: The candidate's most general career goal is to independently conduct high quality research that will leverage improvements in access to health services. A related career goal is to advance theoretical understanding of transformations of public health and medical systems and how these changes affect access to services by vulnerable populations. His proposed research agenda and training program have been fashioned to catalyze development of research skills needed to meet his research and career goals. The proposed research agenda is to study several mechanisms through which increases in managed care may have affected provision of care for the uninsured by local health departments (LHDs) and physicians. The candidate will examine the extent to which increases in managed care have: a) diverted Medicaid revenues away from LHDs, reducing their cross-subsidization and provision of care for the uninsured; and b) decreased the Medicaid revenue and overall revenue of physicians, leading to a decrease in their provision of charity care. He also will examine the extent to which increases in managed care have: a) decreased physicians' autonomy (indicated by decreased ownership, decreased perceived clinical freedom, and increased size of practice), leading to decreased charity care; and b) increased discontinuation and privatization of LHD services resulting in a decrease in LHDs' ability to assure access of the uninsured. This research will aid development of strategies for improving access to health services among the uninsured. The analyses will require that the candidate learn new techniques of statistical analyses and application of theories from the fields of health economics and the sociology of health institutions and professions. Through courses and regular interaction with a statistical mentor, he will acquire new statistical analytical skills. To analyze and interpret physician responses to organizational and financial incentives and constraints on the provision of charity care, the candidate will study the theoretical and empirical literature on physician agency, including physician motives and power under the complex conditions accompanying increased HMO and Medicaid managed care penetration. He will study this literature through formal courses and through interaction with mentors, applying this knowledge to the analyses. ? ?
