I would concur. From my research one of the best representations of
privatization is major medical center concentration of physicians. In the
Masterfile data, I define this as 75 or more physicians at a zip code.

In the United States about 75% of physicians are found in major medical
center zip codes with only 35% of the US population. It is very difficult
to provide health access to 65% of the population with 25% of the
physicians. It is a bit easier with physician choice of family medicine
since only 50% of family physicians are found in major medical centers and
this allows 50% to serve 65%. Family physicians are more likely to arise
from students with origins outside of major medical centers, they are more
likely to be trained in locations (not much more likely though) outside at
higher levels, and they are more likely to serve the lower and middle
income populations outside.

Family medicine choice is about health policy. In the 1970s and 1990s when
US health policy supported primary care and health care in rural and  lower
income populations, family medicine choice and primary care choice peaked.
In addition the economic redistributions were massive during this time
period.

Before 1965 and sufficient growth of Medicare and Medicaid, there was no
distributional health policy and primary care, other than market forces, a
bad solution for rural and underserved locations.

After the growth of Medicare and Medicaid, government support to
restructure medical education to primary care and family medicine focus,
the nation quadrupled primary care production in the 1970s. Because the
favored specialty was family medicine, distribution was also maximized.

Enough policy remained in the 1980s to sustain some distribution and family
medicine choice, although the medical students admitted were less and less
likely to be the rural, lower income, and middle income types more likely
to choose family medicine.

During the 1990s the nation doubled Medicaid from 1990 - 1995 (state and
federal). Health policy increased primary care reimbursement and decreased
specialty reimbursement, policies expanded distributional support programs.
Most important, government and business forced a shift of emphasis away
from major medical centers and toward primary care and locations outside of
major medical centers. Managed care reports were used as a weapon to
accomplish this. Anesthesia, Radiology, and Pathology residents almost
vanished, as well as others most connected with major medical center
careers. Family medicine became the preferred career and even medical
students with major medical center origins chose family medicine, resulting
in peak levels.

Unfortunately the major medical centers did not like the mandates and
government programs, together with insurance they have long campaigned that
government programs are incapable of effective work. They also were
punished by managed care and responded. The government also did not support
the primary care effort with dollars, the effort was mandated. This was
very different in the 1970s when sufficient additional government resources
were provided for the primary care and family medicine emphasis and new
schools emphasizing the same. The rebound from managed care was fast and
furious, and has continued since this time.

Also admissions has changed dramatically in the past decade with now 70% of
medical students from the top 20% in income and the greatest levels of
increase in the highest income levels, These will become physicians that
have such a narrow range of origins, they will be less and less likely to
understand their patients or health care systems to meet any needs other
than major medical centers.

Family medicine rates are well into single digits. With more expansions
(medical students, residents, specialty fellowships) planned, they may well
be diluted to the lowest levels of all time. Also the lower and middle
income origin students have been increasingly excluded from admission.
These are the students most likely to be found in rural, underserved,
primary care, and family medicine careers. No physician group is found in
rural areas at higher than the 10% rural physician workforce other than
those born rural and family physicians. No physician group is found in
underserved areas at higher than the 6% national average other than those
with underserved origins or family physicians.

Reason for FP to go to rural and underserved locations - market forces and
government policy

Market forces and policy - FPs away from major medical centers can do
procedures, hospital, ER, and bill more, using the current flawed health
policy that favors these codes usually reserved for hospital and
subspecialty physicians. FPs in major medical centers are not allowed to do
these things.

Policy support - Also FPs are supported by rural health clinics, critical
access hospitals, National Health Service Corps, provide half of the
Community Health Center phycians, and increase in concentration with
distance from major medical centers, areas of greater physician need. FPs
are also not savvy on government policy. They leave $2 million on the table
each year in bonus payments, but this does not stop urban or specialty
physicians from applying and getting the funds, even when they are
ineligible (Bonus Payment Study, Schepps Center, NC) But this also explains
why in some states more J-1 Visa physicians are taken by medical schools
for faculty rather than serving in underserved areas in the state, why CHCs
now locate next door to major medical centers to help defray costs, why
rural health clinics were almost terminated due to abuses, etc. (market
forces gone awry, poor supervision, salaries too high for specialists,
socially and financially organized versus those not organized is a bad
choice for funding competition)

Market forces shape the American way from birth to education to college to
professional school to health care coverage to health care access to health
care cost and quality. If you live in the major medical center 35% of the
population, the environment is great. If you live in the bottom segments,
things look bleak. If you life in the middle, it may be even more difficult
since you once had it better and are losing it, even if you are both
working.

By the way, physician assistants and nurse practitioners are the fastest
rising source of specialists and major medical center practitioners.
Created for pure primary care and health access, they now create 1 - 3 new
subspecialties a year (market forces). Major medical centers are sponsoring
more programs and for good reason for them. PAs and NPs are incredibly
valuable and versatile. They can bill nearly as much as a physician, yet
cost far less for salaries and benefits. (market forces)

PAs leaving primary care make 10% more, (market forces).

Each year 1 - 2 percentage points of physician assistants (the entire
100,000 and soon growing at 10,000 a year) leave primary care, family
medicine, and rural locations and have done so for over the past
decade.(AAPA annual surveys) - market forces set up by health policy, also
the smaller and more distant entities such as family physicians are losing
the battles to the big commercial insurance entities (Blue Parties
settlement)  and this makes it difficult to pay PA and NP what they are
worth

The fastest growing PA and NP use - chain stores - loss leaders to sell
more product - market forces

Primary care in major medical centers - loss leaders - if a primary care
physician only loses $100,000 a year (revenues minus salary and benefits
and support costs) then he or she is doing well. The major medical centers
cost shift funding from referrals, lab, path, services, to cover the
difference.

Until the nation supports primary care and peoples outside of major medical
centers, the cracks in the foundation will widen

Major reason for NP - poor support of nurses. Major reason for poor support
and increased salaries for nurses - major medical centers don't want to pay
more.

Each NP was once a nurse in an important role, including nursing faculty.
Leaving nursing to become and NP, with less than 50% in primary care an
falling, does not help primary care or hospitals or clinics in need of
nursing. Losses of nursing faculty are now cited as a reason for fewer
nurses. Nursing shortages should increase pay, but they do not. This should
not be a surprise to you now.

Physician distribution is about market forces that divided into inside and
outside of major medical centers.

Physicians with origins inside stay inside at the highest levels
Physicians with training inside stay inside at the highest levels
Physicians shaped by health policy that favors inside stay inside at the
highest levels.

Physicians with origins outside are more likely to be found outside
Physicians with training outside are more likely to be found outside
Physicians supported by funding that supports health care for the lower and
middle income populations that are outside are more likely to be found
outside

Inside populations are the greatest concentrations of income, education,
professionals, wealth, health resources, medical schools, and major medical
center environments, in the US the populations most associated with major
medical center location are Asian Indian, Asian, legal immigrant foreign
born (due to immigration policy), and all others of most urban, highest
income origins. For medical students you can add parents who are
professionals, faculty, or physicians.

Outside populations are urban underserved and rural populations that are
not associated with a rural major medical center.

The probability of admission is greater for medical students from inside
and the probability of distribution is reduced by the same factors.

The probability of admission is less for medical students from outside and
the probability of distribution is enhanced by the same factors.

Example

Black students have half the probability of admission but 2 - 3 times the
probability of distribution and this is doubled by family medicine choice
to 6 times levels of urban underserved location

Rural students have half the probability of admission, but 2 times the
probability of distribution and this is tripled by family medicine for
rural or for rural underserved locations.

Hispanic or low income rural has one third the probability of admission and
a 3 times distribution factor, doubled or tripled by FM.

Nations that want to distribute
1. must position their education and preparation to admit a representative
population of students by origins, a balance of inside and outside
2. must prepare and train their physicians for representative careers and
locations inside and outside
3. must sustain the education, economic, and health policies to accomplish
this and to support needed professionals of all types in rural areas,
especially teachers, public servants, nurses, and primary care physicians

The United States is allowing market forces to control each of the major
policies
This is a decision not to distribute resources, and a lesson to other
nations such as Canada.

Robert C. Bowman, M.D.
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