Follow-up review: State Office of Primary Care, access to primary care services

FOLLOW-UP REVIEW

State Office of Primary Care: Access to Primary Care Services
May 2002

Performance Audit Operations Division Russell W. Hinton, State Auditor Department of Audits and Accounts

254 Washington St. Atlanta, GA 30334

This is a Follow-up Review of the Program Evaluation of the State Office of Primary Care: Access to Primary Care Services that was released by the Performance Audit Operations Division in December 1999.

The purpose of the Office of Primary Care is to assist in improving access to primary healthcare in medically underserved areas. Primary care services are basic health services that are most often provided by physicians specializing in general practice, internal medicine, family practice, pediatrics, or obstetrics and gynecology. Other providers of primary care services include physician's assistants, nurse practitioners, and certified nurse midwives.
The Office is responsible for designating areas of the state as Health Professional Shortage Areas (HPSAs) and as Medically Underserved Areas (MUAs) where the delivery of primary care services falls below federal standards. These designations enable communities to become eligible for federal programs designed to improve the availability of and access to health care. The Office administers the J-1 Visa Waiver Program that enables foreign medical students to receive additional medical training in the U.S. and then remain in this country by practicing in a HPSA for at least three years. Without the Waiver Program, these persons would have to return to their home country for at least two years. As part of its recruitment and retention responsibilities, the Office administers the National Health Service Corps' Federal Loan Repayment and Scholarship Programs.
The Office is also responsible for developing a Primary Care Access Plan that identifies gaps in the primary care system, prioritizes the needs in various areas, and plans future healthcare initiatives. The Plan, which is updated each year, ranks every county based on six high-risk indicators: low birth weight rate; infant mortality rate; cancer deaths; cardiovascular deaths; percentage of population below 200% of the federal poverty level; and percentage of population over age 60. Using this ranking, the 40 "neediest" counties are designated priority counties and targeted for primary care intervention.

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Prior to the release of the program evaluation in December 1999, the Office of Primary Care was transferred from the Department of Human Resources to the Department of Community Health and placed within the Office of Rural Health Services. In October 2000, the Office of Rural Health Services was relocated from Atlanta to Cordele; the Office of Primary Care was later renamed the Primary Care/Recruitment and Retention Programs. To avoid confusion, however, we have chosen to refer to the Programs as the Office of Primary Care (or Office) for this follow-up review.
The 1999 program evaluation focused on the activities of the Office to improve access to primary care services in rural and medically underserved areas of Georgia. The objectives of the evaluation were to:
evaluate the methods used by the Office to identify the state's medically underserved communities and determine if these communities have a genuine need for primary care services;
determine the extent to which the Office has helped improve the accessibility and availability of primary care services in the state's medically underserved communities; and,
determine how effectively the Office has coordinated its efforts with other primary care organizations to improve the accessibility and availability of primary care for underserved communities.

Finding (as reported in 1999): The Office of Primary Care has not been effective in achieving its overall purpose of increasing the accessibility and availability of primary care services in rural, underserved areas of the state. Current Status: Although there has been some improvement since 1999, access to primary care is still limited in many rural Georgia counties, including the priority counties targeted for assistance by the Office of Primary Care. The 1999 program evaluation found that only 14 (36%) of the counties targeted for assistance in 1995 experienced an increase in the number of primary care physicians from 1994 through 1998. Overall, the number of primary care physicians increased by only 10% (from 187 to 206) during this period.
As shown by Exhibit 1 on the following page, our follow-up review found that from 1998 through 2000, the number of primary care physicians in the 39 targeted counties increased by 13% (from 206 to 233), with 20 counties experiencing an increase. In 10 counties,

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however, the number of primary care physicians decreased, and in nine counties the number of primary care physicians remained the same. It should be noted that of the 39 counties designated as priority counties in 1995, 34 were priority counties in 1998 and 26 were priority counties in 2000.

Exhibit 1 Change in Primary Care Physicians1: 1994-1998 and 1998-2000

39 Priority 39 Priority Counties2 Counties

1994-1998
Counties with an Increase in 14 (36%) Physicians
Counties with a Decrease in 15 (38%) Physicians
Counties with No Change in 10 (26%) Physicians
Total Increase in Physicians 19 (10%)

1998-2000 20 (51%) 10 (25%) 9 (23%) 27 (13%)

Other Rural Counties

1994-1998 (N=79)

1998-2000 (N=79)

55 (70%)

47 (59%)

Urban Counties 1994-1998 1998-2000
(N=41) (N=41)
36 (88%) 32 (78%)

12 (15%)

17 (22%)

4 (10%) 7 (17%)

12 (15%)

15 (19%)

1 (2%)

2 (5%)

215 (21%)

169 (14%) 1,174 (33%) 402 (8%)

1 Physicians specializing in general practice, internal medicine, family practice, pediatrics, and obstetrics/gynecology. 2Beginning in 1996, the State Office of Primary Care designated 40 counties each year for targeted assistance.

Source: Georgia Board for Physician Workforce

In its written response to our follow-up review, the Office indicated that its programs had, in part, led to improved access to primary health care. The Office noted that while 65% of Georgia counties do not have adequate physician distribution, 50% of these counties have improved health status (based on their rates of infant mortality, deaths from cancer and cardiovascular disease, and low birth-weight babies).

Finding (as reported in 1999): The Office of Primary Care should be held accountable for meeting specific objectives that are in line with its overall purpose. Current Status: Although the Results-Based Budgeting (RBB) objectives (desired results) cited in the 1999 evaluation have been revised, the current objectives cannot be used to evaluate the Office's overall effectiveness. No data is collected by the Office to measure its RBB objective of increasing the percentage of the rural population in Georgia that have access to rural health delivery systems. The Office's other objective (to increase the percentage of counties that meet the ... Standard of 191 physicians per 100,000 population) includes all Georgia counties, not just those counties in which there is a shortage of primary healthcare services.
In its written response to our follow-up review, the Office cited four examples of outcomes the Office hopes to attain in 2003. These outcomes, however, cannot be used to evaluate the Office's effectiveness. One of the desired outcomes, for example, is to facilitate better

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coordination among all primary care providers... Another outcome is to compile an Unmet Needs Report that includes data on the estimated uninsured population...
Finding (as reported in 1999): The Office of Primary Care should take steps to more effectively assist rural and medically underserved communities in Georgia with their primary care access problems. Current Status: In its written response, the Office indicated that it has taken steps to enable it to provide meaningful technical assistance and/or financial resources tailored to meet the specific needs of local communities. The Office has developed an Unmet Needs Report that enables it to determine the type and amount of resources that have gone into each community to improve healthcare access. The Office also cited two initiatives that have been developed to provide financial resources to local communities: the Rural/Health Systems Program and the Access Georgia Rural Health Matching Grants Initiative. Through the Rural Health Systems Program, funds totaling $2.7 million were disbursed to 11 organizations for projects designed to improve access to healthcare in different regions of the state, including 14 of the 40 priority counties targeted for assistance. Through the Rural Health Matching Grants Initiative, the Office has made awards totaling $1.8 million to nine rural community organizations to increase access to health care services by creating regional partnerships. These regional partnerships cover 12 of the priority counties.
Finding (as reported in 1999): The state does not have a coordinated and targeted approach to effectively address the maldistribution of primary care physicians in Georgia. Current Status: Additional efforts are needed if the state is to have a more coordinated approach to improving access to medical care. As noted in the 1999 program evaluation, the state has multiple programs designed to encourage the location of physicians in rural, underserved areas. Because of a lack of uniformity in the criteria used by the different programs however, they tend to have a greater impact on the overall supply of physicians than on the placement of physicians in rural, underserved areas. While the Office of Primary Care, for example, targets assistance at the 40 priority counties with low health status indicators, the state's medical education scholarship program provides scholarships for medical school students who locate in counties with populations less than 35,000 (currently 108 counties). Similarly, the state's medical education loan repayment program allows physicians to pay off their loans for medical school by working in counties that have been designated as Health Professional Shortage Areas (currently 131 counties).
In its written response to our audit follow-up, the Office indicated that the creation of the DCH Healthcare Workforce Policy Advisory Committee in 2001 signified an attempt to foster increased coordination in addressing workforce shortages. The Committee brings together representatives of the Office of Primary Care, the Georgia Board for Physician Workforce, the State Medical Education Board, the Area Health Education Centers, and other organizations involved in the recruitment and retention of health care professionals in the state's medically underserved areas.

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Finding (as reported in 1999): Action should be taken to promote mid-level health care professionals as an effective alternative for improving primary care access in rural and medically underserved areas. Current Status: As recommended in the 1999 program evaluation, the Physician's Assistant Act was amended in 2001 to increase the number of physician's assistants who can be licensed to one physician from two to four. There have been no changes, however, in state laws that prohibit Advanced Practice Nurses from practicing without physician supervision and from prescribing medications. As noted in the 1999 program evaluation, these statutory limitations may slow the utilization of these mid-level health professionals in rural, underserved areas.
Finding (as reported in 1999): The State Office of Primary Care should consider revising its method of identifying the state's priority counties for primary care intervention. Current Status: As recommended in the 1999 program evaluation, the Office has taken steps to utilize a regional approach in its efforts to identify and address the primary care needs of medically underserved areas. In its written response, the Office noted that the goal of its Access Georgia Rural Health Matching Grants Initiative is to increase access to health care by creating regional partnerships. Although the Office also noted that it agrees with the 1999 recommendation to establish benchmarks for evaluating changes in the health care status of the 40 priority counties, such benchmarks have not yet been established.
Finding (as reported in 1999): The State Office of Primary Care should review its allocation of state funds to state Primary Care Centers. Current Status: The Office of Primary Care is no longer responsible for funding the state's Primary Care Centers (located in Hall, McIntosh, Talbot, and Webster County). Funding for the operation of the Centers was transferred from DCH to DHR in fiscal year 2001.
Finding (as reported in 1999): Consideration should be given to alternative strategies that have been implemented in other states to improve primary care access. Current Status: The Office has taken action to identify and implement alternative strategies used in other states. In its written response, the Office cited several programs that have been initiated as a result of meetings and conferences with officials from other states. Two examples of programs that have resulted from these interactions include: a program to provide funds to communities to implement innovative approaches for providing healthcare to the uninsured, and a revolving loan program to assist rural providers make capital improvements.
For additional information or to request a copy of the Program Evaluation, contact Paul E. Bernard, Director, Performance Audit Operations Division, at 404-651-8855.
Or see our website: www2.state.ga.us/Departments/AUDIT/pao/pao_main.htm

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