Translating Most Needed Health Access: Nebraska

Experiential Place and Health Access

Robert C. Bowman, M.D. rcbowman@atsu.edu

Nebraska has become more diverse in many ways and has developed inner city health access needs to go with longstanding rural health needs.

Most in need of rural health access – about 35% of the state’s population not within 75 miles of Lincoln or Omaha and also somewhat distant from I-80

Origins Expected to Result in Most Needed Rural Health Access – 2 times odds ratios rural practice

Origins in any town in the state that is at least 75 miles from Omaha or Lincoln
Lower and middle income origins
First generation to college
Graduates entering medical school 3 or more years later, especially those with a previous serving career or health career (1.5 odds ratios)

Origins Least Likely to Result in Most Needed Rural Health Access – 0.5 odds ratios of rural location

Most urban origins in Nebraska or another most urban location
Highest income parents
Physician or professional parents
Birth in a county with a medical school, likely same for Omaha or Lincoln origins
Private school or top property value school district origins
These origins are associated with top standardized test scores
Combinations of all of these concentration factors are likely to result in even lower health access career choice as well as top standardized test scores
These origins are also associated with departure from the state for graduate medical education, subspecialization, and departure from the state to practice in higher concentrations in other states

Career Choice of Family Medicine – Triples rural location for UNMC graduates as with other origins or medical schools or medical school types.

2009 UNMC graduates with Large Metro out of state, Lincoln, Omaha, or suburb origins had 3% family medicine choice
2009 UNMC graduates from large rural towns had 10% family medicine choice
2009 UNMC graduates from the remainder of the state had 20 – 30% family medicine choice
Family medicine choice is associated with lower and middle income and lower and middle population density origins, first generation to college, and older graduates

Career Choices with Lower Probability of Rural Location based on national data

Subspecialty – 0.4 odds ratios of rural location
Hospital Support Specialty – 0.6 odds ratios of rural location
General specialty (surgery, orthopedics, urology, ob-gyn) – 0.8 odds ratios
Internal medicine or pediatrics – even odds of rural distribution, but mainly to larger rural locations
These are also career choices associated with greater departure from Nebraska

Impact of Allopathic Public School – 1.3 times odds ratios, perhaps 1.5 times for the UNMC rural effort

Directions for Nebraska Moving Away from Health Access

Deteriorations in rural, lower income, and middle income origin Nebraska children such that fewer are prepared for medical school from birth to admission (Nebraska did have double the national rate of medical school admission but has declined due to declining economics, education, income distributions, and replacements in admission by more exclusive children with more exclusive scores
More are admitted that have lower probability of rural distribution
Fewer family medicine graduates in all birth origins for UNMC medical students
Fewer family physicians nationwide that previously found their way to Nebraska where salaries and scope of practice were a better fit for them
Fewer medical students from other states choosing family medicine resulting in fewer finding their way to Nebraska family medicine residency programs
Urban primary care in Nebraska dissolved in the past decade with Lincoln and Omaha primary care physicians retiring, leaving, or converting to non-primary care specialties again with state health policy partially responsible with cuts of significant urban populations from Medicaid coverage – these shortages in urban areas complicate rural workforce efforts
Urgent, emergent, and convenience care efforts compromising continuity primary care efforts and stealing primary care workforce to become locums, emergent, urgent, hospitalist, and specialist workforce
US health policy less and less supportive of basic health access – primary care, care of rural and lower income and middle income populations – higher costs to deliver care and reimbursements that are stagnant, delayed, or more complicated
US policies that favor top concentrations of physicians with the most lines of reimbursement and the highest degree of reimbursement in each line
US health policy sending the least funding to rural Nebraska
Shortages of rural physicians increasing as the nation fails to graduate the types of physicians most likely to distribute resulting in even less federal and state health funding going to rural Nebraska – economic disruptions from lack of health spending in a location or population
Subspecialty hospitals concentrating profit, revenues, physicians, and patients away from smaller and rural hospitals.

Principles of Health Access Summary Points

Steps to Health Access

Basic Health Access Concepts To Review

The Basic Table - Taxonomy, Themes, and Theories Related to Experiential Place and the Principles of Health Access

Experiential Place and Health Access Considerations

The Counterproductive and Untrue Perspective of the Impossibility of Health Access

Nebraska: A Practical Application of Experiential Place and Workforce

Why Physician Workforce Needs New Tools (and a health access perspective)

Basic Health Access Index

Physician Workforce Studies