States That Concentrate and States that Distribute

 

Robert C. Bowman, M.D.

 

If you do not understand differences state to state in the United States, you cannot plan health care for an entire nation. It is not a surprise that the health care plan that we have does not fit the United States. It mainly fits the health care in 3400 zip codes involving 75% of physicians and 90% of medical schools that are found in 4% of the land area in top concentrations.

 

Also to understand health care cost, quality, and access, one must understand birth to age 6 investments in children as the ultimate solution. Investments in the youngest children involving nurturing, child development, and education would appear to be the best possible investments for a state or nation in any area, but this is especially true of health. The reason is that people make the decisions to invest in health or not, just as they invest in education or not, or in their own children or not.

 

Of course the caveat is that the state or nation making the investment also is able to benefit from the investment. When states that invest show little progress and states that invest little dominate, it is even possible for the “evidence” to favor those who fail to invest. Such is the United States design for health, education, and more. Until there is accountability and movement by all states, especially those most economically able, toward better investments in children with a better American child, true recovery is not possible.

 

At the current time in the United States there seems to be little point in investing in children. States such as Iowa, Nebraska, Kansas, Minnesota, Wisconsin, and North Dakota continually donate teachers, nurses, and physicians to other states but now find it more difficult and more costly to obtain the needed professionals. These are states with top college completion rates and other measures of efficient and effective society.
Why should their investment in children be compromised by the US design that favors top concentrations in people, income, health design, and property value? Even a cursory examination demonstrates that states that concentrate have poorer health, especially in areas related to population crowding such as infectious disease. Did it profit the state of Louisiana to stack resources in harm’s way below sea level? What about 150 – 200% increases in Florida coastal county populations each decade? Why do we concentrate health resources in bayous as in the Texas Medical Center where two floods have resulted in earthworks that would make Robert E. Lee proud? The next major earthquake could take out major concentrations of health care in Los Angeles, San Francisco, St. Louis, or other locations. FEMA warned the nation about all of these areas dating back before 2000. Seems that those who profit from concentrations fail to do the one thing that could help limit damage and facilitate recovery – distribute people and health resources. By the way, the other aid to pandemic preparation and modification is adequate nurses, which will be 1 million short by 2020. Nurses are also the result of investments in lower and middle income children as well as sufficient investment in nurses. Nurses, teachers, public servants, and family physicians have been left behind, just like the lower and middle income populations that they arise from and that they depend upon.

 

Meanwhile other states invest little and obtain the professionals that they need. A number of states benefit from policies involving the least investments in children. The lack of lower and middle income investments typically results in a number of consequences. These include inefficient function in a number of areas such as education, economics, job performance, and increased costs in areas involving public security.

 

While some states with low income, low property values, and great poverty clearly do not have the ability to make the necessary investments, there are other states with the top economics in the world. Having achieved a certain level of economic advantage over other states and nations, they find it easier to obtain what they need by economics rather than investing in children. In addition these are states that manage to escape responsibility for their actions. They do not even see their great advantage and the consequences that result since the consequences are in other locations and populations at some distance.

 

The nation also plays a major role in these inequities beyond simple tolerance. The basic policies have been to allow “market forces” to shape children, states, and the nation. Unfortunately market forces policies leave lower and middle income children behind. Lower and middle income parents find it difficult to balance child raising and making a living. Education is funded based on property taxes. States allow gaps in funding to exist with lower and middle income children left behind. Lower and middle income children have the less access to education that leads to college preparation or better test scores. The result is much the same with higher status children attending college at 90% levels with half this level for middle income and one third or less for lowest income. The top 146 colleges that shape the nation’s leadership have 74% arising from the top 25% income level and only 3% from the bottom quartile.1 Medical schools are much the same with 60% (more now) arising from the top 20%, 80% from the top 40%, and only 20% arising from the bottom 60% in income for decades of past graduates. Those in the top segments are increasingly concentrated in not only income, but most urban origins, children of professionals, even fewer elite colleges attended, and more. Single dimensions such as income fail to capture the combinations of concentrations that are most rewarded in America.

 

Of course this makes matters far worse for those not with combinations of concentrations. Because of poor investments in children in past decades, state budgets are depleted by the costs of prison, legal costs, social programs, and health care. Poor economic performance and productivity, at least in part due to poor investments in American children, limit American competitiveness in the world markets. Health care and energy costs cripple American businesses. The same impairments are most evident in areas such as government, health care, and education. These are sectors dominated by the costs of service oriented professionals – public servants, nurses, and teachers. Not surprisingly these front line human infrastructure personnel have had no real income gains in 30 years. In addition, changes in children due to poor investments make their jobs more complex and less productive. In addition they are often scapegoated for national problems in government, health care, and education. Few have any idea that these front line infrastructure positions that help make the nation efficient and effective are predominantly lower and middle income children growing up and serving. The nation depletes the service oriented pool and becomes less efficient and less effective without efforts that continually assure that each new generation of Americans has a better age 0 – 8 start than the last.

 

For these and other reasons, the United States is moving steadily toward maldistributions in multiple areas such as income, population, economics, education, and health resources. Each of these maldistributions also contributes to maldistributions of physicians. Physician concentrations are even more dramatic than population concentrations. For example in the super center zip code locations with 200 or more physicians, the United States population is also concentrated with 1700 people per square mile or 17 times the 100 person per square mile average for the nation. The super center concentrations of physicians were 19.1 physicians per square mile or 64 times greater than the 0.3 physician per square mile average for the nation. Super centers with 200 or more physicians at a zip code have 19.1 physicians per square mile in about 0.5% of the land area. This is a greater concentration than the 18 people per square mile found in rural underserved areas of the nation with 40% of the land area.2

 

Extremes of concentration on both ends are inefficient and ineffective. Population growth is a reasonable measure of efficiency. The most concentrated locations are losing population. Also the least densely populated areas are losing population. The top 51 counties that have top quartile income and medical school concentrations of physicians have top concentrations of people. From 1970 to 2000 these areas lost population share from 22% to 20%. There are also reasons to distribute health care resources known as surge capacity events, pandemics, and natural disasters. Only three interventions are likely to be effective – spreading out health care resources, spreading out population, and producing more nurses. The United States is concentrating health resources by admission, training, market forces, and current policy. Current policy also concentrates populations, often in locations vulnerable to plate tectonics or flooding.

 

More about nursing is indicated since no one appears to be aware of this situation. Not only does the United States fail to advance lower and middle income children to address shortages, it fails to support existing nurses, and steals existing nurses from needed areas. Nurse practitioners were promoted as vehicles of primary care, but at best only contributed about 1/3 of the primary care per graduate of a family physician and now it takes about 7 – 9 nurse practitioners to contribute the same primary care as a single family physician. Departures from primary care have devastated NP primary contributions. Although NP declines have not been as great as the total loss (<10% remaining) of internal medicine as a future source of primary care or the decline to less than 25% of physician assistants likely to remain in primary care for a career, the NP losses are considerable. Less than one-third of nurse practitioners will remain in primary care and NPs have the fewest years in a career, even fewer years coming with graduatet degree and nurse doctor degree lengthening of training, lowest activity (most inactive or part time), and lowest volume of primary care.

 

Nursing faculty has been depleted to become nurse practitioner specialists and more and more NP graduates serve no primary care at all. Now even stronger market forces capture NPs and PAs to locations with top concentrations of income, health care, and specialists.

 

The nation has effectively compromised health access and primary care after billions in investments. Those who made little investment again benefit without responsibility. 

 

The concentrations of physicians are supported by concentrations of income, education, professionals, graduate medical education dollars, research dollars, Medicare and Medicaid funding and policies, other government programs, foundation funding, private health care insurance, medical schools, health resource investments, and a number of other concentrations.

 

It is interesting that physicians have been coded by concentrations of income and people, but not the most obvious coding - concentrations of physicians. Until the United States understands concentrations and why concentrations are created (income, education, resources, physicians), it will not understand

 

  1. The types of medical students most likely to distribute,
  2. The types of medical schools most likely to distribute,
  3. The policies and practices associated with distribution,
  4. Primary care,
  5. Health access,
  6. Family practice, and
  7. The primary care forms most likely to distribute to those in most need of health care

 

Studies have illustrated the role of family physicians and primary care by comparing super center, major center, and distributional locations. In these studies family physicians and primary care physician dominate distribution while concentrations are the rule in major center and super center careers and locations.  The medical school zip codes had the lowest percentages of primary care but the highest concentrations with 200 – 300 primary care physicians per 100,000 people. In fact the super center and major center concentrations are the only locations with more than the 100 primary care physicians per 100,000 recommended as a sufficient level.

 

This study compares state distributions of physicians. The states with concentrations of physicians are favored greatly in the current medical education and health policy era. The states that have the lowest concentrations of physicians in major centers and super centers face numerous difficult obstacles.

 

One caution is necessary. Those reading this article should not have the impression that only a small portion of the United States population is impacted. This is a major defect of studies that focus on shortage areas, rural areas, certain minority populations, or states without concentrations of physicians. The current policies and practices of the United States leave 65% of the population behind. This is just one of many different studies illustrating just one of the perspectives of the populations left behind in proximity to physicians, financial access to physicians, transportation access, the child development and education and personal development to know when to access physicians, the family ability to access physicians (single parent, both parents working), public security to allow access to physicians, new obstacles such as co-pays and higher deductibles that impair access for those with numerous barriers, and other dimensions.

 

 

 

Physician Distribution By Concentration Coding in Concentrational States

 

All Outside of Physician Concentrations within each State

Inside of Physician Concentrations

 

Marginal Urban

Urban Under-served

Marginal Rural

Rural Under-served

All Outside

All Inside

Super Center 200 or more

Major Center 75 - 199

US

13 – 16%

4%

3.5%

3%

20 – 25%

72 – 76%

43.0%

29.2%

DC

0.7%

10.4%

0.0%

0.0%

11.1%

88.9%

67.8%

21.1%

NY

10.9%

2.1%

2.0%

0.8%

15.7%

84.3%

59.7%

24.6%

MD

13.7%

0.9%

1.5%

0.3%

16.4%

83.6%

62.5%

21.0%

HI

6.6%

0.7%

11.2%

0.5%

19.1%

80.9%

52.1%

28.8%

IL

13.5%

3.1%

2.5%

1.7%

20.8%

79.2%

53.9%

25.3%

MA

19.3%

1.7%

0.9%

0.2%

22.1%

77.9%

51.2%

26.7%

CA

15.5%

5.1%

1.1%

1.1%

22.7%

77.3%

44.1%

33.1%

PA

18.1%

1.9%

4.1%

0.6%

24.6%

75.4%

47.0%

28.4%

DE

14.8%

2.6%

7.5%

0.0%

24.8%

75.2%

10.2%

65.0%

OH

17.2%

3.2%

4.6%

1.3%

26.3%

73.7%

43.2%

30.5%

MI

16.9%

2.5%

5.4%

1.5%

26.3%

73.7%

50.5%

23.2%

LA

7.1%

11.1%

0.0%

8.5%

26.7%

73.3%

45.6%

27.7%

MO

14.5%

2.6%

4.3%

5.3%

26.8%

73.2%

53.6%

19.7%

CT

23.2%

1.7%

1.6%

0.4%

26.9%

73.1%

40.9%

32.2%

TN

15.5%

3.0%

3.8%

5.9%

28.1%

71.9%

47.5%

24.4%

Military and international locations were not included.

 

The basic United States physician distribution by concentration categories are seen in the first row. About 72 - 76% of physicians are found in concentrations. The higher level is a calculation that includes residents and fellows. This includes 50% in super center concentrations averaging 1100 physicians per 100,000 population. An additional 25% of physicians are found in major centers averaging 400. The national average is 300. Primary care physician concentrations in 2005 (but not now after decline) were above the recommended 100 per 100,000 only in super centers and major centers. In all other locations primary care physician concentrations were half (marginal) to one-third (underserved) the recommended levels. In the urban locations outside of concentrations family physicians are 25% of the physicians and in the rural locations outside of concentrations family physicians average 35% and can reach 100% in the most isolated, underserved, or lowest income locations.

 

There are a few constants seen in the distributions. Most states have a fairly consistent 10 – 16% of physicians found in urban marginal locations and also about 20 – 30% in major center locations. These anchor the middle with the major changes state to state being the super center concentrations at one pole and the underserved and marginal rural distributions at the distributional pole. The marginal urban locations also have the greatest variation and some of these zip codes with further examination have subspecialists indicative of physician concentrations even though these zip codes have less than 75 physicians. New zip codes with top concentrations are constantly being created in a nation where health care eats more and more gross domestic product.

 

The physician patterns within various states are stacked toward concentrations or stacked toward distributions. States with more physicians in super center locations have fewer physicians (lower percentage) that distribute outside of concentrations. They also have fewer family practice and primary care physicians, the physicians most associated with distribution. These are also states with lower physician assistant primary care percentages. There is a close relationship between family practice physicians and physician assistants. States that drive off family physicians also drive off physician assistant primary care or convert PAs and NPs to specialty care.

 

States that concentrate physicians are following the patterns shaped by past decades of changes.  Under current health policy guided by market forces, health systems that make the “correct” business decisions employ the most specialists, convert flexible primary care training forms (especially internal medicine, nurse practitioner, and physician assistant forms) to specialties with greater reimbursement, and focus on higher reimbursed emergency, urgent, and hospital care. Gathering the most federal funds from all sources is also important.

 

Medical schools appear to make the decisions that result in top concentrations at the highest levels and benefit from all lines of revenue and the top reimbursement in each line. This is a reason that family practice and primary care physician are their lowest percentages in the nation at medical school zip codes.

 

Other than Delaware, these states with top concentrations all have their own medical schools. Delaware is surrounded by states with top concentrations of medical schools and integrated with medical education (Jefferson, various graduate programs) with these states. Delaware also has major center physicians (65.3%) but fewer super center physicians (10.7%), a likely impact of not having a focus of concentration such as a medical school or a predominant health system.

 

This may not be a bad thing for health care costs as the Dartmouth catchment areas demonstrate the highest health care costs around older medical schools with top concentrations such as subspecialists and graduate medical education.

 

Graphic   TopCostMS.GIF

 

It is quite interesting that solutions for regional variation elude researchers when graphics demonstrate major causes of cost problems. Also the great concentration of health resources in small areas makes health care difficult for surrounding populations. Cost, quality, and access problems can be understood in the context of United States people divided into rich and poor in income, education, economic, and health care distributions.

 

 

It is important to understand that rural locations can also be super center or major center locations. In the distributional states the rural concentrations do not have 200 or more physicians. States with rural medical schools or states that had physician organizers decades ago (Rochester MN, Cooperstown NY, Danville PA, Marshfield WI) have super center concentrations. Super centers and major centers in rural geographic locations are not typical rural practice locations. Just like urban super centers and major centers they have the lowest percentages of family physicians and primary care physicians. This is an advantage of coding by concentrations rather than geographic coding alone. State workforce analysis based on county types or RUCA small and isolated rural locations can be distorted by a single zip code with 150 to 500 physicians in a particular county or RUCA code. Workforce, recruitment, retention, and reimbursement patterns are different for the rural super center and major center locations. One thing is not different however. The rural specialists are twice as likely to have rural origins just like the primary care physicians in all rural locations. Of course with only 8% of physicians entering the United States workforce with rural origins, even the rural concentrations suffer. Fifty years ago rural males were over 25% of the entering workforce. Now rural males are less than 4%. The slow steady progressive changes in admission, training, and policy have made it difficult for all distributional states.

 

The sixteen distributional states were listed with their physician distributions.

 

 

Physician Distribution by Concentration Coding for Distributional States

 

Distributional Practice Locations Outside of Concentrations

Inside of Physician Concentrations

 

Marginal Urban

Urban Underserved

Marginal Rural

Rural Underserved

All Outside

All Inside

Super Center 200+

Major Center

75 - 199

US

13 – 16%

4%

3.5%

3%

20 – 25%

72 – 76%

43.0%

29.2%

WY

7.1%

0.0%

31.9%

23.4%

62.4%

37.6%

0.0%

37.6%

MT

17.8%

2.9%

14.0%

18.1%

52.9%

47.1%

0.0%

47.1%

NH

24.0%

2.0%

24.4%

0.4%

50.7%

49.3%

18.0%

31.2%

MS

11.4%

7.5%

3.6%

27.0%

49.4%

50.6%

32.9%

17.7%

ME

17.5%

1.0%

17.6%

11.9%

48.0%

52.0%

21.8%

30.2%

ID

25.3%

1.2%

10.3%

10.1%

46.9%

53.1%

9.7%

43.3%

SD

19.9%

0.9%

16.9%

8.5%

46.2%

53.8%

23.2%

30.6%

VT

16.1%

0.0%

27.2%

2.4%

45.7%

54.3%

24.8%

29.5%

AK

22.6%

2.5%

14.7%

4.1%

44.0%

56.0%

29.1%

27.0%

ND

18.9%

0.6%

16.2%

6.4%

42.1%

57.9%

0.0%

57.9%

KS

22.9%

1.1%

13.0%

4.6%

41.6%

58.4%

16.8%

41.6%

AR

17.8%

6.3%

5.1%

12.4%

41.6%

58.4%

31.0%

27.4%

OK

18.8%

5.6%

4.4%

12.3%

41.2%

58.8%

33.7%

25.2%

NE

22.5%

1.6%

14.0%

2.7%

40.8%

59.2%

26.8%

32.3%

IA

14.3%

4.5%

15.8%

1.9%

36.6%

63.4%

31.7%

31.8%

 

The distributional states tend to be states with increased percentages of rural physicians. The states with the most distribution of population have the most distribution of physicians. As states have concentrations of people in one or two locations, the concentrations of physicians increase.

 

 

States with fewer in major medical center locations have a combination of marginal and underserved physicians in rural and in urban locations. These are also states that are often without medical schools and states that have fewer points of physician concentration into major medical centers.

 

Distributional states have suffered under current medical education and current health policy. International graduates are essential for concentrational states that often have more than 25% of physicians from international medical schools. International graduates have not been a consistent solution for the distributional states. The United States does not support “excess” graduate medical education positions in distributional states so international graduates have 1) no origins in the state, 2) no medical school in the state, and 3) no graduate training in the state. Distributional states depend heavily upon those who were born, raised, trained, or had first practice in the state.

 

For a variety of reasons these states have not supported osteopathic training or the osteopathic public schools that have the highest levels of distribution, family practice, and primary care. Oklahoma is the only distributional state with an osteopathic school.

 

These are all states that are most commonly dependent upon a single public medical school as the source of physicians. Not having a medical school to “grow your own” can be a problem. International graduates have not contributed and are less of an option with the decline in J-1 Visa. Osteopathic medical schools have not been supported. Allopathic schools are not graduating the family physicians needed for these states.

 

Successes in states such as Arkansas, Nebraska, and Kansas have involved a coordinated statewide approach with significant distributions of family practice training across these states for decades. North Dakota and South Dakota have instituted medical schools and statewide efforts at slightly later periods. Current workforce “teaching” is that medical schools are very expensive. Current thoughts fail to consider the specific needs of distributional states, the lower costs of osteopathic training, and the major advantages of family medicine graduates including 30 years of primary care services per graduate, the highest levels of distribution beyond major medical centers, and the greatest levels of rural and of underserved distribution.

 

States without medical schools have shipped medical students to other states for training, but the results have not always been satisfactory. The problems can involve the home state that often sends children of concentration (highest status, most urban, children of professionals, political influence) or the fact that medical school and graduate training involves the most concentrated locations (super centers, specialists, urban lifestyle, concentrations of professionals) that may not be the most appropriate for distributional states.

 

Another problem can be graduate training. West Virginia Osteopathic leads the nation in rural and rural underserved and total underserved distribution, but the state has fewer graduate positions in family practice and primary care. Many are asking questions about the expansion to 200 positions a year and are wondering if the same admission or training can be applied across the new addition students and faculty. The biggest question is likely to be whether these students will have to leave the state for graduate training.

 

States such as Oklahoma recognize two important facts 1) that their children leaving the state are less likely to return and 2) the state has greater distributional needs such as rural underserved that require more family physicians. Oklahoma has never been fond of loan repayment and recently terminated the remnants. Oklahoma maintains current scholarship and incentive programs, including paying $1000 more a month salary for family practice residents and $1000 more additional a month for those matching to a shortage need location. Attention to the types of students most likely to serve a state and meeting their needs as medical students, residents, and in the first years of practice can shape different outcomes for a state. The Oklahoma approach recognizes that experiential place involving the most recent influences is one of the best areas for intervention in practice location. 

 

Admissions of children of distribution, distributional training, and family practice emphasis are important factors for states with distributional needs. Federal policies have not been helpful.

  • Community Health Centers and National Health Service Corps programs were poorly adapted to these states.
  • J – 1 Visa Waiver Obligations have not attracted the numbers or the retention.
  • Rural physicians leave 3 million dollars on the table each year instead of filing for bonus shortage area funding.
  • Many of these distributional states have locations just below federal criteria for assistance, mainly because they distribute income and education more equitably compared to concentration states that intensify poverty levels and qualify at higher levels.
  • Medicine pediatric, physician assistant, and nurse practitioner developments once held promise, but the primary care contributions of each of these new forms of primary care have become more and more limited. Specialization rates continue to increase and more move into major medical center careers and locations and away from primary care. These involve transitions that are not helpful to distributional states.

 

On the other hand Critical Access Hospitals and Rural Health Clinics have been essential to the survival of many physicians, small systems, and communities.

 

A common theme is involved. Improvements in methods of reimbursement are much better than qualifying schemes and grant funding.

 

Physician Careers in Distributional States

 

1987 – 2000 Class Yrs

FPGP

Internal Medicine Grads

Office Internal Medicine

ResGrads Retained Office IM

Office Pediatrics

Office Pediatric Retention

Office Primary Care

US

316791

14.2%

28.0%

10.8%

38.7%

10.3%

55.6%

28.9%

WY

388

30.7%

17.5%

8.2%

47.1%

5.7%

77.3%

38.9%

AK

722

30.3%

15.4%

7.1%

45.9%

9.6%

65.2%

38.2%

SD

712

23.5%

25.1%

10.8%

43.0%

7.2%

62.7%

35.7%

ID

1087

26.5%

15.7%

7.9%

50.3%

5.5%

63.3%

35.8%

MT

822

27.5%

18.9%

10.6%

56.1%

6.1%

74.0%

39.2%

MS

2181

16.4%

26.0%

10.0%

38.6%

9.4%

69.1%

30.5%

NH

1410

18.3%

26.2%

10.4%

39.8%

10.1%

67.1%

34.2%

OK

2812

22.3%

22.4%

8.6%

38.3%

8.1%

53.3%

31.0%

ME

1496

25.1%

23.8%

12.3%

51.7%

7.7%

71.3%

39.0%

IN

5645

19.8%

23.1%

8.7%

37.7%

9.4%

54.4%

31.3%

ND

658

26.0%

26.3%

10.0%

38.2%

5.6%

70.3%

35.1%

NE

1705

21.9%

22.5%

8.3%

36.8%

8.7%

65.8%

32.6%

AR

2269

25.6%

23.0%

6.6%

28.6%

9.4%

58.4%

35.1%

VT

797

18.8%

24.5%

9.9%

40.5%

8.4%

71.6%

32.5%

NV

2086

13.9%

28.4%

15.5%

54.6%

7.6%

56.6%

32.8%

KS

2291

24.8%

22.9%

8.2%

35.8%

7.8%

50.0%

35.0%

 

Distributional students, medical schools, and states are associated with higher ratios of family physicians and more primary care residency graduates remaining in primary care careers in addition to greater levels of physician distribution. The same has been true of decentralized or distributional physician assistant and nurse practitioner programs focused on the family practice mode of care.

 

In past decades family physicians were produced at better levels and many distributional states attracted family physicians who were tired of lower salaries, poor support, and practice restrictions in major medical center states (privileges, ER, inpatient, procedures, obstetrics). In the past there was a consistent drift to many of these states from birth to medical school to residency and during changes of location in subsequent practices. This may not continue. There are fewer family physician graduates and many will have tighter connections to their home states or states where they have been in education or training.

 

The United States does not appear to understand primary care, family practice, or states with needs for improved distribution. Admitting the children that best represent the various populations within a state is a consistent theme of improved distribution and is also a solution for retaining physicians (and the investments resulting in physicians) instate. Family physicians are also most likely to remain instate with reference to residency training, medical school location, and birth location, but only in states with situations favorable to family physicians (primary care policy, scope of practice, not major medical center states). Bridging the gaps between birth to college to medical school admission, from medical school to residency (accelerated programs, Oklahoma incentives), residency to practice (North Carolina, Wisconsin, others), and movements within a state or back to a state (Iowa Statewide efforts Roger Tracy) are all methods successful in improving levels of the most needed physicians. More family medicine residency positions has also worked, but only when more medical students are encouraged to choose this permanent form of primary care by federal and state health policy. Medical schools that graduate only rural physicians or family physicians is also used in other nations such as Australia, an appropriate example for many of these states.

 

For the distributional states the major center percentages are higher with fewer in super center concentrations. The urban marginal location percentages of physicians remain relatively constant as in states with concentrations. Urban marginal locations are often adjacent to super center and major center locations. Marginal urban locations have relatively high income levels and lower levels of poverty. Despite these advantages, marginal urban locations do not do much better than urban underserved locations with the lowest income levels and poverty levels at 21 – 24%. Concentrations of physicians may actually suppress nearby physician levels. Few are able to compete against the advantages in funding that the nation gives to locations with concentrations. This difficulty in competition also involves a national competition. Distributional states lose out in all of the major distributions of health funding – Medicare, Medicaid, GME, research, foundation, health insurance and health insurance coverage, specialty reimbursement, and the most specialized billing codes. Distributional states depend upon reimbursements for primary care and for lower and middle income people. The current policies of the nation do not support these areas well. Federal programs designed to support physicians also depend upon higher levels of poverty and poorer health care outcomes. Distributional states also distribute income, education, poverty, and economics such that fewer have extremes of poverty and the poor health outcomes associated with poverty. The end result is that many sites may not qualify in distributional states. Sometimes federal programs require a certain level of resources to gain funding. Frontier locations in distributional states cannot qualify because they do not have enough resources (Frontier Center, Carol Miller).  It would seem ludicrous that programs designed to boost resources would exclude locations that had deficiencies in resources. Such is the national design. The one state in this group that has benefited most from the J-1 Visa waiver program is North Dakota. The state that played a major role in initiating the program.

 

Wyoming, Alaska, Idaho, and Montana do not have their own medical schools and are prominent with the least physicians in super center locations. Medical schools do tend to have the greatest physician concentrations and graduate medical education contributes to this greatly. The other states except Nebraska and Oklahoma have one medical school. Nebraska has a public and a private school while Oklahoma has two public medical schools and for a short period of time also had a private medical school. New Hampshire and Maine only have a private medical school. Arkansas implemented a decentralized medical education effort rather than a single concentration. Kansas, Oklahoma, Indiana, and North Dakota have branch campuses.

 

States with super center and major center physicians above average have fewer family physicians and primary care physicians. States that have populations distributed instead of concentrated have greater needs for family physicians. Urban marginal and underserved physicians are 20 – 30% family physicians. Marginal rural and rural underserved locations have 32 – 38% family physicians but the levels range from 25% to 100%. Family physicians increase to the highest percentages in rural Community Health Centers, whole county primary care shortage areas, isolated rural locations, and lower income rural locations. As population, income, education, physicians, and health resources decrease other types of physicians decrease and family physicians remain stable or increase.

 

Distributional states have suffered under current medical education and current health policy. International graduates are essential for concentrational states that often have more than 25% of physicians from international medical schools. International graduates have not been a consistent solution for the distributional states. There are at least two reasons. These tend to be states without graduate medical education positions and international graduates do not prefer rural locations. Overall international graduates are found in rural states at the lowest levels. They have the most urban locations and 70% of those with birth origins listed in the Masterfile were born in cities with medical schools. The United States medical school foreign born graduates and those born in the most urban and highest income counties have a similar pattern of top concentration.

 

For a variety of reasons there are a number of states that could use the rural, underserved, primary care, and family practice outcomes of osteopathic schools that have not supported the osteopathic public medical school model. West Virginia’s osteopathic school has over 40% in rural locations and 22% of graduates in rural underserved locations. Texas and Oklahoma osteopathic schools contribute most needed health access. Ohio osteopathic has the top instate retention of workforce. Osteopathic public schools in other states greatly exceed the health access contributions of allopathic schools.

 

Allopathic public schools also make significant contributions, but many are changing their pattern. Limited state support keeps them on track for state needs. The US health policy design for medical schools dictates a different pattern, one that ignores state health access needs.

 

This is a major problem as states with single allopathic public medical schools are also states dependent upon a single source medical school for a large percentage of instate physicians. Declines from 60% to 50% to 40% to 30% of graduates instate for residency or practice are a huge problem, particularly for primary care. This is because primary care production is so low, that outside sources cannot make up the difference. Specialty care has a solution – concentrate resources. Primary care has no solution as the United States is destroying flexible primary care and graduating family physicians, the remaining permanent primary care form, at lower and lower levels. Meanwhile the populations in need of basic health access local primary care such as the elderly are doubling in the next twenty years and reside 70% in locations with 20% of physicians. Only the family practice forms with 50 – 60% of graduates found in zip codes with 70% of the elderly are real solutions.

 

The Taxonomy of Experiential Place is an important concept for distributional states. Previous life experiences shape future career and location choice in physicians.

 

  • Physicians born and raised in a state, attending medical school in a state, and graduating from a residency in a state have the top instate retention. For family practice residencies this can be 70 – 85% in distributional states since these are states that are supportive of family practice and primary care as compared to concentrational states that have lower salaries and support.
  • Not having a medical school to “grow your own” can be a problem as fewer gain admission to medical school, fewer train instate, and there are fewer instate graduate medical education positions to keep training instate, to attract allopathic and osteopathic residents, or to attract international graduates. Distributional states attract few from international origins.

 

Retention from residency to practice within the same state is about 50%, but again this depends upon the number of specialty positions open in a state, economics, and geography. A smaller state has fewer specialty positions and very few subspecialty positions open at a given time. A state with many competitive neighboring states can lose out in the competition. States at greater distances from concentrations of physician training are also at a disadvantage. Unless the graduates share previous life experiences, family, colleagues, or other connections, it may be difficult to retain graduates instate or to return graduates to a state at the completion of training.  

 

The graduate medical education positions of the nation are not equitably distributed. Newer schools, states without medical schools, states with smaller medical schools capture a much lower per capita share. This inhibits the most important experiential place connection to a state, the instate life experience of a residency program. States with concentrations of physicians have concentrations of graduate medical education and reap a triple reward of GME funding, top dollar subspecialty proceeds, and physician workforce.

 

Allopathic schools are not graduating the family physicians needed for these states. The 1970s public schools (allopathic and osteopathic) that were created were ideal for distributional states. These schools are finding it difficult to maintain their focus on distribution, family practice, and primary care under current policy. Their class sizes also remained low due to the lack of government support.

 

Experiential place is important to understand for states that send their instate medical students to another state for training.

  • The students selected for a distributional state should be selected for their probability of an instate practice and a family practice career.
  • Their training should be instate if possible but should always be focused on environments and practice needs of the state. This means primary care, rural locations, and family practice. This type of training also graduates more rural specialists along with rural primary care as seen in the outcomes of the Duluth graduates that do the Rural Physician Associate Program that are selected and trained for rural and family practice.
  • Distributional states often admit medical students that are a poor match for a return home. The children of professionals, medical students with poor connections to their state (that often have higher scores), or medical students intending specialty careers are not a good choice as they are likely to be found in subspecialties in powerful economic states rather than returning home to practice.
  • The training locations of medical schools, especially training locations in top concentrations of physicians, are not a good match for distributional state needs.
  • Family practice is not a consistent emphasis.

 

Family practice emphasis is poorly understood. By orienting admissions and training for rural and the broadest generalist career choice and now the only dependable primary care form, it is possible to obtain the entire range of physician careers and locations. Those who are admitted from narrow origins and trained in the current narrow concentrations have nothing to oppose current market forces national policy that concentrates and shapes physicians to practice in states and cities with concentrations of physicians, income, growth, and economics.

 

Successes in states such as Arkansas, Nebraska, and Kansas have involved a coordinated statewide approach with preparation involving the lower and middle income children likely to choose family medicine and remain instate, admissions that reflect state population in geographic and socioeconomic origins, and training during medical school and family practice residency spread across the state for decades. Of course changes in admission and training together with US health policy penalizes states that attempt to distribute instead of following the preferred pattern of top concentration.

 

 

The Folly of Allergies to Bricks and Mortar

 

Current workforce “teaching” heard at national workforce conferences is that medical schools are very expensive. This has resulted in increases in dependence upon physician importation. Somehow rational thought has failed. There are a number of major reasons to oppose this line of thought.

  • International medical graduates are a poor investment as they only supply half of the workforce of a US origin graduate. Losses include 23% of workforce prior to entering the workforce and another 20 – 30% depart for other nations at graduation or within a few years. International graduates are solutions for teaching hospitals that need cheap labor, but are not efficient solutions for US workforce problems, especially primary care where international graduates of foreign origins supply the absolute lowest primary care per graduate.
  • Weakening other nations by taking their most educated that are most likely to lead other nations seems to be a huge problem now as indicated in the Middle East, Africa, South America, etc. In other words these nations are made more vulnerable to terrorist elements and the long term cost to the United States in defense, human rights, and other areas can be astronomical.
  • It is expensive to build the medical schools in recent years, but there are less expensive models that have been ignored in planning. Schools that focus on education rather than research or clinical care are far less expensive and may have advantages.
  • Exclusive children specialize and concentrate while more normal students have much higher probability of needed health access careers. By producing too few and too exclusive and by exclusively supporting the most exclusive careers and locations, the United States has assured the collapse of basic access to health care. The higher status children do better on admissions testing to a major degree because of their parents and their background similar to those that set the standard for standardized tests such as the MCAT. Admission of more normal medical students with more normal scores is not associated with any quality problem, in fact there may be some indications of problems for physicians that have top MCAT and GPA, especially with lower people skills abilities. The students that are more normal in origins and scores do have a few percentage points of medical student with higher difficulty as a group, but have much higher choice of health access careers as a group. The problem is that the individuals who will have difficulty as well as those that will choose health access careers are not able to be identified prior to admission. However for basic access to health, erring on the side of broader access to admission is a desirable medical education endeavor. Appropriate preadmission efforts have also been able to reduce the academic difficulty of those more normal. Also a decompressed first year of medical school also can shift those that do have early difficulty to better performance during school, on boards, and in graduation. The major problem is that United States medical education does not have a design for lower and middle income children, lower and middle income people in need of health care, and fails to push for policy that supports lower and middle income people in the health policy design. There is also no design for permanent primary care, a major design defect.
  • Another problem is that of departures of the economics related to physicians. Many states lose significant birth to graduation investments to other states. International graduates of foreign origins leave for home nations at 20% levels and increasing percentages have been leaving the United States. The current policies are not good ones for US economics, especially for the majority of states that have lesser degrees of concentrations.
  • It is a travesty that medical education has become a prime example of the futility of investing one’s self in the path to medicine. Admission probability is stacked against origins involving lower and middle income, lower or middle population density, lower social organization, and origins that are not associated with concentrations of physicians (birth in a medical school county). Matters are worse. Only half of the entering physician workforce positions are available to those of multiple generations in the United States. Half of entering physicians are foreign born or have a parent who is foreign born.
  • The studies of physician quality do not indicate MCAT as a factor. Studies do indicate that communication skills are a problem for as many as 25% of the recent graduates entering the workforce.3 Numerous studies consistently indicate better quality or at least the perception of better quality from physicians who match up in race, ethnicity, language, gender, and socioeconomics to their patients. Mismatches can be a problem. Transitions to the United States, to the United States health system, and to United States locations in need of physicians can be a problem.
  • International graduates and foreign born United States graduates have the lowest percentage choice of rural practice locations. Without obligations, international graduates and foreign born US graduates have average to below average choice of primary care and underserved populations. International graduates do have the top concentrations in the most urban settings, especially those from China, India, and other nations where they arose from the top population density environments in the world. When US workforce steadily increases with regard to physicians comfortable only in top concentrations, this is ideal for 4% of the land area in top concentrations but leaves behind 65% of the United States population that does not share such locations. Foreign born in America and foreign born physicians in other nations are born, raised, educated, and trained in concentrations of physicians, professionals, and medical schools including parents, colleagues, private schools, and other connections. Expecting distribution from such individuals, especially without family medicine choice to double their underserved contribution or triple their rural contribution, is not reasonable.

 

A comparison of the various costs and risks of different graduates is needed. International medical graduates are the least efficient and most costly form. Rather than a temporary crutch to boost United States workforce, importation has become dependency.

  • About 10% fail to complete residency training. Delays and movements to other residency programs are common with additional years required. Some return to specialize. The average international graduate has a loss of 7 – 8 years of a physician career compared to a United States medical school graduate.
  • About 20% of international graduates return to home nations. Another 8% remain chronically unemployed. An increasing percentage leaves the United States for better opportunities in Europe or Asia at the completion of residency or within a few years. The average delay in entry into the United States workforce costs 7 – 8 years, limiting workforce contributions the same way delays limit nurse practitioner contributions.4, 5

 

Each international graduate entering a United States residency program represents half of the workforce provided by a resident supplied by a United States medical school. After completion of training, there are still difficulties with language, culture, communication, and productivity unless the graduates speak excellent English or Spanish.

 

Rural contributions of international graduates are the lowest of graduates in percentage, even with the J-1 Visa waiver effect and even without considering that half of the international graduate workforce is lost after beginning residency. Loss of J-1 Visa defeats primary care and underserved contributions in international graduates.

 

There are clearly benefits of different types of international graduates. Graduates with superior English and Spanish skills make top contributions in areas such as mental health and urban underserved areas. Matches of race (Nigeria, West Indies, Haiti) also match up to predominantly black counties, a group of counties with significant workforce needs. However such graduates often do not have backgrounds compatible with long term service to predominantly black rural counties. The experiential place solution for such counties is found in graduates born in these counties that are found 25% in predominantly black rural counties in practice. This is boosted to 50% return for those choosing family medicine for 1987 – 2000 graduates found in 2005 locations. Origins shared times the family practice multiplier is the solution. The real barrier is too few doing well enough to gain admission, a societal problem that will require a societal fix regarding children left behind.

 

Ethnicity, race, and language matches are seen for the Universidad Autonoma De Guadalajara (UAG) that ranks in the top 5 in urban underserved percentages as well as numbers with 20% of 85 graduates a year found in United States underserved urban locations. Schools in the Philippines also contribute in rural and urban underserved dimensions.

 

There is a way to maximize all of these factors.

 

The top family practice models of distribution only have one limitation. They do not have the ability to select the medical students that they need. It would also be optimal for them to be able to prepare the medical students for distributional primary care.

 

A medical school that admitted, trained, and graduated family physicians for distribution would be the least costly, the most effective, the most efficient, and the most health policy resistant model in the nation. This model would attract and admit those most likely to choose family medicine and to distribute, those in the 65% of the population left behind.

 

 

1.         Carnevale A, Rose S. Left Behind: Unequal Opportunity in Higher Education, Reality Check Series, . In: Kahlenburg R, ed.

. New York: The Century Foundation Press; 2004:p. 106.

2.         Bowman RC. The Physician Distribution By Concentration Coding System. 2008. http://www.ruralmedicaleducation.org/basichealthaccess/pdCcoding.htm. Published Last Modified Date|. Accessed Dated Accessed|.

3.         Tamblyn R, Abrahamowicz M, Dauphinee D, et al. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. Jama. Sep 5 2007;298(9):993-1001.

4.         International Medical Graduate Section of the American Medical Association. Report on International Medical Graduates. Chicago 2007.

5.         Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural Remote Health. Jul-Sep 2008;8(3).

 

 

 

 

www.basichealthaccess.org

 

www.physicianworkforcestudies.org

 

www.ruralmedicaleducation.org