One Per Cent Solutions
The nations and states that have better health, education, college, public security, and retirement security invest 1 % more of GDP in age 0 – 6 children. These are Nordic nations that invest 1 – 2% compared to the United States that spends 0.5%. States in the United States that invest more in children share the top outcomes in education, college completion rates, health, state budget relief, and more.
States that fail to invest in children must steal infrastructure (basic serving professionals) from other states and nations. States such as California, Texas, New York, and Florida take teachers, nurses, physicians, counselors, and public servants away from states where families, communities, and states invest more in children. This spreads the inefficiencies to all states and nations and makes it appear that investments in children fail. The only true failure is failure to invest early enough and enough in children.
Perhaps even more devastating is the increasing promotion of the myth that government programs and investments are ineffective. Programs that are efficient, effective, and low in cost exist
· When they are annually and dependably funded as infrastructure (education) rather than dependent upon expensive, inefficient, insufficient, and undependable grant funding
· When they target the youngest ages
· When they are coordinated such that failures in one system (child care, security, health, trained personnel, housing) do not compromise advances in child development.
· When they are complimented with local, neighborhood, community, private, and volunteer efforts and direction.
Remedial programs in the teen years and beyond have increasing costs and decreasing rewards. Most amount to little more than isolating challenging children from others to prevent more damage. Alternative schools, hassles with school systems over what constitutes equality in education, and individuals or special populations that must consistently file suits to receive minimal levels of support are the rule rather than the exception.
Having enough professionals, enough well-trained professionals, and the distribution of professionals to the most needed locations is a key part of interventions.
In studies of physician distribution, it appears that the total package of changes needed for so many levels from birth to training to practice is overwhelming. Changing child development, education and quality teacher distribution to lower income areas and younger grades, higher education, and professional school admissions and training is indeed a daunting task. However the nation only has about 5 – 6% of physicians in urban underserved areas and 10% of physicians in rural areas. The rural areas in need are served by about 5% of the nation’s physicians, just like the urban underserved needs. Improvements of only 1% in these two physician locations is all that is needed to greatly change access to care, reduce the cost of inappropriate emergency room and hospital care, and improve the quality of care for the middle and lower income Americans in most need of care.
Physician distribution, at least for primary care, can also be accomplished by graduating more family physicians. The nation increased choice of family medicine by 5 percentage points in the 1990s by changing the priorities of funding and career choice. Medical students were given a clear message that physicians in hospital careers would have difficulty finding jobs and those in primary care could expect to enjoy increasing support, especially those depending upon Medicare, Medicaid, and clinical reimbursements. Reimbursements for hospital careers were cut and primary care received steadily increasing reimbursement levels. Because the impact increased choice in the US MD Grads that provide 16000 a year and because the impact targeted family medicine, distribution was maximized and prolonged. Family medicine choice doubles distribution over any other specialty choice and family physicians are the only physicians found outside of major medical centers with a majority of graduates. Family physicians also remain active at 99%, remain in family medicine at 97%, and remain in office based primary care at 90%. As little as a sustained 2 percentage point increase would have provided steady increases in health access, physician distribution, and related improvements in cost and quality.
The nation has recently taken a different course of action. Family medicine choice in US MD Grads is plunging toward levels not seen since the creation of family medicine nearly 40 years ago. Losses of this sustained source of primary care, this sustained source of rural and underserved physicians, and this source of women’s health, mental health, emergency care, and a variety of procedures from endoscopy to minor surgery mean that fewer and fewer Americans will have access to primary care, secondary care, and all of the front line health care needs.
One Point Losses
Each year for the past ten years approximately 1 percentage point
· Fewer physician assistants are found in primary care
· Fewer physician assistants are found in rural practice
Each year for the past ten years approximately 0.7 - 1 percentage point
· More top income medical students gain admission
· Fewer lower income and middle income medical students gain admission
· Fewer rural origin medical students gain admission
Each year the MCAT level for admitted medical students increases
· About 0.1 units per year to the current 10.4 level in 2005
In the past 25 years
· Asian Indian medical students have increased from less than 1% to 7%.
· Asian admissions have increased from 4% to 23%.
· Foreign born US MD Grads have increased to 16%
· Medical students born in counties or cities with medical schools have increased to 67%
Rural born, lower income, and middle income origin physicians are found in rural and underserved locations, family medicine, and primary care in the highest levels. The cumulative changes compared to admissions ten years ago for US MD Grads (1997 matriculants to 2007)
· 300 fewer rural born medical students
· 5500 more with parent income over $100,000, increasing to 6800 a year, this includes nearly 1000 more that have parent income over $250,000
· 4400 fewer with parent incomes less than $100,000
· 1500 fewer with parent income less than $40,000, decreasing to
· 1500 in the middle income 2 quartiles
It is very difficult to get medical students who
· have spent their entire lives in academics and sciences and controlled situations
· who have rarely experienced generalism, family medicine, rural populations, and lower income populations
· who have rarely had to problem solve in people and social dimensions
· who have faced little uncertainty and overcome few barriers
· who have rarely spend significant times with different peoples or populations
to choose the front line least predictable careers involving generalist practice, primary care, mental health, women’s health, psychiatry, rural locations, or underserved areas.
Not to Despair
Although the deck seems to be stacked against distribution, family medicine, primary care, rural, and underserved areas and populations; there is no need to despair. Health policy dealt with all of these areas for the few years that it remained in place, a successful natural experiment. Most importantly the changes that need to be made need only impact a small percentage. We need about 1 percentage point more urban underserved physicians and rural physicians in small and isolated locations. This can be accomplished by a few more percent of family physicians from US MD Grads, the richest and most efficient and most lasting form of physician distribution. All the above can be accomplished by “strongly encouraging” (forcing) medical students to choose family medicine, improving reimbursement for primary care and for those outside of major medical centers, and preferably a mix of both.
Distribution: The 70-30 Distributions That Complicate Physician Distribution
Physician Distribution in the United States
Distributional Medical Schools
Changes in Specialty Choice 1987 - 1999
Flaws in the Concept of Controllable Lifestyle