Biobehavioral Aspects of Aggression

ing on the study, must have problems with its health care delivery. Rural areas began to lose their share of physicians with the surge in medical specialization in the 1940s and 1950s and continue to suffer today, despite federal and state programs designed to assist rural practitioners (such as the National Health Service Corps, Rural Health Initiative, Appalachian Regional Commission, etc.) and the development of residencies in family practice at many medical schools. The fact that medical care could be the right of every citizen magnifies the problem, making the easy access to quality care for every citizen the responsibility of the medical profession, the government, and/or both. The authors of this book chose a case-study approach, comparing matched rural self-sufficient and federally sponsored (non-self-sufficient) practices to determine the characteristics that make the former practices financially viable. The purpose of the book is to "explore why financial self-sufficiency has been so difficult to achieve in rural areas" and to articulate "policy changes which would foster self-sufficiency" in rural practices. The first half of the book sets the stage by giving working definitions of "ruralness" and "access to care," and by describing selection and breakdown of practices as to extent of self-sufficiency. There is also a chapter on past rural health policy actions. The final two chapters describe rural practice development and present policy recommendations, while the appendix presents a linear program to maximize practice income by varying reimbursement rates and service mix. The major weaknesses of the book derive from the limitation of its analysis to the more traditional forms of health care delivery. There is only passing consideration, but no statistical analysis, of "physician extenders," such as physician associates and nurse practitioners, and practically no mention of the possibility of application to rural areas of pro-competitive health delivery systems such as Health Maintenance Organizations. The chapters on past policy efforts are quite informative and the indepth analysis of each practice quite complete, but because the authors did not deal with all modes of delivery, this study of only ten practices loses even more generalizability. The findings are reasonable and carefully supported, but are not useful for a policy maker trying to choose, from among HMOs, physician extenders, and private practices, the system that supplies the best health care most self-sufficiently. For instance, the appendix develops a linear model for a rural practitioner to maximize his income by varying reimbursement rates and service mix, but with no mention about the quality of care. This book could serve as a guide to further studies of the problem and as a handbook for physicians planning to set up rural practices. It even has a chapter on practice development. It is not comprehensive enough to be of much service to a policy maker.