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he Indianapolis metropolitan statistical area (MSA) covers 3,532 square miles in central Indiana, which includes Indianapolis (Marion County) and eight surrounding counties. Indianapolis shares its borders and a consolidated local government with Marion County, and is home to about 820,000 of the 1.46 million residents in the Indianapolis MSA. With the exception of Hamilton County to the north, which includes the city of Carmel, and Madison County in the northeast, which includes the city of Anderson and hosts a major General Motors plant, the remaining counties are predominantly rural.2
Demographic characteristics are similar to national averages, but with substantial variations across counties. For example, about 21 percent of Marion County residents are black, compared with less than 1 percent of residents in all other counties except Madison. In 1993, Indianapoliss average annual per capita income of $22,019 was about 6 percent higher than the U.S. average. However, the median family income in Hamilton County was more than 50 percent higher than that in Madison or Marion counties. Indianapolis has a robust economy, with unemployment below 4 percent in 1995.3
Indianapolis ranks very near the U.S. average with respect to many common health status indicators. However, infant mortality is about 14 percent above the U.S. average among white residents and 3 percent above average among non-whites.4 Those rates declined substantially between 1988 and 1994, possibly as a result of community initiatives aimed at reducing infant mortality.5
THE HEALTH CARE MARKET
Indianapolis has about 13 percent more hospital beds per 1,000 population than the U.S. average, and its inpatient utilization rates are about 22 percent higher.6 Most of that bed capacity is located in the urban core of Marion County. Indianapolis also has about 6 percent more primary care physicians and 17 percent more specialty physicians per 1,000 population than the national average.7
In addition to serving Marion County residents, the Indianapolis health care system receives referrals from the southern and central regions of the state. As a referral center, it offers the full spectrum of specialty and subspecialty services through its large, hospital-based health care systems and the University of Indiana School of Medicine. The major health care systems in the core market have distinct geographic service areas for routine care, although certain systems are considered the providers of choice for specific clinical services. Despite above-average service utilization rates, most informants described Indianapoliss health care costs as moderate.
LEADERSHIP AND DECISION MAKING
During recent years, Indianapolis has engaged in a substantial number of economic development activities, most directed at revitalizing its downtown area. These activities have been carried out primarily by local government with the strong support of civic leaders. Thus, collaborative decision making around community issues has an important history in Indianapolis, with results that generally are viewed as positive. However, health care to date has not received similar attention from community leaders.
Instead, health care decision making has remained primarily the province of the major health care delivery systems. Many of the physician leaders within these systems are Indiana natives with long tenure. A significant percentage of local physicians and administrators were educated at Indiana University and the IU School of Medicine and have a common educational and cultural bond.
Religious and consumer organizations appear to play limited leadership roles with respect to health care decision making. The Citizens Action Coalition is establishing a task force on managed care, and the Indiana Primary Health Care Association has worked in support of community health centers and their clients. However, these are very targeted efforts with limited impact on the market as a whole.