Susan 1., Allen W. Imershein, and Michael K. Magill. I992. Rural community and physician perspectives on resource factors affecting physician retention. The Journal ofRural Health 8 (Summer): I85-I96. Council on Graduate Medical Education: Third Report. 1992. Improving Access to Health Care throuB}l Physician Workforce Reform: Directions for the 21st Century. Washington, DC: GPO. Council on Graduate Medical Education: Fourth Report. I994. Recommendations to Improve Access to Health Care Ihroush Physician Workforce Reform. Washington DC: GPO. Coward, Raymond T ., Leslie L. Clarke, and Karen Seccombe. 1993. Predicting the receipt of employer-sponsored health insurance: The role of residence and other personal and workplace characteristics. The Journal of Rural Health. 9 (Fall): 281-292. Coward, Raymond T., Claydell Home, R. Paul Duncan, and Jeffrey W. Dwyer. 1992 Job satisfaction among hospital nurses: Facility size and location comparisons. The Journal of Rural Health 8 (Fall): 255-267. DeFriese, Gordon H. and Thomas C. Ricketts. 1989. Primary health care in rural areas: An agenda for research. Health Services Research 23 (Feb): 931-974. Detsky, Allan. 1978. The Economic fnundations of National HealthPolicy. Cambridge, MA: Ballinger Publishing Co. Duhl, Leonard J. 1990. The Social Entrepreneurship ofCbange. New York: Pace University Press. Duncan, R. Paul, Karen Seccombe, and Cheryl Arney 1995. Changes in health insurance coverage within rural and urban environments-1977 to 1987. The Journal ofRural Health. II (Summer): I69-176. 215

PAGE 225

. Dunkin. Jeri., Nyla Juhl, Terry Stratton, Jack Geller, and Richard Ludtke 1992. Job satisfaction and retention of rural community health nurses in North Dakota. The Journal ofRural Health 8 (Fall): 268-75. Dyck, Sarah. 1994. Interview by author, 15 July 1994, Seattle, W A. Telephone discussion of Community Health Services Development Program Eastaugh, Steven R. and Michelle Regan-Donovan. 1990. Nurse extenders offer a way to trim staff expenses. Healthcare Financial Manaaement 44 (April): 5862. Eastaugh, Steven R. 1992. Health Economics: Efficiency. Quality. and Eqyity. Westport, Ct: Auburn House. Edwards, W. Sherman and Martha Berlin. 1989. Questionnaires and Data Collection Methods for the Household Survey and the Survey of American Indians and Alaska Natives. (DHHS Publication No. (PHS) 89-3450). Rockville, MD: Public Health Service. Eisenberg, Barry S. and James R. Cantwell. 1976. Policies to influence the spatial distnoution of physicians: A conceptual review of selected programs and empirical evidence,: Medical Care (June): 455-468. Elder, William G. and Bruce A. Amundson. 1991. The W AMI rural hospital project part 3: Building health care leadership in rural communities. The Journal of Rural Health. 7 (Fall): 511-525. Ernst, R.L. and D. E. Yett. 1985. Physician Location and Specialty Choice Ann Arbor, MI: Health Administration Press. Freeborn, Donald K. 1985. Physician satisfaction in a prepaid group practice HMO. Group Health Journal. 6:3-12. Freeborn, Donald K. and Roderick S. Hooker. 1995. Satisfaction ofPhysician Assistants and other nonphysician providers in a managed care setting. Public Health Reports. 110 (Nov/Dec): 714-719 Frenzen, Paul D. 1991. The increasing supply of physicians in U.S. urban and rural areas, 1975 to 1988. The American Journal ofPublic Health 81: 1141-47. Frenzen, Paul D. 1993. Health insurance coverage in U.S. urban and rural Journal ofRural Health. 9 (Summer): 204-214. 216

PAGE 226

' i Fryer, G.E., Curt Stine, R.D. Krugman, and T.J. Miyoshi. 1994. Geographic benefit from decentralized medical education: Student and preceptor practice patterns. The Journal of Rural Health. 10 (Summer): 193-198. Gordan, Rena J., Joel S. Miester, and Robert G. Hughes. 1992. Accounting for Shortages ofRural Physicians: Push and Pull Factors, in Wilbert M. Gesler and Thomas C. Ricketts, eds., Health in Rural North America: The Geoppby o{Health Care Seryices and Deliyezy. New Brunswick: Rutgers University Press. Gutman, Amy. 1983. For and against equal access to health care, in Ronald Bayer, Arthur L. Caplan, and Norman Daniels, eds., In Search of Equity: Health Needs and tbe Hea}th Care System. NY: Plenum Press. Hanson, Charlene M., Susan Jenkins, and Rebecca Ryan. 1990. Factors related to job satisfaction and autonomy as correlates of potential job retention for rural nurses. The Journal ofRural Health 6 (July): 302-316. Hart, L. Gary, Denise M. Lishner, and Bruce A Amundson. 1991. The WAMI rural hospital project part 5: Community perception of local health care services. The Journal ofRural Health 7 (Fall):542-559. Hartley, David, Lois Quam, and Nicole Lurie. 1994. Urban and rural differences in health insurance and access to care. The Journal of Rural Health. 10 (Spring): 98-108. Helms, L. Jay, Joseph P. Newhouse, and Charles E. Phelps. 1978. Copayments and Demand for Medical Care: The California Medicaid Experience. Santa Monica, CA: Rand Corp. Hershey, John C. and Dean H. Kropp. 1979. A re-appraisal of the productivity potential and economic benefits of physician's assistants. Medical Care XVll (June): 592-606. Herzberg, Frederick, Bernard Mausner, and Barbara B. Snyderman. 1959. Motivation to Work. New York: John Wiley and Sons, Inc. Herzberg, Frederick. 1966. Work and the Nature ofMan. New York: John Wiley and Sons, Inc. 217

PAGE 227

Hicks, Lanis L. and John K. Glenn. 1991. Rural populations and rural physicians: Estimates of critical mass ratios by specialty. The Journal of Rural Health 7 (Sup}: 357-372. Hicks, Lanis L. 1990. Availability and accessibility of rural health care. Journal of Rural Health 6 (Oct): 485-505. Hicks, Lanis L, and John K. Glenn 1989. Too many physicians in the wrong places and specialties? Populations and physicians from a market perspective. Journal ofHealth Care Marketing 9 (April}: 18-26. Hoefler, James M. and Khi V. Thai. 1993. The politics and economics of health care finance: Tough questions and no easy answers. Journal of Health and Human Resource Administration 16 (Fall): 121-143. Hoffinan, Catherine. 1994. Medicaid Payment for nonphysician practitioners: An access issue. Health Affilirs. (Fall):140-152. Hupcey, Judith E. 1993. Factors and work settings that may influence nurse practitioner practice. Nursini Outlook 41 (July-August) 181-185. Institute ofMedicine, Committee on the U.S. Physician Supply. 1996. Lohr, Kathleen N. Neal A Vanselow, and Don E. Detmer, Editors. The Nation's Physician Workforce: Options for Balancing Supply and Reqyirements. Washington, D.C.: National Academy Press. Institute of Medicine, Committee on the Future of Primary Care. 1994. Donaldson, Molla, Karl Yordy, and Neal Vanselow, Editors. Defining Prinw:y Care: An Interim Report. Washington, D.C.: National Academy Press. Jacobs, Philip. 1987. The Economics of Health and Medical Care. Rockville, MD: Aspen Publishers, Inc. Jacobs, Philip. 1991. The Economics ofHealth and Medical Care, 3rd Edition. Gaithersburg, MD: Aspen Publications. Jacoby, ltzhak. 1991. Geographic distribution of physician manpower: The GMENAC legacy. Tbe Journal ofRural Health. 7 (Supplemental): 427-436. Kindig, David A and Hormoz Movassaghi. 1989. The adequacy of physician supply in small rural counties. Health Affairs 8 (Summer): 63-76. 218

PAGE 228

. I Kletke, Phillip R., William D. Marder, and Richard J. Wtllke. 1991. A projection of the primary care physician population in metropolitan and nonmetropolitan areas, in AHCPR Conference Proceedings: Primazy Care Research: Theory and Methods. Washington, DC: GPO. Knoke, David and Peter J. Burke. 1980. Log Linear Models. Newbury Park, CA: Sage Publishing, Inc. Koelbel, Pamela Wilkie, Sara G. Fuller, and Terry R. Misener. 1991. Job satisfaction of nurse practitioners: An analysis using Herzberg's Theory. Nurse Practitioner 16 (April) 43, 46, 48, 50, 52, 55-5f5. Kralewski, John E., Yuanli Liu, and Janet Shapiro 1992. A descriptive analysis of health insurance coverage among farm families in Minnesota. The Journal of Rural Health. 8 (Summer): 178-184. Larson, Eric H., L. Gary Hart, and Jeffrey Hummel. 1992. Rural Physician Assistants: Results from a Survey ofQraduates ofMEPEX Northwest. Rural Health Working Paper Series Working Paper # 17. Seattle, W A:. W AMI Rural Health Research Center. Lawler, Therese G. and Mary C. Valand. 1988. Patterns of practice of nurse practitioners in an underserved rural region. Journal of Community Health Nursing 5:187-194. Lee, Richard C. 1991. Current approaches to shortage area designation. The Journal ofRural Health 7 (Supplemental): 437-450. Lemler, Sharon F. and Anna K. Leach.. 1986. The effect of job satisfaction on retention. Nursing Mana&ement 17 (April) : 66-68 Lewis, Charles E., Rashi Fein, and David Mechanic. 1976. A Right to Health: The Problem of Access to Primazy Medical Care. New York: John Wiley & Sons, citing President's Health Message of 1971. Washington, D.C.: The White House, 18 February 1971. Ludtke, Richard L. and Kazi Ahmed. 1990. Community Diagnostics: Methods for Local Assessment. Fargo, NO : Lutheran Health Systems. Makuc, Diane M., Bengt Haglund, Deborah D. Ingram, Joel C. Kleinman, and Jacob I. Feldman. 1991. The use of health service areas for measuring provider availability. The Journal of Rural Health 7 (Supplemental): 347-356 219

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: Marmor, Theodore R. 1973. The Politics ofMedicare. Chicago: Aldine Publishing Co. Marmor, Theodore R. and Jon B. Christianson. 1982. Health Care Policy: A Political Economy Approach. Beverly Hills, CA: Sage Publications. Marshall, Catherine and Gretchen B. Rossman. 1989. Designin2 Qualitative Research. Newbwy Park, CA: Sage Publications., Inc. Carlos J., I. Jon Veloski, Barbara Barzansky, Gang Xu, and Sylvia K. Fields. 1994. Medical School and Student characteristics that influence choosing a generalist career. Journal of the American Medical Association 272 (Sept.):661-668. Mason, Henry R. 1975. Medical school, and eventual practice location. Journal of the American Medical Association. 223 (July): 49-52. Amanda H. and John Luehrs. 1990. State Initiatives to Improve Rural Health Care. Washington, DC: National Governors' Association. Mendenhall, Robert C., Raul A. and Richard E. Neville. 1980. Assessing the utilization and productivity of nurse practitioners and physician assistants: Methodology and findings on productivity. Medical 18 (6): 609 Miller, Michael K., C. Shannon Stokes, and William B. Clifford. 1987. A comparison of the rural-urban mortality differential for deaths from all causes, cardiovascular disease and cancer. Journal of Rural Health 3 (July): 23-34. Moscovice, Ira. 1989. Strategies for promoting a viable rural health care system. Journal ofRnral Health 5 (July): 217-230. Moscovice, Ira and Roger Rosenblatt. 1979. The viability of mid-level practitioners in isolated rural communities. American Journal of Public Health 69 (May): 503-505 Mott, Frederick D. and Milton I. Roemer. 1948. Rural Health and Medical Care. New York: McGraw-Hill Company, Inc. David and Chava Nachmias. 1987. Research Metbods in the Social Sciences. New York: St. Martin's Press. National Association of County Health Officials. 1991. ArEXPH Assessment Protocol for Excellence in Public Health. Washington D.C.: NACHO 220

PAGE 230

National Health Service Corps Revitalization Amendments of 1990, U.S. Code, vol. 42, sees. 101-108. National Rural Health Association. 1994(a). Community Involvement Offers Hope to Rural Health Care Systems: A Report to the Northwest Area Fourulation. Kansas City, MO: NRHA National Rural Health Association. 1994(b ). Health Care in Frontier America: A Time for Change. Rockville, MD: Office of Rural Health Policy, Health Resources and Services Administration. National Rural Health Association. 1992. Study of Models to Meet Rural Health Care Needs Throuah Mobmrntion of Health Professions Education and Services Resowces. (DHHS Pub No. HRSA-240-89-0037) Rockville, MD: Health Resources and Services Administration. Nelson, Eugene C., Arthur Jacobs, Karyn Cordner, and Kenneth G. Johnson. 1975. F'mancial impact of physician assistants on medical practice. The New England Journal ofMedicine. 293 (1): 527. Newhouse, Joseph P. 1993. Free for All? Lessons from the RAND Health Insurance Experience. Cambridge, MA: Harvard University Press. Newhouse, Joseph P., Albert P. Wtlliams, Bruce W. Bennett, and William B. Schwartz. 1982. How Have Location Patterns of Physicians Affected the Availability of Medical Services? Santa Monica: Rand. Newhouse, Joseph P. 1978. The Economics of Medical Care: A Policy Perspective. Reading, MA: Addison-Wesley Publishing Company. Norris, Tyler. 1993. Colorado Healthy Communities Handbook. Denver: National Civic League. Norusis, Marija J. 1993. SPSS for Wmdows Base System User's Guide Release 6.0. Chicago: SPSS Inc. Norusis, Marija J. 1994. SPSS Advanced Statistics 6.1. Chicago:SPSS Inc. Office of Shortage Designation. 1996. Quarterly Report ofHealth Professional Shortage Area Statistics as ofDecember 31, 1995. Bethesda, MD: DHHS. Orloff: Tracey M. and Barbara Tymann. I 995. Rural Health: An Evolving System of Accessible Services. Washington, D.C.: National Governors Association. 221

PAGE 231

Shihua, Jeri Dunkin, Kyle J. Muus, Robert Harris, and Jack M. Geller. 1995. A logit analysis of the likelihood of leaving rural settings for registered nurses. The Journal of Rural Health. II (Spring): 106-I13. Pathman, Donald E., Thomas R. Konrad, and Thomas C. Ricketts, ill. 1994. Medical education and the retention of rural physicians. HSR: Health Services Research. 29 (April): 39-58. Pathman, Donald E., Thomas R. Konrad, and Christopher R. Agnew. I994. Studying the retention of rural physicians. The Journal of Rural Health I 0 (Summer I994): 183-I92. Pathman, Donald E. and Christopher R. Agnew. I993. Querying physicians' beliefs in career choice studies: the limitations of introspective causal reports Family Medicine 25 (March): 203-207. Pathman, Donald E. I991. Estimating rural health professional requirements: An assessment of current methodologies. The Journal ofRural Health 7: (sup): 327-346. Perry, H.B. I976 Physician Assistants: An Empirical Analysis of Their General Characteristics, Job and Job Satistaction. Baltimore: Johns Hopkins Univ., Dept of Social Relations Rabinowitz H.K. I988. The relationship between medical student career choice and a required third-year family practice clerkship Family Medicine. 20 (Mar-Apr) : II8-I2l. Record, J.C., M. McCally, S.O Schweitzer, R.M Blomquist, and B.D. Berger. 1980. New health professionals after a decade and a half. Journal of Health Politics. Policy, and Law, 5, 470-497. David M. and Kenneth R. Harbert. I99I. Measuring the financial productivity of physician assistants MOM Journal (November/December): 46-52. Rhodes, J.F. and F.A. Day. 1989. Location decisions of physicians in rural North Carolina. The Journal ofRural Health. 5 (Spring): 137-153. Riley, Katherine, Wayne Myers, and Ronald Schneeweiss. 1991. Recruiting physicians to rural practice: Suggestions for success. The Western Journal of Medicine. 155 (Nov) : 500-504. 222

PAGE 232

Riner, Mary Beth. 1989. Expanding services: The role of the community health nurse and the advanced nurse practitioner. Journal of Community Health Nursing 6 (Apr): 223-230. Root, Jan and Stuart Challender. 1993. Isochronesa method of tracking and analyzing geographic access to rural health care. (Task Force on Rural Health Policy Development Working Papers) Salt Lake City: Utah Department of Health, Bureau ofPrimary Care and Rural Health Systems. Rosenblatt, R.A and Alpert, I .I. 1979. The effect of a course in family medicine on future career choice: A long-range follow-up of a controlled experiment in medical education. Journal ofFamily Practice. 8 (January): 87-91. Rosenblatt, Roger and Ira Moscovice. 1978. The growth and evolution of rural primary care practice: The National Health Service Corps experience in the northwest. Medical Care. 16 (October): 819-827. Rosenthal, T.C., G.L. Rosenthal, and C.A Lucas. 1992. Factors in the physician practice location puzzle: a survey ofN Y State residency-trained family physicians Journal ofthe American Board of Family Practice 5 (May-June): 265-73. Rowland, Diane and Barbara Lyons. 1989. Triple Jeopardy: Rural, poor, and uninsured Health Services Research. 23 (February): 975-1004. Rural Health Clinics Act of 1977. December 13. P.L. 95-210, H.R. 8422. Safiiet, Barbara J. 1992. Health care dollars and regulatory sense: The role of advanced practice nursing. The Yale Journal on ReiJllation 9: 149-220. Sharp, Ansel M., Charles A. Register, and Richard H. Leftwich. 1992. Economics of Social Issues. Homewood, IL: Richard D. Irwin, Inc. Shi, Leiyu, Michael E. Samuels, Thomas R. Konrad, Thomas C. Ricketts, Carleen H. Stoskop( and Donna L. Richter. 1993. The determinants of utilization of nonphysician providers in rural community and migrant health centers. Journal ofRural Health 9 (Wmter): 27-39. Staub, Geoff. 1994. Special Report: Physician compensation winning at the compensation game in an era of health care reform. Hospital Physician 30 (January): 45. 223

PAGE 233

Summer, Laura. 1991. Limited Access: Health Care for the Rural Poor. Washington DC: Center on Budget and Policy Priorities Sweet. Judith B. 1986 The cost-effectiveness of nurse practitioners. Nursins Economics 4 (July/August) 190-193. Tabachnick, Barbara G. and Linda S. Fidell. 1989. Using Multivariate Statistics, 2nd CA: Harper Collins. Tilden. Nelson A and Christopher D. Tilden. 1995. Ensuring Access to Primary Health Services in Rural Areas. Kansas City: National Rural Health Association. Tourangeau, Karen and Edward P. Ward. 1992. Questionnaires and data collection methods for the Medical Provider Survey. (AHCPR Pub. No. 9200042). National Medical Expenditure Survey Methods 4 Agency for Health Care Policy and Research. Rockville, MD: GPO. Tri, Debra L. 1991. The relationship between primary health care practitioners' job satis&ction and characteristics of their practice settings. Nurse Practitioner 16 (May): 46, 49-50, 53, 55. United Way. 1990. Building Healthier Communities: The United Way. Report of the Strategic Planning Committee ofUnited Way of America. Arlington, VA: United Way of America. U.S. Congress. Senate. Special Committee on Aging. 1990. Defining the Frontier: A Policy Cballen&e;. l01st Cong., 2nd Sess., 23 July. U.S. Congress. Office ofTechnology Assessment. 1990. Health Care in Rural America, OTA-H-434. Washington, DC: GPO. U.S. Department ofHealth, Education, and Welfare (DHEW). 1976. Methodological Approaches for Detenninin& Health Manpower Supply and Requirements. (DHEW Publication No. [HR.A] 76-14512. U.S. Department ofHealth and Human Services (DHHS). 1993. Office of Inspector General. Access to Rural Health Care: Successful Community Initiatives. Washington, D.C.: GPO. 224

PAGE 234

I ; U.S. Department of Health and Human Services (DHHS). 1992. Current Estimates from the National Health Interview Survey. 1991. Series 10: Data from the National Health Survey No. 184. Hyattsville, MD: DHHS. U.S. Department ofHealth and Human Services (DHHS). 1991. Eighth Report to the President and Consress on the Status of Health Personnel in the United HRSA, Bureau ofHealth Professions. Washington, DC: GPO. U.S. Department of Health and Human Services, Health Care Financing Administration. 1987. Health Care Fmancina Review, 8 (Summer): 10, 25. U.S. Department ofHealth and Human Services, Health Resources Administration 1981. The Health Professions Requirements Model: Structure and Application. (DHHS Publication No. [HRA] 1-15. Yerby, John E. 1992. Improving the supply of physicians in rural areas. Journal of the American Medical Association. 268 (September): 1597-1598. Wagenaar, Theodore C. and Earl Babbie. 1989. Practicins Social Research Fifth Edition Guided Actiyities to Accompany The Practice of Social Research. Belmont, CA: Wadsworth Publishing Co. Weiss, David J., Rene V. Dawis, G. W. England, and L.H. Lofquist. 1967. Manual for the Minnesota Satistaction Questionnaire. Minneapolis: University of Minnesota Work Adjustment Project, Industrial Relations Center. Welch, Gilbert H., Eric B. Larson, and W. Pete Welch. 1993. Could Distance be a proxy for severity-of illness? A comparison of hospital costs in distant and local patients. HSR: Health Services Research 28 (October): 441-458. Wennberg, John and Alan Gittelsohn. 1982. Variations in medical care among small areas. Scientific American. 246 (April): 120-135. White, Catherine H. and Maureen Claire Maguire. 1973. Job Satisfaction and Dissatisfaction among hospital nursing supervisors: the applicability of Herzberg's Theory. Nursing Research 22 (January-February): 25-30. World Health Organization. 1988. WHO Healthy Cities PrQject: Promoting Health in the Urban Context. WHO Healthy Cities Papers No. I. Copenhagen: F ADL Publishers. Zeckhauser, Richard and Michael Eliastam. 197 4. The productivity potential of the PA The Journal ofHuman Resources 9 (Wmter): 95-116. 225