Understanding Poverty and Physician Workforce

Robert C. Bowman, M.D.

The poverty locations for this page involve office-based primary care physicians at high poverty zip code locations. Poverty zip codes have a Community or Migrant Health Center at the zip code or have at least 20% of the population at or below the US poverty level.

Major Points

Poverty level determinations are higher in states with higher poverty levels (Puerto Rico, LA, MS)
It is difficult for primary care physicians to choose poverty locations with the current health system. Those who are willing to choose poverty locations are likely to have more Medicaid, more poor patients, and more patients who cannot or will not pay bills.
Improvements in reimbursement appear to be associated with an increased primary care and family medicine numbers. The time periods involved include the 1965 - 1978 allopathic medical school graduating classes, coincident with the creation of Medicare and Medicaid. Another time period includes the late 1990s, associated with health reforms, Medicaid increases, and more emphasis in primary care reimbursement (and decreased subspecialty reimbursement). The physicians graduating during these time periods were also at poverty locations in 2004 at a higher level. It is entirely possible that health policy conditions that exist at or around the time of medical school graduation may also shape future practice plans with distribution impacted decades later.
Improvements in reimbursements have improved the numbers of rural family physicians with 30% of initial FP graduates choosing rural locations in the early 1970s and a 45% improvement in rural family medicine physicians for the 1995 - 1998 graduates compared to 1989 - 1992.
The physicians most likely to be in poverty locations have other sources of revenue. These sources include medical schools, public health departments, hospital based revenues, and other sources. The physicians in such poverty areas are not likely to be office-based primary care physicians. The percentage of family practice physicians increases as the population in poverty percentage rises from 5% to 20% and then drops abruptly when the level is 25% or above. Internal medicine and pediatrics levels are relatively flat with a tendency for more in the areas with lower poverty levels. When considering the urban locations only, there is little difference in poverty location for any primary care specialty. When considering rural areas, the family medicine variation with poverty % is more pronounced. Rural areas tend to have more working poor or others just below the poverty level. Practice Activity of Physicians and Rural Location

Birth Origins and Poverty

Pop Density by county of birth	Not pc in poverty	Office-based PC in poverty Location	All docs allo grads 1987-2000	OffBased PC in Poverty
0 - 250	37152	1660	38812	4.3%
250 - 1000	38381	1589	39970	4.0%
1000 - 2500	46011	1680	47691	3.5%
2500+	52147	1733	53880	3.2%

Those born in rural areas (lower income level) tend to choose poverty locations more often. Granted that part of this is higher choice of primary care, but socioeconomic origins may also have impact. Ethnicity has impact on poverty location in primary care, regardless of birth origins, also in relation to income levels by ethnicity.

Medicare growth rates may have influenced student choice of office-based primary care.

Note: Primary care reimbursements increased in the 1990s even though Medicare growth was slowed. Medicaid got a spike of improved funding during this managed care era.

Medicare was created in 1965 after many previous attempts and over the sustained opposition of the AMA. Medicare dramatically changed the way the nation financed health care. Poor areas and elderly populations had a source of care and there were also new sources of revenue. Rural areas with both poor and elderly had perhaps the greatest impact with tremendous cash flow to such areas. The transfers also reduced elderly in poverty from 30% to 10%. Young people have seen the opposite direction with increasing poverty.

Medicare still is a key component financing family medicine and family medicine is the major physician for Medicare patients. The broad spectrum of special health care need groups in America depend more upon family medicine.

Graphic from http://www.graham-center.org/x386.xml authors Mold JW, Fryer GE, Phillips RL Jr, Dovey SM, Green LA. Family physicians are the main source of primary health care for the medicare population. Am Fam Physician 2002;66:2032

When rural areas, when poor people, when less educated peoples are all doing poorly, the impact is greatest upon family physicians who are the ones most likely to care for such patients, or not care for them as the case may be. More and more poor patients have increased out of pocket costs and are less and less able to afford health care (Kaiser study).

The early years of Medicare had tremendous growth fueled by pent up demand from patients who had been putting off health care for years.

The impact of Medicare and Medicaid in the 1990s reform years involved two impacts, an increase in primary care reimbursement and decreases in specialty reimbursement. During the 1990s there were a series of efforts aiding physician distribution including support for rural hospitals, rural health clinics, and Community Health Centers.

Source is AMA Masterfile, all active physicians (not inactive or residents)

Practice zip code (or other zip code if missing) is coded by RUCA

Practice Activity and Poverty Practice Location

The practice activity of physicians in the highest poverty zip codes areas are medical teaching, research, and hospital resident. Peds cardio and forensic psychiatry are the top careers in poverty zip codes. These are careers supported by hospital, teaching, and public health.

	Urban	Urban Over 20% Pov	Rural	Rural Over 20% Pov	All Over 20 % Pov	% Rural
administration	10898	19.9%	959	11.7%	19.2%	8.1%
hospital full-time	32265	15.5%	4612	15.6%	15.5%	12.5%
hospital resident	64602	23.5%	1889	26.8%	23.6%	2.8%
inactive	51591	10.5%	11158	12.8%	10.9%	17.8%
Locums	333	6.9%	87	9.2%	7.4%	20.7%
medical teaching	6819	29.7%	394	12.7%	28.8%	5.5%
not classified	21924	20.5%	1632	23.7%	20.7%	6.9%
office based	326860	14.9%	50424	15.7%	15.0%	13.4%
other	2474	12.7%	284	10.6%	12.5%	10.3%
research	9225	27.7%	295	9.2%	27.2%	3.1%
	526991	16.3%	71734	15.6%	16.2%	12.0%

Note that there are very few residents of any type training in rural areas (2.8%).

Rural vs urban not different in most categories except researchers, with fewer in rural zips.

Inactive docs tend to be located in rural areas, a reflection of retirement and an important area to understand in doing physician workforce.

The declines beyond 1999 cannot yet be confirmed until another year of data. Changes in office-based physicians appear to be related to increases in FP and PC docs. These increases are related to health policy involving relative increase in reimbursement of primary care as compared to specialty care.

This table involves only office-based primary care physicians. It is not possible to interpret studies of all US physicians since those with residencies over 3 years in length have not completed training and chosen practice locations for the class years of 1999-2000 or earlier in some specialties. Even the graduates of 2000 may have incomplete data in 20 % of cases for location and specialty. There is enough to see some dramatic improvements across the nation for health care access followed by declines.

These career change tables also illustrate the difficulty in interpretation of workforce studies that do not allow for health policy. The Title VII studies had ending points in the late 1990s. The lifestyle career choice studies began in this era. Student career choices had very little to do with lifestyle or Title VII since the very potential to have a job at all or to have an increasing income compared to a declining income was at stake. New physicians or new entrants to any job market have to be sensitive to the viability of such careers.

Health policy at the end of the 1997 - 2004

Decreases in primary care reimbursement
Major increases in reimbursement for non-primary care physicians
Recession forcing cuts in Medicaid patient numbers and support at federal and state levels without any improvements.
Efforts to limit medication use may also decrease patient care visits for Medicaid patients (why go to the doctor’s office if you are not willing to make the copay or if you have to wait days for an answer about even getting some prescriptions).
Offices with high percentages of Medicaid patients face the growing challenge of patients showing up for appointments at all or on time less an less, a reflection of other impacts on day care, transportation, and Medicaid limitations.

In addition, students may well perceive family medicine and primary care as less viable options.

Liability and tuition costs seen as great and growing problems with greater impacts upon lower paid physician specialties. National reports regarding the decline of family medicine and primary care, including questions regarding major overhaul of the specialty and changing the length of training, and the increasing cost of paperwork.

Those not likely to choose family medicine (FP Unlikely) were born outside of the US 50 states or in US counties of over 1 million. Those who are FP Likely are those born in the US 50 states in counties of less than 1 million. Birth Origins and FP Choice

Those with urban origins choose poverty locations more often by a 1.1 percentage point margin. Those born in more rural areas choose rural poverty areas at a 3 percentage point higher rate. Those likely to choose urban poverty areas are involved in medical teaching or subspecialty care. Even with just the office based primary care physicians, the relationships are the same. The urban born FP Unlikely group has a slight edge in choice of zip code practice locations with over 20 % in poverty, but in the areas of family medicine choice, rural family medicine choice, and rural practice choice for all physicians, there is a big advantage for FP Likely admissions (born outside Urb Inf code 1 in Urban influence code 2 - 9 or military base birth).

Rich zips have less than 20% of the population in poverty. Note that this graphic is not a "match rate" of exiting graduates, but is a snapshot of physician locations as of 2002 - 2004 as noted in the AMA Masterfile. Physician career choice and location may well be influenced by national health policy and this influence may well last for the entire 30 or more years of practice for a physician.

One interpretation would be that during periods of increasing primary care reimbursement the nation has an increase in primary care physicians, primary care physicians locating in "richer" areas and also an increase in those choosing zip code locations in lower income areas. With an increase in reimbursement, there is a 5 - 6 percentage point gap created between physicians choosing rich or poor areas. At times of stagnant or declining primary care reimbursement, the gap is a narrow 1 - 3 percentage point difference.

It may well be that when the government emphasizes primary care, physicians respond by increased career choice, with increased numbers there are physicians that also tend to choose poverty locations as well. The managed care era had the most abrupt change in primary care choice with some groups up 50 %. The earlier period of sustained increases at the initiation of Medicare and Medicaid had a more profound effect over time.

Indianapolis Presentations regarding physicians and poverty

Reimbursement and Physician Distribution

Physician Workforce Studies