 Examining a child's ear in the UNC Charlotte Nursing Center (Karen Haar) |
PhysiciansHospitalsMedical and Information Technology |
In 1970, 7.1 percent of the U.S. Gross Domestic Product (GDP) was devoted to health care expenditures. By 1999 this figure had nearly doubled to 13 percent. Hospital and physician costs account for the largest shares of those expenditures. Total per capita health expenditures in the U.S. in 1998 were about $4,000 for the entire country and $3,200 for North Carolinians. In North Carolina during 1998, per capita costs for hospital services were $1,292 as contrasted to $1,432 for the U.S. Per capita physician payments for physician services in 1998 in North Carolina were $836, compared to $1,165 for the whole country. Interestingly, the supplies of physicians and hospitals have demonstrated very different trends over the past several decades. In 1970, there were 334,000 licensed physicians in the U.S. and by 2000 there were over 700,000. By contrast, there were approximately 7,000 general hospitals in the U.S. in 1970, and by 2000 there were only about 6,000. These trends are a testimony to the changing nature of health care delivery. Examinations of distributions of physicians and hospital beds in North Carolina assist in understanding the changing nature of these resources.
Physicians continue to comprise the keystone of the health care system for most people within the United States. Most of the time the doctor is the first person to whom people turn for care when faced with unusual medical conditions or ailments. Doctors will continue to be central in the medical care delivery process for the foreseeable future. Historically, the South has lagged behind the national average in the ratio of population numbers served per physician. Recent growth trends and changes in the nature of health care delivery have offset this condition to some extent. Analyses of reasons for physician shifts from one area to another within the United States have suggested various forms of income attraction as well as degrees of urbanization and population numbers as leading explanations. As urban-rural differences in the geographical distribution of physicians continue to be pronounced, researchers have attributed this trend to the attraction of large cities and other places with higher income potential. As noted earlier, by the early 1970s there were about 300,000 non-federal practicing physicians in the United States, and by 2000, there were nearly 700,000. At that time, North Carolina ranked about 30th nationally in physicians per 100,000 persons and by 2000, it was close to the national average.
The distribution of physicians within North Carolina in has continued to reflect the nature of urbanization in the state as well as locations of medical schools. Physicians have clustered in larger cities where there are more hospitals and other medical facilities as well as opportunities to earn a higher income.. Figure 10 shows the heavy concentrations of physicians that have persisted in the most urbanized parts of the state. In addition, counties with the largest numbers of physicians have seaside golf or mountain resort amenities, medical schools, or contain larger cities.
Medical school loan repayment programs and other incentives have induced more physicians to locate in rural parts of the state over the last decade. The pattern within Figure 11 indicates how many rural counties have reported a reduction in the number of persons per physician. Another pattern of change that is revealed by this map is that the number of physicians increased not only in urban counties but also in the suburban counties that are adjacent to them. Still, about a dozen rural counties actually showed an increase in the number of persons per physician from 1990 to 2000.
Initial indications are that the story of hospital supply is
just the opposite of that of physicians. Historically, hospitals have been
associated with the status of many communities. To many people, they also are
viewed as the pinnacle of available medical care. But the rising cost of health
care delivery and rapid technological change have altered that impression.
More and more community hospitals can no longer afford to exist as single entities
as outpatient care has replaced inpatient care for many routine hospital functions.
Further, much local duplication has been eliminated through mergers of hospitals
and health care groups. Thus, patterns of hospital use have also changed drastically
even within the past two decades. Many surgical procedures that only a few
years ago required a stay of several days in the hospital are now performed
as outpatient surgery. And some forms of treatment that often took weeks now
only take a few days. Figure 12 displays patterns of the distribution of population
per hospital bed in 2000. . As North Carolina follows the nation in decreasing
dependence on hospitals for many forms of health care, urban places continue
to have the largest numbers of available beds. In fact, the number of North
Carolina counties that do not have a hospital at all increased from 15 to 18
between 1980 and 2000. All of these counties are rural, either in the Mountains
or in the northeastern sector of the Coastal Plain. The change in population
per hospital bed from 1990 to 2000 is shown within Figure 13.
What the maps cannot show is a strong trend for larger, urban health care systems
to form extensive health care networks by acquiring or merging with a number
of smaller facilities over a multi-county region. Many of the smaller hospitals
are converted to primary care units and more specialized care and facilities
are centralized in the large central hospitals. Increasingly, therefore, management
of larger shares of hospital resources are directed from the offices of the regional
systems in the major cities.
Hospital mergers have left many cities with only one hospital. During the 1990s, Blue Cross and Blue Shield of North Carolina and other third party carriers have simply stopped offering coverage for members who use hospitals in specific counties due to increased costs. While a host of factors may account for these higher costs, presumably a major one is the lack of competition. Yet, many hospitals serve as medical education centers as well as care facilities. There are four medical schools in the state, each associated with a university: Duke University, East Carolina University, University of North Carolina at Chapel Hill, and Wake Forest University, formerly Bowman Gray Medical School. In addition to the medical schools, a number of hospitals have residency programs for the further training of beginning physicians. Large programs are offered in several areas the lack a medical school, especially in Asheville and Charlotte.
The tendency to concentrate major health care facilities in either large urban centers and/or at medical schools is largely a result of the development of expensive medical technologies. The North Carolina Department of Health and Human Services controls the acquisition of expensive equipment through a “Certificate of Need” program that requires requesting hospitals to justify the need for the item. The Department seeks to reduce redundancy of linear accelerators, magnetic resonance imaging machines and other sophisticated technologies. Additionally, it is felt that the largest and more medically important locations that exist already are best prepared to support highly specialized super-regional treatment centers for specific ailments and the expensive equipment that typically is required. Referred to as the “focused factory” model, the best examples of this approach are seen in the several university hospitals in the Raleigh-Durham area. Another approach is evident in an “integrated delivery systems” model, in which a full range of health care services are offered, from primary care to specialized treatment. In this case the larger urban hospitals expand and incorporate other facilities into a network within the metropolitan region, as noted above. It is the larger hospitals in the network that provide specialized treatment and which have the sophisticated equipment that is required. This model is best exemplified in the Charlotte and Greensboro/Winston-Salem regions.
Advancements in medical technology support both models. In the past this tended to involve the use of main frame computers by hospitals and larger group practices, primarily to handle billing. Today, information technology has expanded to include more interactive record keeping and diagnostic/treatment information. Regional networks extend the benefits of this technology to many urban and rural parts of the state. However, the acquisition of newer technologies, staff training, budget management and the implementation of performance measures are led by the larger, urban-based medical centers and at places such as the new School of Information Technology at UNC Charlotte and at North Carolina State University, with its long tradition in information programs.
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