Robert C. Bowman, M.D.
The nation's poor support of primary care results in a number of distributions of importance in health access and other areas. In some cases the patterns of distribution are completely reversed.
Areas Without a Community Health Center or a Family Medicine Residency Program
| Location | All Other | FP | IM | Ob-Gyn | Peds | FP / PC | Total |
| Urban Served | 47% | 22% | 16% | 11% | 9% | 41% | 43512 |
| Urban Underserved | 46% | 20% | 18% | 12% | 10% | 37% | 8810 |
| Rural Served | 41% | 32% | 14% | 14% | 6% | 54% | 16308 |
| Rural Underserved | 39% | 30% | 18% | 13% | 7% | 49% | 7905 |
| Urban MMC | 62% | 8% | 17% | 9% | 7% | 21% | 133445 |
| Rural MMC | 59% | 13% | 13% | 10% | 7% | 33% | 4934 |
Generalist pediatrics and family medicine that normally increase across then nation for urban underserved areas (both) and for rural areas (family medicine) decrease with increasing poverty levels within major medical center locations. Further cuts in Medicare and Medicaid and the continual strains upon Major Medical Centers are not likely to enhance generalist career reputations and choices in major medical centers. The nation should not be surprised that primary care career choices are at record low levels and Primary Care Retention levels are poor with the nation losing all forms outside of generalist pediatrics and family medicine.
About 87 – 90% of the internal medicine, pediatric, medicine pediatric, and family medicine physicians in the Masterfile are office based primary care physicians. There are differences in distribution based on geography, socioeconomics, and other factors. Differences and Definitions
Family medicine has repeatedly demonstrated great value in the care of rural and underserved patients. Family physicians are the physicians of choice in Community Health Centers with 50% of total physicians. Family physicians are found in lowest concentrations in major medical centers, urban settings, and highest income counties. As counties decline in population density, education level, facilities, physicians, and income; the levels of family physicians increase. Office based family physicians are about 7% of major medical center physicians, 30% of rural physicians, and 67% of the physicians in isolated rural areas in low income counties. Family physicians are 20% of the primary care physicians in major medical centers and increase to 66% of the primary care physicians in whole county shortage areas. Choice of family medicine doubles rural location and underserved location outside of major medical centers for all types of birth origins and for nearly all medical schools. Family Medicine Physician Distribution
Office based pediatrics physicians have maintained generalist choices despite health policy. This is all the more remarkable since 69% remain in major medical centers to practice. Primary Care Retention
Office based internal medicine levels have declined from 54% of all internal medicine residency graduates to less than 20%(Garibaldi 2005) in the last ten years. Internal medicine is also unique in that about 15% of physicians in most settings are internal medicine physicians. (Birth Origins, Bowman)
The nation’s major medical centers have a very different composition of physicians with reference to primary care. Subspecialty physicians dominate the location. The domination is even greater in major medical centers in higher poverty settings. Family physician and generalist pediatric percentages decline with increasing poverty level and as a percentage of total primary care physicians.
The second graphic is more detailed and involves comparisons of primary care and the percentage of primary care supplied by family medicine. Similar changes involve pediatrics with declines with increasing poverty level. Internal medicine is stable to increasing across the range however this includes all in a particular specialty, not just the office based component. Those in hospital, administrative, teaching, and research increase in internal medicine from left to right.
The lack of generalist primary care in the higher poverty major medical center settings suggests that:
Inadequate Primary Care Support
Little discussion is needed here. Generalist internal medicine choice in all internal medicine residencies is at record low levels. Internal medicine impacts appear to occur during residency as noted during managed care choice changes. Family medicine choice in US MD Grads is nearing all time record lows. Family medicine influences appear to be earlier with health policy impacts during medical school critical as noted by peak levels for the 1995 – 1997 class years. (five) Pediatric generalist levels have been constant, again suggesting choice of career before medical school. This is also true of the older, rural born, and lower income origin family physicians. Five Periods of Health Policy and Physician Career Choice
Losses of primary care capacity are not limited to declines in new graduates. Family medicine levels remain constant with 90% continuing in primary care throughout their careers. Pediatric levels are also 65 – 70% retained. Internal medicine continues to decline and medicine pediatrics nearly vanishes with less than 10% remaining for the 1987 match. The losses in primary care also include newer sources created for primary care, rural, and underserved areas. Thousands of physician assistants and nurse practitioners each year are leaving primary care for new opportunities, increasing salaries, no call, and other benefits. Primary Care Retention
There is little doubt that health policy has shaped most of these changes with more to come. Declines in Medicare and Medicaid and declines in primary care share within Medicare and Medicaid compound the problem. At least family physicians can do procedures, practice broad scope away from major medical centers, and practice in lower cost areas for living and working. Generalist pediatrics does not have these advantages and is stuck within major medical centers and must endure restrictions in privileges, the highest cost locations, the lowest salaries, and constant consideration as a loss leader.
The concept of loss leader is common for all primary care in major medical centers. No longer do major medical centers have exclusive rights. Primary care types are being used by chain stores to draw in customers, along with flu shots and lower generic drug prices.
This is more than enough regarding market force distortions.
In defense of many of the major medical centers in poverty areas, the unemployment rates are high, education is a problem, housing is bad, social programs are being cut, economics are poor, health insurance coverage is low, and state and federal government has retreated from support of medical education. The support for major medical centers comes from graduate medical education, research funds, and other sources where primary care has low, less, or no funding.
Perhaps as important is that the major medical centers have created their own competition. No longer are medical schools the only major medical centers. Physicians and other personnel and corporations have created new medical centers and even newer types such as subspecialty centers. A few have abused the rules resulting in massive complex rules, making health care more inefficient for the rest, and ever more favoring competitors who do not have at least part of their mission as training physicians for the future.
Major medical centers include medical school zip codes and zip codes with 75 or more physicians. This is a less than adequate and conservative categorization since this does not include physician assistants, nurse practitioners, and other assistants who function much as physicians in revenue generation at much lower cost. These subspecialty, hospital, and emergency room contributions to health care have not been counted as subspecialty workforce.
Major medical centers have supported medical schools and graduate training, medical school expansion, and new physician assistant and nurse practitioner programs. They dominate accreditation, graduate funding, and all forms of clinical reimbursement. Those that desire to structure a different health care environment can do so, within the limits of competition and the acceptance of their patient populations. Of course there are few incentives to do so with unlimited costs and massive increases in costly emergency care.
Major Medical Centers and Health Care Costs
The states with the most physicians in major medical centers do have the greatest health care costs. They also have the fewest family physicians and generalists for a number of reasons having to do with distributions of education and health policy. Whether the increased costs are a function of the lower levels of education or the poor support of generalists has yet to be considered but both share significant correlations with health care costs. Health policy that shifted funding toward primary care and away from major medical centers was associated with reduced rate of health care cost increases. This allowed the economy to catch up with health care costs and restored economic prosperity in the nation. Other nations that have lower health care costs also have much greater investment in child development and broader participation in education. The United States leaves far more children behind and has more at the top levels. The least educated and the most are two of the most costly populations regarding health care and other areas.
Major medical centers in higher poverty areas may also face the most complex patients and those with the most difficult social conditions. One could debate whether the medical students or residents trained in such settings would be overwhelmed by attempting to deliver primary care to the most difficult patients facing the most difficult environments. That many of the most impoverished areas remain next to some of the largest sources of economics for a city or county is a testament to divisions of income and education in America. That some have had conflicts with nearby neighborhoods is not a surprise.
In Closing
Further comments are invited regarding the graphic and comments. The impressions of the author are gathered from categorizations of major medical centers, the impact of birth origins on career choice, differences in specialties, and personal observations from a variety of practice settings from solo rural practice to major academic centers.
Other opinions can only add to the value of the discussions.