Strategy, Stratification and the Role of Higher Education in Training More Primary Care Physicians in the Era of the Affordab
Total Page：16
File Type：pdf, Size：1020Kb
“STRATEGY, STRATIFICATION AND THE ROLE OF HIGHER EDUCATION IN TRAINING MORE PRIMARY CARE PHYSICIANS IN THE ERA OF THE AFFORDABLE CARE ACT” by REBECCA LANE SANDIDGE (Under the Direction of Sheila Slaughter) ABSTRACT Increased access to primary care is the bedrock upon which the Patient Protection and Affordable Care Act (ACA) is founded, thereby necessitating growth in the health care workforce. This multiple case study explores how within the “field” of medical education strategic actors are varying institutional strategies in response to the incentives in Title V – Health Care Workforce to educate and train more primary care physicians. It also examines how the legislation may be exacerbating existing stratification within medical education in a single state. Findings suggest that the ACA fails to address the main impediment of increasing the primary care physician supply, signaling that the shortage of physicians will continue or that other health professions will subsume more primary care responsibilities. Furthermore, strategic action in response to the ACA is partially based on the prestige economy and thus can be explained by a commitment of academic leaders to maintain stratification within medical education. INDEX WORDS: Medical Education, Institutional Strategy, Affordable Care Act, Strategic Action Fields, Prestige Economy “STRATEGY, STRATIFICATION AND THE ROLE OF HIGHER EDUCATION IN TRAINING MORE PRIMARY CARE PHYSICIANS IN THE ERA OF THE AFFORDABLE CARE ACT” by REBECCA LANE SANDIDGE B.A. and B.S., The University of Georgia, 2004 M.A., The Ohio State University, 2006 A Dissertation Submitted to the Graduate Faculty of The University of Georgia in Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY ATHENS, GEORGIA 2015 © 2015 Rebecca Lane Sandidge All Rights Reserved “STRATEGY, STRATIFICATION AND THE ROLE OF HIGHER EDUCATION IN TRAINING MORE PRIMARY CARE PHYSICIANS IN THE ERA OF THE AFFORDABLE CARE ACT” by REBECCA LANE SANDIDGE Major Professor: Sheila Slaughter Committee: Libby V. Morris Erik C. Ness Electronic Version Approved: Suzanne Barbour Dean of the Graduate School The University of Georgia August 2015 iv DEDICATION To my beloved mother, Dr. Linda Rochell Lane, whose rich legacy inspires me to believe in more, accomplish more and give more of myself to the pursuits and people I cherish. I hope you are smiling down with pride. v ACKNOWLEDGEMENTS It takes a village to write a dissertation and I am thankful to each and every person who helped me achieve this dream. Most importantly, I thank God for blessing me with the fortitude and support system needed to accomplish this feat. To my amazing and dynamic advisor, Sheila Slaughter, who pushed me to think deeper and ask the tough questions – thank you. I appreciate your unwavering belief in my abilities to produce a dissertation on a topic many questioned and your belief in me when my own belief waned. To my committee Erik Ness and Libby Morris, thank you for responding to my last minute requests for meetings, emails, and the often frantic state I was in. You are brilliant academics but most importantly you are caring individuals whose support I value. To my Emory University family I would not have been able to complete this without your support. Mary Horton and Sabrina Mallett you all gave me the push I needed five years ago to start this journey and you have remained steadfast in your belief in me. Kathleen Edwards and Julie Barefoot, I am grateful for your understanding, flexibility, and humor. Angela Bostick and Marie Nicole Wedekind thank you for watching Sophia, providing sustenance and asking “when are you going to finish this damn thing” to ensure I stayed the course. I am honored to have you in my life. Corey Dortch your mentorship, patience, advice and friendship knows no bounds and I am truly grateful to have met you all those years ago as bright-eyed undergraduates. To my dear friends simply known as “The Girls,” I am so fortunate to have you all in my corner. Each one of you epitomizes determination, professional success, whit and grace. Our vi time together was often just the study break I needed. Thank you for continually encouraging me to be my best self. Collectively we can and will take over the world! To my farther Col (ret.) Willie Lane, thank you for encouraging me to always have a seat at the table. From day one you have instilled in me the value of hard work and focus; two traits that continue to carry me to new professional heights. My wonderful brother, Kareem, thank you for role modeling kindness, wisdom and patience in the throes of adversity. You are the most gracious person I know and I am blessed to be your little sister. To my tenacious daughter Sophia Rochell Sandidge, you are my inspiration. I stayed the course to be your first role model, to show you that no matter the circumstances you can do whatever you put your heart and mind to. Your energy, love and intellect is limitless. Thank you for choosing me as your mother. I will always love you my sweet girl. Lastly to my dear husband Mark Sandidge. Wow, “we made it!” I would not be here had you not loved me and allowed me to follow my dreams. I would not be here had you not believed in me 100%. You support is my bedrock and your love is my comfort. Thank you for being my good man. vii TABLE OF CONTENTS Page ACKNOWLEDGEMENTS .............................................................................................................v LIST OF TABLES ......................................................................................................................... ix CHAPTER ONE: INTRODUCTION ..............................................................................................1 The Ascent of Medicine and the Primary Care Physician .......................................4 The Rise of the Specialist ........................................................................................6 Societal Needs and the Current State of Medical Education ...................................9 Theoretical Overview.............................................................................................11 Medical Education and the ACA ...........................................................................15 CHAPTER TWO: REVIEW OF LITERATURE ..........................................................................18 Graduate and Professional Education ....................................................................18 Medical Education and Academic Health Centers ................................................22 Policy Reports ........................................................................................................29 Summary ................................................................................................................32 CHAPTER THREE: RESEARCH DESIGN AND METHODOLGY ..........................................35 Research Design.....................................................................................................36 Data Collection Strategy and Analysis ..................................................................50 Studying Up ...........................................................................................................53 Limitations and Trustworthiness............................................................................57 Summary ................................................................................................................60 viii CHAPTER FOUR: CASE ANALYSIS ........................................................................................62 Introduction ............................................................................................................62 Emory University School of Medicine: “Creating a Primary Care Narrative” .....63 Georgia Regents University: “It’s Not Easy Being a State School” ......................77 Morehouse School of Medicine: “The People’s Champion” .................................90 CHAPTER FIVE: DISCUSSION AND CONCLUSION ...........................................................101 Understanding the “Shock” of the Affordable Care Act .....................................102 Emergent Theme ..................................................................................................109 Conceptual Findings ............................................................................................111 Implications for Research ....................................................................................115 Lingering Questions .............................................................................................116 REFERENCES ............................................................................................................................119 APPENDICES A Interview Protocol ......................................................................................................129 ix LIST OF TABLES Page Table 1: Interview Participants by Institution ................................................................................51 Table 2: Adapted Model of Case Study Tactics for Four Design Test ..........................................60 1 CHAPTER ONE INTRODUCTION The passage of the Patient Protect and Affordable Care Act (ACA, PPACA, or Affordable Care Act) is an imperfect solution for health care policy. It attempts to cover all citizens while still sustaining earlier policy decisions that created protected populations (such as the poor and the elderly through Medicaid and Medicare) and favored