From the Family L list serve

A big, academic health system accused of intimidation for informing
about "payment at time of service", and not accepting uninsured
patients.  Of course that may be how the achieve break-even operations.
Daily Health Policy Report
Coverage & Access | Petition Alleges New UNC Health Care System Policy
Limits Access to Care for Low-Income Patients [Aug 21, 2006]
      A new policy at clinics in the UNC Health Care
<http://www.unchealthcare.org/>  system in North Carolina has limited
access to care for low-income patients, according to a petition recently
submitted to system President Erskine Bowles with signatures from more
than 1,100 state residents, the Raleigh News & Observer
<http://www.newsobserver.com/102/story/476090.html>  reports. John
Hammond, a retired University of North Carolina-Chapel Hill professor,
and Florence Soltys, a faculty member at the UNC schools of medicine,
social work and nursing, led the petition effort. The petition alleges
that most UNC clinics do not schedule appointments for uninsured
patients. In addition, according to the petition, a new policy at the
clinics that requires payment at time of service limits access to care
for low-income patients. The clinics use an automated appointment
confirmation system with a telephone message that informs patients of
their obligation to pay at the time of service. Hammond said that the
policy represents "a conscious effort to intimidate, embarrass or
otherwise discourage people from showing up." Bowles and UNC-Chapel Hill
Chancellor James Moesor plan to meet with UNC Health Care CEO William
Roper to address the concerns raised in the petition, a Bowles
spokesperson said. UNC Health Care receives more than $40 million
annually in state funds and is "traditionally a break-even operation,"
according to the News & Observer. Roper said of the petition, "The
notion that anything we have done has in any respect moved us away from
our historic mission to serve the people of North Carolina is just
wrong, wrong, wrong" (Fisher, Raleigh News & Observer, 8/18).


New Research - From my definitions of underserved

The US MD Grads are 16,000 of the 22,000 – 23,000 added to the US workforce
each year. The locations and career choices are those listed in the
American Medical Association Masterfile in 2005 locations. 1 The United
States is good at concentrating income, education, people, and physicians.
•     Major medical center (MMC) locations have 75 or more physicians at a
single zip code when considering all active physicians listed in the
Masterfile. The major medical center category includes major clinic,
hospital, and medical school zip codes. This is a conservative measurement.
Geographic reviews note close proximity and similar concentrations of
physicians and other demographics zip codes adjacent to existing MMC codes.
These adjacent codes are part of the “served” or low poverty locations and
share most of the characteristics of major medical center zip codes. The
categorization of medical school zip codes used main medical school,
internal medicine department, and family medicine zip codes. More detailed
searches would find more physicians in medical school codes, in adjacent
zip codes, or in brand new zip codes.
•     Underserved and high poverty locations involve two types of
categories. The high poverty locations have 20% or more in poverty. The
designated zip codes are contained within whole county primary care
shortage areas, include a Community Health Center, or have a National
Health Service Corps designation. Many of the zip codes fit 2 or 3 of these
criteria. Comparisons of physicians, population, ratios, and ratios of
physicians to those in poverty demonstrate little difference between high
poverty and designation area zip codes. Major medical center, military, and
“served” locations were excluded from these locations on the basis of
numbers of physicians, characteristics of the zip code, income levels, and
poverty levels. Where zip codes were unique or had low levels of
population, geographically adjacent zip codes were used.
•     Served locations have less than 20% of the population at the zip in
poverty and have no special designations. Where the zip has no population
assigned to it, the population of the nearest zip code was used. In the
case of smaller zips with few people the zip codes were averaged using data
from adjacent zip codes. This “smoothing” involved 129 zip codes and only
28 physicians.

Major Medical Center (75 physicians or medical school, 3335 zip
codes,361939 physicians graduating since 1971, 90 million people, 10
million in poverty or 11.6%, 4 physicians per 1000 and 34.6 physicians per
1000 in poverty.

Served or low poverty locations 0 - 20% in poverty at zip and no
designation, 19225 zips, 129781 physicians, 130 million people, 11.4
million in poverty or 8.8%, 1 physician per 1000 people and 11 per 1000 in
poverty

High poverty, over 20% and no designation, 3845 zip codes, 14588
physicians, 24.6 million people, 6 million in poverty, 24.2% in poverty,
0.59 physicians per 1000 or 2.45 per 1000 in poverty

Underserved - has a whole county primary care, NHSC designation, or is a
zip code with a Community Health Center, 5457 zip codes, 14566 physicians,
28.4 million people, 6 million in poverty, mean poverty 21%, 0.515
physicians per 1000 and 2.44 per 1000 in poverty

US totals 31977 zips with 522817 physicians since 1971 grad class, 273.8
million (out of 281), 33.8 million in poverty, 12% poverty, 1.9 physicians
per 1000 and 15.43 for physicians per 1000 in poverty

Most people in poverty are in the shadow of major medical centers. The
combination of high poverty and designated areas into one underserved
category is not a problem. Designation may depend more upon the level of
local and state organization than criteria. Coding of 273 million out of
281 million people is nearly complete, certainly within the range of
constant changes in zip codes. Further studies using the major medical
center, underserved and high poverty, and “served” categorizations can be
useful in understanding physician distribution.

There will be more exposures published.

Sadly you will not see the heroes that stay in underserved areas such as
Creighton who could have moved out west and away from black, Hispanic,
Sudanese and poor whites in eastern Omaha, but chose to stay and serve. Or
those who stay as "loss leaders" in numerous family medicine clinics,
departments, and residency programs. Our clinic has tens of thousands of
visits and losses exceeding 1 million, but considering that we generate 6
to 1 in referrals, radiology, lab, and other ancillary services, we are not
loss leaders, we are just seen that way by the current terminologies.
Somehow our patients may also be seen that way, a major mistake for anyone
and this includes more than just medical schools.

You will also not see the state or federal government as prominent in this
story Cutbacks in Medicaid and other areas make it difficult to meet all of
the missions of a medical school.

When we categorize in different ways, we begin to see differently,
hopefully much differently.

Robert C. Bowman, M.D.
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