The survey found that there may be fewer differences, at least clinically, between practicing in rural areas and urban ones than one might think.

"Most of the physicians were pretty pleased with how rural medical practices worked for them," says Tim Skinner, executive director of the National Rural Recruitment and Retention Network in La Crosse, WI. "There are a lot of plusses to the practice of rural medicine--and actually many of the rural practices have the same equipment, the same technology as suburban and urban practices do. Much of it is quite up-to-date."

Of those surveyed who have practiced in rural areas, for example, 31 percent said they think profitability among rural practices was about the same when compared with their urban counterparts, and 23 percent even said rural practices were more profitable. Only 18 percent said practicing in a rural setting was more frustrating than working in an urban facility, and 45 percent said urban and rural settings were "about the same" in regard to frustration.

There are, however, stark differences between the two--especially when it comes to connecting with patients. Of those surveyed who had practiced in rural areas, 52 percent said they think doctors have a closer relationships with patients in a rural practice, compared with 3 percent that said they think doctors have closer relationships with patients in an urban or suburban practice.

"What's different is you have a more personal connection," says Jim Stone, MD, who practices in Atlantic, IA. "Medicine has become a volume-based profession, and in an urban setting you have much less time to spend with patients."

The survey also gauged the physicians' thoughts on lifestyle comparisons between urban and rural settings. Predictably, the findings were all over the map--31 percent said they liked rural settings more, 19 percent said they preferred urban settings, and 15 percent said life was about the same.

Doctors say where one prefers to practice is simply a matter of the type of person they are and the lifestyle they are accustomed to. "I think it really has a lot to do with the physician's personality and also the desires of the physician's family," says James C. McLoughlin, MD, a surgeon who practices in Ogdensburg, NY. "Rural settings can be more attractive to physicians who are interested in control of lifestyle: no traffic, little pollution, first-name basis for many conversations, really getting to know the people in a community. For the physician who likes the anonymity of a big city, rural life would probably not be desirable; however, for someone who enjoys solitude and space, rural life can be attractive."

Because of this, Skinner says rural facilities need to look at a potential physician's background and interests when trying to recruit. "A physician who is going to go to a small, rural community in Wisconsin is probably going to be very interested in hunting and fishing, as opposed to the physician who is going to go to a desert area in Arizona and New Mexico who might be more interested in cultural artifacts, archeology, anthropology, and desert life," Skinner says. "You have to look at those preferences."

Smaller facilities should also take steps to show potential physicians that they will not be overwhelmed by being the only, or one of few, doctors in a community. McLoughlin suggests community and rural hospitals seek partnerships with larger city or teaching hospitals by becoming part of an extended telemedicine network. That way, physicians practicing in the rural location don't feel isolated from colleagues, McLoughlin says.

"When a 'tough case' comes into the hospital, the rural practitioner would have access for input from a larger department of physicians or possibly even from those practicing at an academic center," McLoughlin says. "Avoiding the isolation of 'now I'm stuck with this patient that I can't figure out' should be a major goal of any rural hospital trying to recruit physicians."

Perhaps the most telling finding from the LocumTenens.com survey was why physicians who had not practiced in a rural setting had never done so. The three top answers were: never found the right opportunity there (26 percent), never been offered a position there (23 percent), and never considered it (19 percent). Only 4 percent answered they never practiced in a rural setting because they did not want to work there.

"As a former physician recruiter, I thought it was stunning to see that only 4 percent of responding physicians with no rural practice experience said they didn't want to practice medicine in rural America," says LocumTenens.com Senior Vice President Pamela McKemie. "What we'd like rural hospital executives to 'get' from our survey results is that physicians from all types of environments are open to practicing rural medicine, but you've got to approach them about your opportunity before they can consider it."

This is another example of why rural facilities need to be a little more cognizant of making sure the invitation to practice isn't restricted to a small group of physicians who are born in rural areas, Skinner says.

"We really need to emphasize the connection between the community development piece and the medical staff development piece," Skinner says. "In a small town they have to put that together because lifestyle issues have a great deal to do with people either appreciating a smaller community or not."

Skinner says it is crucial that facilities not only promote satisfaction among staff working with patients and practices in rural facility, but also work with the community as a whole to help draw potential physicians. He suggests healthcare providers tout agencies and resources such as social and human services that can potentially support physician practices. Stipulating how close the nearest college is for potentially furthering the physician's education, developing a strong community-based Web site, and promoting available leisure activities in the area are all ways providers can work with the community to attract physicians.

"The smaller the town, the more important the community development piece is," Skinner says. "What they can do is they can really step up and say, 'This is what our schools offer, here are our recreational and cultural activities.' If the community piece is missing, they might pass on a rural practice even if they offer the physician and the physician's family everything that they need."

After largely abandoning the capitation model nearly a decade ago in favor of paying providers on a fee-for-service basis, Massachusetts' largest insurer is coming back to the market with an updated plan for paying hospitals and doctors a flat fee for caring for its members...and providers seem receptive to the change.

Blue Cross and Blue Shield of Massachusetts says the plan offers a way to rein in runaway costs while rewarding providers for giving more efficient and higher quality care. And providers say they are open to the idea a new payment system, as long as they get the information the need to effectively manage the care and control costs.

The concept of capitation has been around for years and is still widely used in several markets across the nation. But capitation was also the payment system behind much of the managed care backlash that dominated the healthcare debates of the late 1990s.

Blue Cross of Massachusetts, however, says the program it is rolling out is eliminates the disincentives that were prevalent in previous versions of capitation--disincentives that encouraged rationing of care and/or cherry picking of members. Additionally, it is offering the program as a voluntary option for groups that are interested in participating.

"We actually want to pay for outcomes," says Chris Murphy, a Blue Cross and Blue Shield of Massachusetts spokesman. "So instead of a model that rewards only for volume and complexity, our system will give them a set amount to keep the patients healthy and when they do then we'll give them bonuses of up to 10 percent."

To ensure fairness from one group to the next, Murphy says the insurer will adjust payments according to the relative health of their assigned patients. This risk adjustment will be performed annually to account for patient transfers and changes in health status.

The move could be a good one for rehabilitating the image of capitation, which has been maligned in the past for blindly transferring the financial risk to providers without also giving them the controls to effectively manage care.

While providers concede that the system is ripe for a change in the way they are paid for rendering care, they are cautious about the program in light of past problems with capitation.

"One concern is that there is surprising little information for physicians regarding the cost-effectiveness of various elements in healthcare. So in order to deal with this situation you have to be able to shop, you have to be able to consider substitutions or what tests can be safely dropped without compromising care," says B. Dale Magee, M.D., M.S., president of the Massachusetts Medical Society. He maintains that simply moving the financial risks to the doctors without recognizing their need for this data and their ability to manage it is a recipe for disaster.

"Just as you don't treat every patient the same, you don't necessarily treat every physician group the same," says Magee. "You have to do a needs assessment and make sure that you're providing them with the appropriate resources to do the job that they're being asked to do."

While Blue Cross' action is sure to create waves in Massachusetts where capitation was largely excised from the market, it's not alone in ramping up the use of the fixed pricing scheme to control costs. Physicians and hospitals responding to HCPro's most recent capitation survey reported that risk contracting was coming back in vogue in their markets.

Overall, 30 percent of the respondents said that capitation was rebounding in 2007, compared to the 15 percent who said it was declining. In 2006, however, only 7 percent said capitation was on the upswing compared to 53 percent who said it was on the way out.

So what's happening in your market? Will capitation play a bigger role in your operations in 2008 or has that ship sailed?