dividing, prioritizing, conquering health access and physician
distribution. Sounds like stragies for war
The Eight Americas article about health status and outcomes fit so well
with what I see in education and in medical school admissions that I am
working on a Six Americas article - 3 areas categorized by physician
levels: Major medical centers Served Areas Underserved Areas In two
dimensions of Rural vs Urban
For the 3 areas involving 522,817 physicians graduating from all medical
schools in the world since 1971 and practicing in the US
1. MMC zip codes (medical school or 75 doctors at a zip code) physicians
69.2% 361,939 physicians 129,935,621 people
2. Served physicians (between MMC and underserved) 24.8% of physicians,
89,994,404 people, 129,781 physicians
3. Underserved physicians 5.6% - Evenly split between 2.8% or 14,588 in zip
codes with 20% or more in poverty (my call) and 2.8% or 14,566 in zip codes
with a CHC, NHSC, or whole county primary care shortage designation
(federal call). There are 28,363,078 in "designated" zips and the poverty
level additions include another 24,604,434 (20% or more in poverty). - Not
much difference in the two underserved categories in income, poverty
ratios, physicians, etc. It is likely that the urban underserved and rural
underserved peoples at these zip codes have lower levels of organization
that have inhibited the official pursuit of designations and government
programs. Also cities and states that distribute income, education, and
resources better are less likely to have the extremes of poverty that help
generate government funding, like the midwest. This makes matters worse
since the major medical centers and urban served areas are the most
organized.
About 1 million people are in military zip codes, this leaves 273,802,932
coded out of a 2000 population of 281 million.
The total US poverty population of 33,882,083 was divided evenly with 30.8%
in MMC, 33.7% in urban served, and 35.2 in underserved locations. Again
those in underserved locations were balanced evenly with 17.6% in poverty
designated codes and 17.6% in federally designated codes.
The "appearance" of poverty is an interesting concept. Poverty population
is well hidden in major medical center zip codes with levels of 11.6% and
also in urban served locations with similar highest income levels and only
8.8% in poverty. Poverty is more difficult to avoid in underserved areas
with 24.2% levels in poverty designated zip codes and 21.0% in CHC, NHSC,
and whole county PC shortage codes. Health care and education needs are
more easy to hide among the major medical center areas, or can be out of
view in rural areas. This can inhibit response.
I find it fascinating that the highest poverty levels are not in the
federally designated codes. Also I confess to "cheating" or smoothing the
data during the process. I could not stomach the federal designations in
zip codes with less than 14% in poverty (some studies are also saying the
same thing). by smoothing the federal designations. Where a facility (CHC,
NHSC) somehow got a designation with less than 14% in poverty in the
federally designated zip codes, I overrode their designation and called it
a "served" location. I also moved some with 19% poverty levels up when
county poverty levels and adjacent zip codes had higher levels. This
smoothing involved only 128 physicians in 41,000 zip codes but it did
change the populations. The federally designated zip codes are likely to
have slightly lower levels of poverty than 21%.
One area needs to be made clear. I made a choice not to include major
medical centers as underserved locations. I kept each type exclusive to one
another. The statistics and ratios of poverty support this decision as also
do the correlations with primary care needs in states. This also reinforces
the level of control of major medical centers regarding the populations
within their "jurisdiction." They can choose to serve the underserved, but
they often make choices that do not take this option. This does tend to
bias the study in favor of those outside of major medical centers, such as
family physicians. Of course they concentrate in every location except
major medical centers. FPs do have double the rural and double the
underserved rates of other types of physicians across their origins and
across nearly all medical schools. 1174 of 1250 comparisons for 5
specialties for 125 medical schools.
Areas with higher income, less poverty, and greater employment are able to
sustain physicians. Primary care physicians continue to decrease steadily
with increasing poverty level. Much beyond 20% in poverty, the last major
bump before falling off into the depths of poverty involves community
health center zip codes and family medicine residency program zip codes.
Other primary care training programs would likely also contribute in these
areas but I do not have their zip codes. Beyond the 20% and the reach of
government support, primary care drops to the lowest levels.
Who makes decisions to serve those in most need of care?
By area
Major medical center area service to those in poverty involves decisions
made by major medical centers. Increasing funding to these locations is
unlikely to result in care for those in poverty without careful controls.
There are too many other influences on major medical centers as indicated
by recent trends such as the loss of PAs and NPs away from primary care and
to emergency care, hospitalists, and subspecialties. Shifts away from
Medicare and Medicaid and government support for low income patients,
medical education, and other funding sources do make it harder to care for
those in poverty since these changes require difficult trade-offs and
internal conflicts between those with established revenue streams. This
makes it likely that "cherry-picking" will occur with major medical centers
and physicians moving away from poverty populations and responsibilities
for the most complex patients.
What is disturbing is that in recent decades and especially in recent
years, major medical centers have figured out all of the various government
programs from CHCs, to bonus programs, to rural health clinics to J-1 Visa
programs. In some cases the major medical centers have created problems
resulting in reforms and increased hassles for all attempting to deliver
needed care.
Urban and Rural Served Areas have the economics, employment, and capability
of addressing much of the 9 - 12% in poverty although this does vary
greatly across the nation. Some government assistance could level the
playing field. The major studies of capitalism and economic growth in the
entire US is a study of health care moving out into these urban and rural
served areas and transforming them into Major Medical Centers.
Rural areas are going both directions. Some are more like Served Areas that
are heading for major medical center designations and some are underserved,
then there are the high minority and low income rural areas with huge
problems in health, education, economics, and more for 6 million Americans.
Outside of these areas, rural America is 90% white.
Major medical center America is 70% white, again a huge contrast. Major
medical center America has the greatest levels of professionals,
facilities, universities, Asian, foreign born, Hispanic, proximity to
medical schools, college degrees, and college prep. The major medical
center origin students all have the highest levels of medical school
admission and the lowest levels of distribution to rural and underserved
areas. Any medical school can graduate subspecialists and major medical
center physicians. Few have mastered physician distribution.
Urban underserved and rural areas are far more complicated. The short term
solutions may not help much. Longer term solutions involve education, child
development, and health policy changes. It is difficult to build and
support facilities and market share without stable physicians. Federal
policies shift health care funding away from primary care and toward
subspecialties and major medical centers. Only in 1965 - 1978 and from 1992
- 1997 did physicians march to a different health policy drummer with
massive increases in distribution, led by increased choice of family
medicine, the primary care source that stays in primary care and remains
away from major medical centers. Family medicine gives up major medical
center location with only 42%, and leads in all other categories of
distribution, often by 2 to 1 over other sources of primary care.
What is going on in medicine may be going on in all facets of US society.
Poverty, underserved areas, family medicine, school teachers, public
servants, nurses, counselors, and all who are most connected to middle and
lower income populations depend upon basic child development, neighborhood
security, early education, and balanced opportunity for advancement.
Efforts in these areas are successful in other nations. This is not what we
have. We have emphasis on high school science and math that benefits the
top 30% (current and future) instead of universal preschool that would
benefit the 70% in lower and middle income America. We have standardized
test score worship that keeps lower and middle income types at less than
their full potential. We have merit scholarships driven by test scores that
fail to consider the differences in scores because of differences in
individuals. The SAT, ACT, MCAT all have the same defects, now fixed in
place in the legal system in a way that favors the top 30% in income level.
We even have evidence (Carnevale, former VP at ETS) that research that
might demonstrate that some of the lower scoring and lower income types may
have greater potential than their scores has been squelched. The AAMC VP in
charge of the MCAT states that the MCAT cannot discern performance (first 2
years of medical school) without speededness. Speededness relates to bias
regarding the student rate of processing testing materials. The
distributional types of students that have different origins than the
standard accepted students will test differently and are known to have
lower scores. They also process test materials more slowly. The US News and
World Report worship and accreditation based on board scores all focus on
higher standardized test scores. Want to venture a guess as to who is
buying the college and medical school data that they process? We may well
spend far more on health care than we really know if we include all of the
costs of child development, education, testing, test prep, and more. As
Carnevale noted, 74% of the students from the top 146 colleges are from the
top quartile in parent income. All of these expenditures related to the
preparation of physicians and those who want to become physicians cost the
nation in health care and in other areas.
Not surprisingly we have fewer low income, middle income, rural born, and
truly different and diverse students admitted to medical school. Since 1997
we now have 3000 more out of 16000 admissions a year whose parents make
over $100,000 and 1500 fewer lower income and 1500 fewer middle income
students admitted. Those not of the highest levels are much more likely to
be rural born, diverse, and truly different students who are the most
likely to return to locations outside of major medical centers. What we
have is those with the least social and geographic distance from major
medical centers and typical medical students who are admitted at higher and
higher levels. They are displacing those most likely to return and serve
outside of major medical centers. We also have health policies that reflect
the needs of the top 30%, mainly because they are over 70% of the admitted
medical students. The elite schools dominate medical education and medicine
leadership. The top income and professional origins are even more prominent
in these schools that prepare many of our leaders. Progressing up this
scale (scores, urban, income, professional parent, exclusive upbringing)
means less and less awareness of the needs of the bottom 70%.
http://www.unmc.edu/Community/ruralmeded/awareness.htm
The concentration of wealth and income proceeds at a staggering rate, as
does the growth of chronic poverty and hopelessness and violence.
Again to remind you of my other post. Although this seems overwhelming, it
is not. What we need is just a few percent. A slow but steady shift over
time is what we need. It also helps to have some shake um up times. This
was Medicare and Medicaid, the Health Reform/Managed Care era, etc. 9/11
could have been the same kick in the pants that we needed and took
advantage of as in Sputnik plus the Man to the Moon speech (1961)
http://www.unmc.edu/Community/ruralmeded/kennedy_and_crisis.htm but we
missed this opportunity. We can ill afford to miss the next one. A standard
operating procedure of war is to choose the battleground. When we choose
the status of women and children across the nation or across the globe
starting with our own nation and those closest to us, we will win and grow
more confident of our ability. We will also grow more efficient and
effective. When the enemy gets to choose the territory, we lose abroad, at
home, and in our confidence and hope. This lost hope and the lost hope of
many other nations is by far the worst loss of all.
Robert C. Bowman, M.D.
[log in to unmask]
You can apply the above to education, economics, or a number of other
national systems and distributions. Many of the same factors apply with
professionals like us calling the shots.
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