Patterns of ambulatory medical care in rural Manitoba, determinants of utilization and the effect of physician practice-modality
Wall, Ronald W.
Systemic imbalances in the distribution of general practitioners concern rural residents, physicians, and policy-makers. This thesis investigates patterns of medical care utilization in rural Manitoba to discern the "reality" from the "myth" of imbalances in the distribution of physicians. To overcome methodological limitations of previous work, this research compiled the Manitoba Physician Resource Data Set. By tracking the movement of physicians over the 1990-91 to 1994-95 fiscal years, important workload and explanatory variables were estimated. These, and other data, were analysed to gain insights into the epidemiology of rural ambulatory medical care--that is, the determinants of utilization and the role of practice-modality. From population--physician-supply (macro-level) analysis, imbalances in physician-availability were compensated for by residents' out-of-area care-seeking and adjustments made by physicians in their workloads. Overall, physician-accessibility is comparable across rural Manitoba. Moreover, also through these mechanisms, physician-competition is comparable across rural areas. However, a population's rate of contact and utilization is not predicated on the need for ambulatory physician-visits or physician-availability. Although comparable access was found across small areas, low need populations had relatively higher rates of contact and visits. From practice-profile--physician-practice (meso-level) analysis of the role of payment-modality, fee-for-service group practice provided superior performance: large patient-loads seen, patterns of visits in balance with expected need, and stable physician-practices. These findings, however, may be confounded by self-selection from Manitoba medical graduates concentrated in fee-for-service group practices in the larger rural communities. While stakeholders should be encouraged by the remarkable comparability in physician-accessibility and physician-competition across rural Manitoba, improvements could be made.