Explore the vast range of titles available.

Alliances are the organizations of the future. This article builds on the lessons from industry identifying important areas requiring definition and basic understanding of alliance structure, process, and outcome in health care services.

Summary points The role and structure of rural hospitals is changing, but they continue to be important local and regional centers of health care activity Rural hospitals tend to depend more on Medicare and Medicaid patients Most rural hospitals are organized on a not-for-profit basis Rural hospitals make an important contribution to rural economies; expansion and diversification of the services that they offer will be important in their survival The quality of care provided in rural hospitals is generally equal to that provided by urban institutions, with some exceptions RURAL HOSPITALS: The hospitals most vulnerable to closing or conversions were those that had fewer beds, had lower occupancy rates, were more often managed as a for-profit concern, were less likely to be accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), and had a high percentage of Medicaid inpatient days. 3 Among isolated hospitals, those in markets with higher population density were also more likely to close. 4 Studies that examined the effects of closed hospitals on local communities found significant changes in utilization, and in one case, health status. 5 , 6 , 7 Economic contribution of rural hospitals One of the key arguments in support of the continued subvention of rural hospitals by government and the removal of differential reimbursement rates for rural hospitals, is their contribution to overall rural economies.

The primary study objectives were to 1) determine how many physicians entered primary care practice in rural and urban counties of North Carolina in the 1981 to 1989 period and 2) estimate their length of tenure in these areas. The secondary objective was to identify the physician's demographic, training, and practice characteristics that influence geographic location of practice and length of tenure. A cohort of 1,947 physicians was identified from the North Carolina Board of Medical Examiners database, which included all active, nonfederal primary care physicians who began their initial practice in North Carolina in 1981 or later. The primary outcome was time in practice in a given rural or urban county. Selected data on physician demographic, training and practice characteristics were also available in the database. Approximately one third of physicians beginning their initial North Carolina practice selected a rural county for the location. Almost half of these primary care physicians were still in the county of their initial practice in 1989. An additional 20% of these physicians had changed practice location within the State, of which half chose a similar type of county to that of their initial practice. Length of tenure was similar across geographic locations of the medical practice, with the average length of tenure being 4.6 and 4.4 years among physicians in rural and urban counties, respectively. The strongest predictors of tenure were practice organizational characteristics with physicians in either an office-based solo practice or partnership having longer tenures. These findings provide support for continuing programs that encourage physicians to practice in rural areas; they also suggest the need for programs designed to retain rural physicians in their practices.

This is a study of the employment of nonphysician providers-nurse practitioners, physician assistants, and certified nurse midwives-in both rural and urban Community and Migrant Health Centers and of factors associated with their employment, based on a 1991 national survey of 383 Centers. Results of the survey suggest that nonphysician providers, in particular nurse practitioners and certified nurse midwives, primarily serve as physician substitutes, and are more likely to be employed by Centers that are larger and have affiliations with nonphysician provider training programs. Rural or urban location is not significantly related to the employment of nonphysician providers after controlling for center size. The fact that rural centers employ fewer nonphysician providers than urban centers can primarily be accounted for by their relatively small size, rather than a lack of interest. These findings demonstrate that the use of nonphysician providers is an important way both to achieve cost containment and improve access to primary care for those residing in medically underserved areas

Nurse-midwives can be an effective way to cut medical costs. The use of nurse-midwives in rural North Carolina to provide obstetrical care is discussed.

As rural communities struggle to sustain health services locally, innovative alternatives to traditional programs are being developed. A significant adaptation is the rural health network or alliance that links local health departments and community health centers. The authors describe how a rural local health department and community health center, the core organizations in publicly sponsored primary care, came to share a building and administrative and service activities. Both the details of this alliance and its development are examined. The case history reveals that circumstance and State involvement were the catalysts for service integration, more so than the need for or the benefits of the arrangement. The closure of a county-owned hospital created a situation in which State officials were able to broker a cooperative agreement between the two agencies. This case study suggests two hypotheses: that need for integrated services alone may not be sufficient to catalyze the development of primary care alliances and that strong policy support may override any local and internal resistance to integration.

In the period 1985-89, there was a severe drop in obstetrical services in rural areas of North Carolina, partly because of rising malpractice insurance rates. The State government responded with the Rural Obstetrical Care Incentive (ROCI) Program that provides a malpractice insurance subsidy of up to $6,500 per participating physician per year. Enacted into law in 1988, the ROCI Program was expanded in 1991, making certified nurse midwives eligible to receive subsidies of up to $3,000 per year. To participate, practitioners must provide obstetrical care to all women, regardless of their ability to pay for services. Total funding for the program has increased from $240,000 to $840,000, in spite of extreme budgetary constraints faced by the State. The program and how its implementation has maintained or increased access to obstetrical care in participating counties are described on the basis of site visits to local health departments in participating counties and data from the North Carolina Division of Maternal and Child Health. The program is of significance to policy makers nationwide as both a response to rising malpractice insurance rates and reduced access to obstetrical care in rural areas, and as an innovative, nontraditional State program in which the locus of decision making is at the county level

This article assesses the extent to which managed competition could be successful in rural areas. Using 1990 Medicare hospital patient origin data, over 8 million rural residents were found to live in areas potentially without provider choice. Almost all of these areas were served by providers who compete for other segments of their market. Restricting use of out-of-State providers would severely limit opportunities for choice. These findings suggest that most residents of rural States would receive cost benefits from a managed competition system if purchasing alliances are carefully defined, but consideration should be given to boundary issues when forming alliances.

Drawing from the results of an empirical study, we discuss the strengths and challenges of Area Health Education Centers in three domains—mission, programs, and organization—and highlight their implications for Academic Health Science Center leaders.