What I see in physician location is that the concentrations of physicians
follow concentrations of income, people, health policy funding,
professionals, and medical schools. Areas near these locations have
difficulty maintaining physicians and expecially primary care physicians
and health access. The lowest levels of primary care and family medicine
are in the most concentrated physician locations.

Using geographic coding, proximity to major medical centers seems to
suppress physician location. This also includes commuting counties. It is
as if the potential for having physicians and professionals is sucked away
by the existing concentrations. Many of the shortage areas in or near
metropolitan areas are in this category. 3 counties in Nebraska qualified
for poverty funding for Community Health Centers - one was just below
Omaha, the other was just outside of the Sioux City metro area. The other
was Thurston county - a reservation location. Saunders County sandwiched
between Omaha and Lincoln has been a shortage location for decades. The
population commutes to work and takes their shopping and health care
dollars with them, making economics difficult in commuting locations (until
a reverse pattern occurs with growing urbanization).

Massive displacements of population may also be involved. Divisions in
income continue to widen with lower and middle income moving out and higher
income moving in. The much higher costs may drive those not able to sustain
such an existence away, or else the conditions beyond the highest status
(who can buy their own education and security) are getting poor.

In the top quartile (n=51) income counties in 1970 that had a medical
school, these once held  22% of the United States population but they have
declined to only 20% as growth has been higher in other types of counties.
Only in rural counties of less than an estimated 20 people per square mile
is this low of a population growth seen. This is actually quite shocking
since these 51 counties have top income, top concentrations of
professionals, top amenity location, and more. The two fastest growing
populations in the nation, Asian and Hispanic, growing at 90% per decade
are concentrated in these locations. About 47% of all Asians in the US are
in these counties and 32% of Hispanic populations are in these counties
with only 20% of the population. Blacks are 22% and whites are only 17% in
these counties.

About 40% of the nation's research funding and about 36% of the graduate
medical education funding of the nation goes to these 51 counties with 20%
of the people. These 51 counties also take physicians from all other
counties and all other countries in the world. Only about 20% of US
physicians started out in these counties or trained there in medical
school. For graduate training (adding in international grads) the level
rises to 34% of all GME positions in the nation, dipping back to 27% of US
physicians for practice.

Other top income quartile counties in 1970 that did not have a medical
school (only 3% of the 25% in the top quartile) grew in population at some
of the highest rates in the nation. Again this is a suggestion of some
difficulties with concentrations of resources, controlling for income
levels.

Current plans for medical school expansion are not likely to address the
locations outside of these exclusive counties. About 33% of medical school
admissions for US schools arise from this 20% of the population. In
addition the top status children (70% admitted from the top 20% in income)
gaining admission are a narrower group of origins. Narrow origins are
backed by narrow training. The US continues a major medical center focus of
training that even the students choosing specialities regard as deficient
in multiple primary care areas. US health policy penalizes primary care and
lower income and middle income populations and rewards major medical center
concentrations.

Physicians with origins most closely associated with major medical center
types of locations have 3 - 10 times the probability of admission and the
lowest rates of primary care, underserved, rural, and family medicine
careers in the nation. The past years since 1997 have seen the fastest rise
in medical students admitted with the highest income, likely mediated by a
focus on standardized test scores (reversals of affirmative action, US News
and World Report, focus on higher board scores at the medical school level)
which have also increased steadily over this period since the last
standardization of the MCAT (about 0.1 unit per year for bioscience MCAT up
to 10.6 now). Narrow income and narrow science focus may present a huge
problem if McGill studies on communication (bottom quartile had 70% more
problems as physicians) translate to poorer communication skills in those
with the highest scores, if there are any brave enough to make these
comparisons.

The US currently uses geographic methods to assess physician distribution.
It should consider the more direct measurement of physician concentrations
as a means of understanding physician distribution. Themes present -
exclusive origins, scores, income, schools result in concentration. Those
geographically and socioeconomically distant and different have 50% or
lower probability of admission but 2 - 4 times the probability of
distribution outside of major medical centers. Family medicine choice
doubles or triples this distribution rate found in birth origins.
Specialized career choice and health policy limit physician distribution to
major medical centers.

Mechanics of Physician Distribution and the Economics Associated with
Physicians

46% of United States physicians are in Super Center zip codes with 200 or
more physicians, Family physicians are about 6% of the physicians in these
locations  These are locations that receive top levels of NIH research
funding and graduate med ed GME funding.

Another 24% are in zip codes of 75  - 200 physicians, the FM concentration
is average at 14% and in all other locations other than super centers,
family medicine is 18%, with 30% or more in rural locations or much higher.
FM is the largest share of physicians outside of major medical centers. FM
also does twice the teaching and twice the military compared to other
physicians.

Understanding family medicine is important since family physicians are the
remaining permanent form of primary care with 21 of 25 practice years
(usually longer careers) expected in primary care. Peds is 16 of 25, all
others (IM, PA, NP) are less than 10. Others are limited in volume seen,
inactivity, losses outside of primary care, hospital focus (increasing),
urgent care (increasing), scope of practice, and more. All others are
moving away from primary care at 1 - 2 percentage points or more each year.
The IM or PD residency graduates complete residency and do fellowships at
higher levels. The 200,000 NP and PA graduates for the past decades as well
as newe graduates are departing with each passing year. They are drawn by
market forces and Winner Take All (Robert Frank term) mentality. Physician
assistants make 4% more by breaking continuity to move to a new practice
and make 10% more by leaving primary care altogether (AAPA data). Only the
PAs have moved back to primary care once leaving, and only in the 1990s
when the nation massively shifted toward primary care and managed care
reforms, but the policies are very different now.

The two physician locations above can be combined into a Major Medical
Center category including all zips with 75 or more physicians.

The major medical center zip codes have 35% of the US population and
poverty levels below the 13% average. Health access in these locations is
not a matter of more physicians. The locations have the ability to finance
the physicians and practitioners that they desire. The sites have chosen
less primary care and health access. Increased support of primary care has
increased major medical center hiring of family physicians (from 1100 up to
1800 per class year) and primary care physicians as seen 10 years ago with
reforms. Currently there is no reason to hire primary care as the
reimbursement is poor, overhead costs are high, and the ER and urgent care
locations do better without more primary care. Sadly many of the grants
provided for physician shortage designation areas are going to such
locations who are very good at getting all sorts of grants and getting
better. Even with the grants, major centers can make changes that do not
result in overall increases in primary care and health access. In some
cases the grants may be pursued to protect centers from the excess costs.
New York City hospitals got a special $15 billion grant to change health
care. A better approach would likely have been to insure that the money got
to primary care to help build the capacity that is lacking.

The US locations outside of major medical centers have 65% of the
population in urban underserved, rural underserved, urban served, and rural
served locations. Increases in physician concentration are needed, but are
low because of low support and because of nearby suppression of location by
major medical centers.

Rural areas that are not major medical centers present a more pure model,
especially away from major medical centers. Decades of observations in
states such as Nebraska reveal that the names of physicians change, but not
the numbers in counties. The equation must be changed to relieve chronic
shortages driven by poverty, insurance, and economics. This is also
important in funding medical education. More physicians, more rural medical
education, more rural graduate medical education programs, will not improve
numbers without corresponding increases in health care, economic, and
education funding distributions in rural areas. Increases in physicians in
rural areas require changes in economics, especially health care and
education support, the two major contributors to rural economics. Health
care coverage must be expanded to support the needed health care. This
requires the nation to shift funding from major medical centers to patients
who are "outside." Levels of working poor are high in rural areas. Barriers
such as transportation, deductibles, and two working parents naturally
suppress utilization, lowering the risk of overutilization. Also health
insurance tends to be catastrophic, worthless for primary care or any care
other than in a disaster such as a farm injury. The SCHIP veto (expansion
of children Medicaid coverage moving from the poorest to the lower middle
class) by President Bush may deprive current rural children of coverage and
keeps hundreds of thousands from the coverage that they would have had.

Simple changes do not work. The coordination must involve multiple areas
over decades of time. The United States has demonstrated the ability to
distribute physicians with a variety of interventions, but currently is
choosing not to implement these nor does it have a plan to coordinate this
effort.

Robert C. Bowman, M.D.
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