The design of a comprehensive evaluation of subsidized rural primary care programs on a large national scale is described. Its major purpose is to derive data whose analysis will answer major policy questions about the factors influencing the outcome of the major types of such programs in different communities. This first paper also delineates a typology whichIn the 1960s, the long recognized problem of making good quality personal health services available to people in rural areas was given greatly increased attention in the United States. For many years prior to this, various measures to correct this persistent deficiency had been tried by rural people themselves, by agencies such as governments at local, state, and national levels, and by local and national foundations. Few of these efforts seemed to provide satisfactory solutions. During the 1970s, growing concern about this problem led to greatly expanded and strengthened efforts and some new approaches which included the requirement that subsidized primary care projects adopt specific programmatic goals and particular methods of organization, staffing, and operation.Toward the end of the 1970s, national economic constraints produced increasing competition for the public dollar, thus heightening an interest in comprehensive evaluation studies that might lead to policy changes for future sup-
Surveys of a national sample of 193 subsidized rural primary care programs were conducted in 1981 and 1982 to determine what adaptations the programs might anticipate making given a reduction in their subsidy and what actual changes they made after the implementation of new federal policies and in the face of severe economic recession. During the period between the two surveys,
Subsidized rural clinics and providers have long depended on the rural hospital for the care of some of their patients; the hospital has also been a source of revenue for these providers and programs. We studied a representative national sample of 116 subsidized rural clinics, focusing on the impact on rural clinic costs and revenues of the use of the hospital by the clinics' providers. Both clinic costs and revenue are reduced by the use of the hospital by rural practice providers, but costs are lowered to a greater extent than revenues, thereby enhancing the financial self-sufficiency of the subsidized clinic. The cost savings affect all aspects of clinic operation, but especially laboratory costs, community services costs, and administrative costs. The dependence of these rural clinics on the hospital indicates that the condition of subsidized rural clinics would be worsened by decreased availability of hospital services.
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