Doctors for Seniors Legislative Bill

Brave Sponsors Wanted That Will Do What Is Needed and Turn the Language of Health Access into Legislative Language

Robert C. Bowman, M.D.

Studies demonstrate

Health Workforce Needs By Age in Physicians per 100,000 People

http://bhpr.hrsa.gov/healthworkforce/reports/physiciansupplydemand/growthandaging.htm

Primary care demand is extreme in the early years and the later years of life. Unlike the middle years when health needs can be delayed with less consequence, Americans at the extremes of age face greater consequences when health care is not accessible - and health care is getting less accessible.

The Primary Care component in the table is about 33% of the physician workforce needed for care of seniors. This is not the design of health care workforce. The nation’s top ranking medical schools graduate 10% who remain in primary care who locate mostly were senior Americans are not found. Few sources of physicians or non-physicians graduate the workforce needed for seniors. What is worse is that medical schools, physician assistant programs, and nurse practitioner programs are graduating more and more graduates but this does not translate to more primary care. This is because the flexible primary care forms have moved steadily away from primary care. Less than 30% of the workforce of these 22,000 graduates will be spent in primary care. Meanwhile 3000 family physician graduates and 3000 pediatric graduates will do the bulk of primary care delivery. American medical schools are making matters worse. They graduate the fewest family physicians, internal medicine graduates remain in primary care at 10%, and pediatric graduates will have only about 50% of careers spent in primary care with current losses.

The combination of exclusive medical education and exclusive US policy has resulted in exclusion of basic health access. This is compounded by nursing leadership that has moved more exclusive and extremely poor US support for nurses with basic health access nursing left behind.

American health policy actually destroys existing nursing workforce as well as primary care internal medicine, primary care and family nurse practitioners, and primary care and family practice physician assistants. These graduates are all converted to hospital and specialty care and away from the most needed primary care area.

Proposals in front of Congress would take 1 billion dollars away from Medicare to train more resident physicians. This proposal would result in

• Fewer dollars for health care for senior health care
• More health care dollars shifted to 4% of the land area where 90% of health care dollars related to physicians are found.
• More physicians found in 4% of the land area in training, locations with less than 30% of seniors and only the wealthiest of the seniors that can afford to live in such locations
• More physicians found in 4% of the land area in practice (following the dollars and training influences), locations with less than 30% of seniors and only the wealthiest of the seniors that can afford to live in such locations
• No more physicians found serving in primary care as the internal medicine graduates supported by this bill remain in primary care and geriatrics at less than 10%. Internal medicine has plummeted from the most important source of primary care to the least important source when comparing 1980s internal medicine residency graduate to the 10% or less choices found in the most recent surveys.

Training programs are actually restricted (by their basic designs of accreditation and funding) from locating in zip codes that do have concentrations of seniors as well as other populations in need of health care. Meanwhile training dollars and clinical dollars are concentrated in locations that do have top concentrations of physicians. Training design must complement the health care needs of the nation. The nation should not just serve the needs of training institutions without some real benefit for Americans in need  of health care.

At a time when populations over 50, over 65, and over 75 will double, the major flaws in the American design are revealed. Senior Americans are left behind in the current health care design like rural Americans, like lower and middle income Americans, like Americans in need of nurses and family physicians in Community Health Centers, like Americans in urban underserved locations, and like Americans in Alaska, New Mexico, Montana, Idaho, Wyoming, North Dakota, South Dakota, Nebraska, Kansas, Oklahoma, Iowa, Wisconsin, Minnesota, Indiana, Kentucky, Tennessee, Alabama, Mississippi, South Carolina, North Carolina, Vermont, Maine, and New Hampshire. The design favors states, cities, and populations that have more physicians already as well as top concentrations of people, income, graduate medical education, research, and health care funding.

Proposals in front of Congress will allow more physicians to specialize and more to locate in states with top concentrations of physicians. There is no proposal that will increase family practice physicians, rural physicians, or physicians for underserved areas. There is no proposal to increase basic health access nurses that will serve the primary care needs of seniors, rural populations, or underserved populations.  The nation will be 1 million nurses short in 2020 and the shortages will impact ambulatory care, rural care, and care for underserved populations even more.

Many believe that health access is difficult to produce. Actually there are designs that have supplied generations of health access physicians. Graduates of the Duluth medical school, West Virginia School of Osteopathic Medicine, and other health access medical schools deliver 64 times more rural primary care than the graduates of the top 20 medical schools ranked by MCAT. Most osteopathic and most allopathic public medical schools deliver health access at higher levels. Only the most exclusive schools with the most exclusive admission and training designs fail in health access.

Exclusive schools fail most in health access. Most needed primary care required by the elderly is supplied by half a geriatrician, 1 family physician, and 2 internal medicine graduates out of 100 graduates of top 20 MCAT schools.

Duluth has an entirely different outcome specific to the needs of older Americans in Minnesota and surrounding states. Duluth outcomes include 45 graduates in family medicine and 5 graduates who stay in primary care internal medicine. This is 50 out of 100 graduates that serve mostly older populations. In addition Duluth graduates actually locate practices in the nation’s top concentrations of elderly. Harvard, Yale, and other top 20 school graduates contribute about 5 out of 100 graduates that locate primary care practices at 70% or greater levels in 4% of the land area in top concentrations away from locations where older Americans are likely to be found. The difference in most needed care for the elderly is staggering in comparison.

Of course nearly all medical schools want to be like Harvard and Yale for the prestige, for the graduate medical education dollars, for the research dollars, for the large endowments, and for the top revenues generated under US health care design.

The Duluth model has pumped out most needed health access for nearly 40 years of graduates with 30% of graduates found in top concentrations and 70% found in practice locations where 65% of Americans and 70% of the elderly are found. Schools once like Duluth, such as Mercer, have moved away from most needed health access. Even Duluth has difficulty convincing  medical students selected and trained for rural family medicine to remain in this pathway. More normal in admission, more normal in training, more normal in career choice, and more normal distributions of health care funding serve most needed health access. It is the funding of health access that has become a major problem. Up until the 2008 class year, 44 – 52% of Duluth graduates chose family medicine careers. In 2009 the level of family practice sank to 36%, a likely indication that optimal admission and training for needed rural health access is unable to compensate for the destructive policies of the nation that convert actual continuity primary care practitioners away from most needed health access to hospital careers, specialty careers, and practices found in top concentrations. Who can choose a permanent health access career when most Americans cannot trust that they can find basic health access?

Top 20 medical school graduates have 80% found in concentrations where elderly are not found with 20% found outside of concentrations. Exclusive admission, exclusive training, and exclusive career choices combine with exclusive policy to move physicians away from elderly, rural, lower income, and middle income populations.

Health care for seniors has been damaged, but this damage has not had a chance to result from the current political leadership or the last decade of political leadership. Health care for seniors has been compromised by a design tolerated by the past two generations of leadership that failed in the most basic requirement of health care – basic access to health. This is particularly tragic regarding the elderly. Their own generation of leadership failed them the most at the time when they will need health care the most. Also the elderly are the Americans that come closest to universal financial access to care. Even universal access cannot help people that do not have basic nurses and family physicians to care for them.

Many will claim to care for older Americans, but they are limited by the truth found in who does actually care for the elderly. Those who have cared for the elderly at the highest levels are also the ones that will continue to care for seniors. The physicians that are found serving seniors, lower income populations, middle income populations, and rural populations are physicians with lower and middle income origins, physicians who were older at medical school graduation, and family physicians. Those least likely to serve senior ambulatory needs are physicians with most urban and highest income origins, physicians with normal or younger age at graduation from medical school, and physicians from exclusive medical schools.

Only about 15 – 20% of older Americans see a general internist for ambulatory care. The major limitation for internal medicine as a source of primary care is that few internal medicine graduates remain in primary care. Those beginning in primary care have declined from 60% to 10% over the past 15 class years of graduates. The US had found new ways to destroy primary care internal medicine as the nation has lost 30,000 more primary care internal medicine physicians in the past 6 years alone. Internal medicine physicians have top concentrations in 33 counties in the United States with top densities of people, income, and physicians. This limits distribution to locations where the elderly are found – away from concentrations.

Three times more seniors see a family physician compared to a general internal medicine physician,¹ even when there are 60% more general internists in numbers across the nation. A national design for care for senior health care needs would have 8000 family medicine residency graduates a year and only 3000 internal medicine residency graduates a year but the design is reversed with 8000 in internal medicine and 3000 in family medicine.

A medical education and graduate medical education design that serves seniors as well as most Americans would result in 8000 more graduates a year in family medicine. See 5000 more FM including links to graphics

Family physicians have consistently been documented to care for seniors of all locations and populations – those poor, those less educated, those in rural areas, those who are minorities.^{1, 2}

Family physicians have location patterns consistent with senior Americans. About 50 – 60% of family physicians are found in 30,000 zip codes where 65% of the US population is found along with 70% of American seniors. Only 25% of physicians and internal medicine physicians are found in these locations. This is because 75% of all physicians and 70% of general internal medicine physicians are found in top concentrations in 3400 zip codes in 4% of the land areas. General internal medicine physicians are found at the highest levels in cities with the top population density, the top cost of health care, the top cost of living, the most physicians, and the most health care resources.

See also Distributions of Physicians by Specialty indicating increasing concentrations of specialists in counties with higher concentrations of people with internal medicine in top concentration counties. Family physicians are found at 30 – 40 per 100,000 for the widest range of populations, regardless of coding. See table at end.

Unfortunately higher costs of living and health care force seniors to move away from top concentrations to more reasonable cost of living locations. When they leave top concentrations and highest costs, they also leave locations with saturations of physicians, specialists, cancer centers, stroke and heart attack centers,³ and primary care. They must leave locations with concentrations of physicians and costs to live with lower and middle income Americans that have more reasonable costs of living. Like seniors, most Americans must move away from such concentrations. Even physician subspecialists that have retired can be tracked to zip code locations away from the highest cost and highest income locations to the marginal and underserved locations where more reasonable costs are found. Only after retirement do they find out the difficulties of the American health design – finding a physician that will see them and will accept the limited fees paid to primary care physicians by Medicare.

The bottom line is that current proposals in front of Congress will not help the most pressing health care needs of seniors – to be able to find a physician that starts in primary care, stays in primary care, distributes to locations where seniors are found, and cares for seniors. A permanent design for health care that works is a design with permanent health access physicians, training in permanent health access, and funding that permanently supports health access. The current funding design that allows specialty health care needs to grow and engulf all other health care needs, including basic health access, is a flawed design that most fails the youngest and oldest and those of lower and middle income that most depend upon basic primary care health access.

The Advantages of Permanent Health Access for Seniors

• Family physicians start 95% in primary care and stay 95% in the family practice form that distributes at highest levels to seniors.
• Family physicians stay 85 – 90% in primary care while all others serving seniors only have 10 – 35% in primary care (IM, PA, NP) and move away from the broad generalist family practice and primary care roles with each passing year.
• Only the family practice forms of MD, DO, NP, and PA can be found serving seniors at higher levels and only the family practice physicians remain in the family practice broad generalist mode that serves all ages and locations.
• Family physicians have 3 times the rural location rates of other physicians. Only the family practice NP and PA forms have similar distribution and once again the NP and PA family practice forms are leaving family practice with each year after graduation.
• Family physicians have two times the urban needed location rates of other physicians, once again these are locations with more seniors compared to urban locations with top concentrations of physicians. If you are a senior that can afford the highest cost of living and health care, then you want to live in 4% of the land area in one of 3400 zip codes with concentrations of physicians. If you are a senior that needs efficient and effective care that is nearby and accessible, you want movement toward broad generalist family practice.
• Family physicians in 2004 were 3 to 4 times more likely to be seen by Americans age 65 or greater compared to internal medicine and nurse practitioner graduates¹ even though the nation only graduates 3000 family physicians a year, 8000 internal medicine graduates, and 7000 nurse practitioner graduates. The difference is that family physicians serve 35 years of primary care with 90% remaining in primary care with 85% active with 100% of the top volume of a family physician for 25 Standard Primary Care years delivered in a career. Internal medicine graduates include nearly half who are foreign origin international medical graduates that deliver the least primary care of all at only 1 to 2 Standard Primary Care years. This results in 2 Standard Primary Care years for internal medicine graduates who have fewer years, lower volume, only 10% remaining in primary care, and lowest activity. This is because 30% of foreign origin international medical graduates deliver no health care in the United States, leaving for other nations at graduation or remaining chronically unemployed. About one-third of nurse practitioners serve in family practice, general internal medicine, and geriatric careers, but only 60% are active, they deliver the lowest volume of primary care of all sources, and they only have 27 year careers instead of the 35 of physicians.

The secrets of primary care, geriatric care, and basic health access are not difficult to understand. To deliver most needed health care, practitioners must stay broad generalists who serve all ages, they must locate practices where seniors and others in most need of health care are found, and they must resist current health care policy and design that packs more physicians and non-physicians (all of the non-family practice forms) in 4% of the land area with already top concentrations of physicians and health resources.

For the elderly, the design of health workforce is crucial. As primary care needs quadruple with advancing age and as personal mobility and travel mobility are impacted by age, the required design is local primary care specific to zip code of residence or a nearby zip code. The solution is entirely about family physicians that distribute equitably to all and are more likely to care for seniors.

The United States has never had problems producing specialists or physicians for top concentrations. The United States has always had problems finding physicians to care for the elderly, rural populations, and underserved populations. Solutions for age 65 and up and for the 65% of Americans left behind are the same – the doctors most needed, the basic primary care funding most needed, and sufficient funding for lower and middle income populations in need of health care, including the elderly.

More funds to not graduate those most needed, are a deception as well as a waste and senior leadership and health leadership should be held accountable.

 

County Population Density	FPGP per 100,000	Comments
Pop Density 1 – 16	34	More Seniors
Pop Density 16 – 32	28.9	In more rural
Pop Density 32 – 64	28.5	Counties and
Pop Density 62 – 125	36.7	FM 40 - 100% of care
Pop Density 125 – 250	47.8
Pop Density 250 – 500	62.9	More rural in nature
Pop Density 500 – 1000	54.3	US Average
Pop Density 1000 – 2500	48.7	US Average
Pop Density 2500 – 5000	82.8	Midwestern Counties
Pop Density 5000 – 10000	42.7
Pop Density 10000 up	21.3	Eastern Concentrations
Only about 3 dozen counties	with 2500 or more	(where policies are set)

See also Distributions of Physicians by Specialty indicating increasing concentrations of specialists in counties with higher concentrations of people.

1.            Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.

2.            Mold JW, Fryer GE, Phillips RL, Jr., Dovey SM, Green LA. Family physicians are the main source of primary health care for the Medicare population. Am Fam Physician. Dec 1 2002;66(11):2032.

3.            Perrotta BL, Perrotta AL. Access to state-of-the-art healthcare: a missing dynamic in consumer selection of a retirement community. J Am Osteopath Assoc. Jun 2008;108(6):297-305.

www.basichealthaccess.org

www.physicianworkforcestudies.org

www.ruralmedicaleducation.org