Primary care access a key to health disparities among counties

Washington If you're a resident of Howard County, Md., chances are fairly high that you have insurance, enjoy good health and have relatively easy access to a primary care physician. Take a short car ride to Baltimore, however, and the situation for residents is much more grim.

In Howard County, ranked as Maryland's healthiest in the most recent County Health Rankings and Roadmaps survey, only 9% of residents are uninsured, and just 8% are considered in poor health. There's one primary care physician for every 577 patients. In Baltimore City, the unhealthiest county in the state, the uninsured rate is nearly twice as high, and there's only one primary care doctor for every 985 patients — a combination that means a significant access-to-care problem.

The comparison underscores a key finding in the 2013 survey: Gaps between the healthiest and unhealthiest counties in individual states are large and continue to grow. The survey highlighted the fact that residents in the healthiest counties are 1.4 times more likely to have access to a primary care physician than those in the least healthy counties. Unhealthy areas also had higher rates when it came to a host of other negative indicators of overall health, including child poverty, teen pregnancy and premature death.

This is the fourth year that the Robert Wood Johnson Foundation and the University of Wisconsin School of Medicine and Public Health have surveyed the health of every county in the U.S., ranking them on a state-by-state basis to gauge the factors determining the health of residents. All survey measures use figures or percentages that take population into account so that a county such as Howard, with a population of less than 300,000, can be compared with Baltimore City's population of more than 600,000.

The rankings are set up so that every state has a healthiest and unhealthiest county despite the overall health of the state. But health outcomes can vary widely within a state, said Patrick Remington, MD, MPH, professor and associate dean at the University of Wisconsin School of Medicine and Public Health, during a teleconference to discuss the 2013 rankings. Louisiana and Mississippi are two states that often rank last in the nation on overall health. But when researchers dig into each state, they find as much variability among individual counties in Louisiana and Mississippi as they do in Vermont, a state that ranks relatively high nationally on patient health outcomes, he said.

Competition drives improvement

Dr. Remington said promoting the results of county rankings has made a difference, “sparking action all over the country as people from all sectors join forces to create new possibilities in health — county by county.”

One of those areas is New Orleans, which has been trying to rebuild its infrastructure after Hurricane Katrina in 2005, said Karen B. DeSalvo, MD, New Orleans health commissioner and senior health policy adviser to the city's mayor. Orleans Parish typically has ranked in the 60-62 range in a state that has 64 counties, Dr. DeSalvo said. “So we've been at the bottom of the pack in one of the more unhealthy states in the country. What we're excited about this year is we've jumped up to number 48, so that's a big leap.”

In addition to overhauling its education system and making improvements to parks and playgrounds, the city has spent seven years on an initiative to develop its primary care infrastructure.

“We had essentially no neighborhood-based primary care before Katrina. People were reliant upon hospital-based services, especially those who were uninsured and underinsured,” Dr. DeSalvo said.

Since then, the city has responded by working with 25 organizations, ranging from small clinics to large hospital systems, to build access to primary care and outpatient mental care, with a particular focus on patient-centered medical homes and health information technology. The initiative has received financial support from philanthropic sources as well as some federal demonstration program funding to expand access to primary care rapidly. “This is a true public-private partnership,” she said.

Dr. DeSalvo said the renewed focus on building strong primary and preventive care at the neighborhood level probably has reduced unnecessary hospitalizations and led to improvements in screening rates for such conditions as diabetes and breast cancer.

Improving patient-reported measures and clinical outcomes is one of the strategic goals recently adopted by the American Medical Association. The AMA is focusing on promoting quality and safety, reducing unwarranted variation in care, and fostering appropriate use of limited health care resources.

Other factors leading to poor health

The fact that fewer physicians and dentists practice in certain communities obviously contributes to poorer health in those areas, said Bridget B. Catlin, PhD. She's a senior scientist at the University of Wisconsin Population Health Institute and director of the County Health Rankings and Roadmaps survey. But, as she and other health care observers pointed out, lack of access is just one of many problems that go hand in hand with poor health among residents. In addition to measuring clinical care outcomes, the survey analyzes health behaviors, social and economic statistics, morbidity, and such physical environment elements as air and water quality.

“Other key factors that influence the health of a community are education, employment, income, and whether people smoke or have access to healthy foods and places to exercise. Some of these factors probably also influence physicians' decisions about where to practice,” Catlin said. “In particular, there is a widespread need for health care providers in rural areas.”

At least in Maryland, the health gap between the highest- and lowest-ranking counties largely comes down to socioeconomic conditions, said Brian Avin, MD, a neurologist and the president of MedChi, the Maryland State Medical Society. Howard County, a suburb of Washington, is one of the most affluent areas of the nation, “so whatever social factors you want to create, Howard is going to be the highest and Baltimore City is going to be the lowest,” he said. There's much more poverty and unemployment in Baltimore, as well as more people on Medicaid or going without insurance, generating more uncompensated care cases. “Obesity, smoking, any individual feature you're going to look at is going to be worse when you're not getting basic care.”

Howard County also has been trying to get all of its population insured, whereas no such strategic initiative exists in Baltimore City, Dr. Avin said.