Basic Health Access Concepts to Review

Robert C. Bowman, M.D.      [email protected]

�        Most Needed Health Access Careers - Underserved, Rural, Family Medicine Multiplier

�        Basic Primary Care

�        Expanded Definitions of �Primary Care� that fail to represent primary care delivery

�        Physician Distribution By Concentration  

�        The Standard Primary Care Year     Graphic SPC year  

       Health Access Failure in Design: Flexible Primary Care Instead of Permanent

       Beyond Policy Declines: Other Influences Moving Primary Care Up or Down

�        Policy, Birth Origins, and Family Medicine Choice

�        Confirmation of Physician Distribution By Concentration and the Standard Primary Care Year � MEPS Studies and Community Health Center Studies and Physician Assistant Studies

�        Experiential Place

�       Confirmation of the Theme Lower Probabilty of Admission and Higher Probability of Most Needed Health Access

�        The Broad Generalist Family Practice Form and Health Access Contributions

�        Rural Workforce Has Multiple Solutions, Not Just Rural Origin Admissions That Are Failing as with failing path birth to admission for all populations more normal and less exclusive, lower and middle income

�        Bivariate Versus Multivariate Studies

�        Best Validity in Complete Populations of Physicians or Non-Physicians with Problems Increasing for Evidence Based, Selected Populations, or Single Schools or Programs

�        Misuses and Misunderstandings Regarding Standardized Testing   MCAT Central

�        Studies Do Not Demonstrate Higher MCAT Scores Associated with Better or Best Physicians or Medical Schools

�        Higher Scores Are Associated with Decreases in Health Access Careers

�        Workforce Research Requires Awareness and a Broad Perspective, Not a Narrow Focus Specific to Funding or Defense of Medicine or Specialty

�        About Birth Origin Studies

�        Unifying Physician Workforce Studies Across the Great Divide

�        Why Birth Origins Are Underestimated   About Birth Origins Coding

Basic Concepts to Review

Most Needed Health Access Careers

The most needed outcomes for optimal health access improvements are additional physicians for rural locations, physicians for urban underserved locations, and family physicians. Most states need all three and every state needs at least two of the three.

Rural coding in this work is most commonly Rural Urban Commuting Area coding using zip codes for physician origins and for practice locations. Studies using the Masterfile consider the most likely single practice location for physicians found in the 2005 version. Not all rural areas are in most need of physicians. Zip codes with over 75 physicians in rural zip codes have top saturations of physicians and primary care physicians. These are not most needed health access practice locations. The RUCA system is integrated into the Physician Distribution by Concentration coding system.

Underserved practices are most consistently populations with lower income or higher poverty or both. Some federal designations are integrated into the underserved coding, but not all. The Physician Distribution by Concentration coding system also integrates income distributions into coding after physician concentrations are considered. National databases of zip codes as well as adjacent zip codes help to understand variations in access to physicians. An appropriate model for health access includes a zip code and adjacent zip codes. This is particularly true for the elderly that consume the most primary care and require local primary care as they age and lose mobility.

Family physicians are included as essential health access for one major reason. Family physicians are the only physicians that distribute equitably according to the population in studies as well as reviews of actual data.^{1, 2} As will be seen, family physicians have 2 to 4 times greater odds ratios of practice location for urban underserved, rural, rural underserved, isolated, whole county primary care shortage area, and Community Health Center locations.^1-5 Studies confirm higher levels of Community Health Center location and ambulatory services for women, adults, and senior citizens even with lower graduate numbers compared to other primary care forms.

To address basic health access the US must address rural, underserved, and family practice. The physician assistants and nurse practitioners that remain in the broad generalist family practice form also deliver most needed health access. Normally they would be considered essential health access. However physician assistants and nurse practitioners are not remaining in family practice. Departures from the family practice broad generalist mode during training, at graduation, and each year after graduation defeat basic health access contributions. For example physician assistants doubled from 3100 to 6500 graduates from 1998 to 2008. The 2008 class year delivers no more primary care than the 1998 class year with twice as many graduates because the 2008 class year only began at 28% in primary care compared to 54% for the 1998 class year. Also departures from family practice down to 20% result in physician assistant rural workforce being supplied by the 2008 class cut in half comp

The only way to consider internal medicine, pediatric, nurse practitioner, and physician assistant graduates to be essential health access is to have a signed contract for 15 or more years of primary care contributions in any one of 30,000 zip codes outside of concentrations. Of course 65% or more are found in 4% of the land area inside of top concentrations of physicians where primary care is saturated and physician concentrations are the greatest of all. As will be explained, there is no reason for IM, NP, PA, or PD to sign such a contract as they and their employers can do better by departing primary care for hospital and specialty careers.

The review of policy impacts on primary care choice, primary care retention, and primary care departures will be extensive. Basically the United States has entered a policy period that is destructive to primary care with active conversion of current class years, recent class years, and past class years of primary care practitioners to hospital and specialty care. All five sources of primary care are at lowest retention in primary care and the remaining permanent primary care form of family medicine is at lowest percentage choice. Basically medical students cannot trust a permanent choice with current policy and even existing primary care practitioners cannot trust policy to support their health access salaries, their health access team members, and the health access facility needs.

Most importantly the nation has not established health access infrastructure in admission, training, policy, or support. Two past reform periods (1970s and 1990s) were important natural experiments that established that the United States could produce health access practitioners, but these two periods failed to establish health access as the foundation for US health care. US health care will continue to fail and seesaw in cost, quality, and access until there is a real health access foundation.

Basic Primary Care

Basic primary care will remain as it always has been � family practice and generalist forms of internal medicine and pediatrics. Shell games distorting primary care should be discarded.

Also the studies will expose sources of primary care that are not primary care. Basically when a source of primary care is no longer producing graduates that remain with a majority in primary care, it ceases being a primary care source and becomes a specialty source. Only family medicine training remains a reliable source of primary care at the current time. Because internists remaining in generalist practice do make contributions and because general pediatricians make important contributions, they remain primary care. Internal medicine training is not primary care training with 90% of internal medicine residents entering hospital and specialty careers. Pediatric training is in the process of dipping below a majority at the current time. Physician assistant primary care starts are 28% but less than 25% is a reasonable estimate. Nurse practitioner primary care is down below 40% and 33% is a reasonable estimate for nurse practitioner primary care retention.

Physician assistants and nurse practitioners actually are better for specialty workforce where lower volume, lower levels of activity, and fewer years in a career. They could also result in lower costs for specialty care due to lower salary and benefit costs although these cost savings have not been passed on to consumers or the nation.  Also nurse practitioner and physician assistant workforce is still counted as primary care even though primary care delivery is lower due to lower volume, lower activity levels, fewer years, and lower primary care retention.

This exposes another problem when workforce leaders fail to understand basic workforce concepts.

Expanded Definitions of �Primary Care�

Expanded definitions of primary care are not helpful for a nation that needs consistent, dependable, long lasting, broad scope, versatile, most needed health access.

Family medicine is over 85% reliable for primary care. Family medicine represents a one stage choice made during medical school. This is a permanent choice for a primary care career. The family medicine match indicates 90% probability of a career spend in health access. In addition the percentage point of residents choosing family practice that do not remain in office based primary care after the medical student match is basically replaced by residents entering family medicine in the second year of residency training.

Essentially the family medicine match numbers actually represent future primary care delivery in numbers and in percentages. In some class years and in some school with 0 � 2 family physicians resulting from the match, there are actually more family medicine graduates that did not �match� into family medicine, arising outside of the match. One interpretation is that the medical students at the school did not receive much training about primary care, family medicine, or health access.

Pediatric graduates are right at the 50% mark remaining in primary care but this will soon be a minority if not already. In some states there are two or more class years of residency graduates without a primary care contribution from pediatrics. This has been common in internal medicine for some time but is more common for pediatrics now just as more medical schools graduate no family physicians. Such is the problem of admission, training, and policy regarding health access. Nationwide pediatric primary care contributions continue for pediatricians. Those who make the multiple decisions required for primary care do deliver substantial primary care. This involves the medical student decision for pediatric training in the match and then the decision to begin in generalist primary care pediatrics at completion of residency and then the decision to remain in generalist pediatrics do contribute.

Internal medicine is in the final stages of conversion to a hospital and specialty care vehicle. Internal medicine match results no longer indicate primary care even remotely. This is because only 10% remain in primary care. Even recent class year primary care contributions were negated as 30,000 primary care internal medicine graduates converted to hospitalist care while more entered hospital, urgent, and specialty care.^6-8 There are consequences when admission, training, and policy focus consistently involves hospital and specialty care. Studies indicate dysfunctional primary care that may drive students and residents away from primary care.⁹

Medical schools that have few matching into family medicine have the most unreliable primary care contributions. Even those who enter so called primary care training are unlikely to deliver primary care.

Emergency care, psychiatry, geriatric, and women�s health are often included in expanded primary care definitions but are not primary care. They do not meet continuity, health access, or broad scope considerations.

Logic regarding true primary care would dictate fewer specialties included in primary care. The logical common sense primary care definition would include family medicine and pediatrics as the only true primary care definition with exclusion of internal medicine, emergency care, obstetrics, and psychiatry. Even so the pediatric match numbers would need to be cut in half to accurately represent future primary care. This would not make some deans happy who are required to report their primary care numbers to legislatures. Of course the legislatures are doing little to support primary care within medical schools, nor do legislatures support medical schools to the degree that they can help shape needed health access production.

It is interesting that medical schools post their match result records of medical student career choices prominently and proudly. Students, schools, and faculty boast of their achievements in terms of prestigious residency positions landed. Of course increases in specialization leave primary care behind. Perhaps in the hopes of mitigating the consequences, medical schools have turned to expanded primary care definitions by including emergency medicine, psychiatry, or women�s health. This still does not address the problem of needed health access that is clearly most closely addressed by family medicine.

In nurse practitioners the geriatric nurse practitioners are 4% and women�s health practitioners are 11%. This is used to increase nurse practitioner primary care full time equivalents to 22,000 out of 39,000 surveyed in 2004 or 56%. Actual primary care is much less for a number of reasons. First of all, nurse practitioners that could not be reached to survey or those in hospital careers that do not list themselves as nurse practitioners are missing. Over 150,000 nurse practitioner graduates are known, but studies are often fatally flawed due to missing, inactive, and part time graduates. Second, the basic primary care specialties should remain family practice, internal medicine, and pediatric care. The geriatric and women�s health practitioners are often involved in care in facilities. Subtracting these components brings a more realistic 41% of nurse practitioners in primary care (but not considering missing graduates).  Also the nurse practitioner primary care declines have been about 2 � 3 percentage points per year ever since the beginning of nurse practitioners. In more recent years the declines have been 1 to 2 percentage points a year. Also the declines have been steady for at least the past decade and are likely to consider for most of the next decade or more. Departures from primary care are guided by benefits to practitioner and employer that are not going to change.^10-12

A realistic expectation of primary care percentage for recent nurse practitioner graduates over the next three decades of health care delivery is 30 � 33%.

Physician assistants have been the most candid regarding their primary care contributions. They have also remained steady in the primary care definition as family medicine, internal medicine, and pediatric specialties. Annual surveys capture the careers and locations of about 30% of graduates and use of year to year data gives a reasonable depiction of physician assistant workforce. With only 28% beginning in primary care and only 20% beginning in the family practice broad generalist role, the primary care, rural, and underserved workforce contributions are departing. Orthopedic, surgical subspecialty, and emergency careers are increasing rapidly. These are also the careers that capture the highest salaries as compared to lowest pay for most needed health access careers.^{13, 14} Also movements toward and away from primary care with policy are captured by physician assistant studies as well as the one-way departures.^15-17

              
Physician Distribution By Concentration Details     Overall Graphic

The Physician Distribution by Concentration Coding system by land area consideration

The Physician Distribution by Concentration Coding system by the physician perspective

The physicians most associated with concentrations can be tracked to origins involving concentrations of people and income that are also origins associated with top probability of admission 2 or 3 times greater.   Physicians found in super centers, major centers, and marginal urban areas arise from physician origins in higher concentrations. Rural careers, family medicine careers, and underserved careers all arise from steady rates across all populations at 0.7 rural physicians per 100,000 per class year, 1 family physician per 100,000 per class year, and 0.5 underserved physician per 100,000 per class year. Selection of physicians with more normal origins and those most likely to choose family medicine would be expected to result in more normal distribution. With selection of physicians with more concentrated origins and with training focused on concentrations, physicians would be expected to concentrate. Concentrations of health funding in super centers and major centers contribute to concentrations and impair distribution.

The Physician Distribution by Concentration coding system divides physician practice locations into super centers with 200 or more physicians at a zip code, major centers with 75 � 199 physicians, and locations outside of super center and major center concentrations of physicians that have less than 75 physicians. The four locations outside of concentrations are urban and rural divisions of marginal and underserved locations.

Marginal zip code practice locations have less than 19% of the population in poverty, no major federal designation, and less than 75 physicians.

Underserved locations can be defined by poverty levels of 20% or greater at a zip code or an underserved zip code can be considered a zip code with a Community Health Center, a National Health Service Corps designation, or a whole county primary care shortage area designation. Underserved coding using the Physician Distribution by Concentration coding system does not consider zip codes with over 75 physicians or zip codes with less than 14% of the population in poverty to be underserved with regard to physicians even with federal designations.

The super center and major center locations with over 75 physicians are the only zip codes that consistently have sufficient primary care physicians. Actually the five primary care sources compete for the primary care role in these zip codes.

The super center and major center physician concentrations do have health access problems, but the problems are not likely to be fixed by more physicians in a zip code with saturations of physicians and primary care physicians. The Physician Distribution by Concentration coding tool begins with concentrations of physicians and focuses on the impact of concentrations of physicians as well as insufficient physicians.

Rural coding for origins and practice locations utilizes the RUCA nomenclature. The rural locations are codes of 4.0 to 10.6 except for the urban focused or commuting codes (4.1, 5.1, 6.1, 7.1, 10.1). The codes 1 � 3 and the commuting urban focused codes are coded as urban.

Super centers and major centers capture about 75% of physicians as compared to the population representation where only 35% of the population is inside zip codes with top concentrations of physicians and 65% of the population is left outside.

Physician Distribution By Concentration Details  

The actual distribution of physicians is far different resulting in a different perspective.

Representation of Population: 65% of Americans Are Outside of Concentrations of Physicians 

Relatively few Americans are found in the 3400 zip codes with top concentrations in 4% of the land area. Most Americans are outside of top concentrations and are unfortunately left out of the health care design that favors concentrations of physicians.

Organized medicine, medical education, major journals, and workforce leadership operates from a much different perspective compared to the United States population. Those interested in health access or matching up physicians to populations are going to have conflicts. Allies for top concentrations are states and cities that benefit from top concentrations of physicians and medical education. Allies for health access should be 65% of the US population and 70% of the elderly, but these are populations that have little awareness regarding the challenges that arise from the health care design. Often the various subgroups left behind compete with one another and with other basic infrastructure such as education, housing, and economic support.

The representations are even more dramatic when considering 4% of the land with top concentrations compared to the rest of the nation and 85 � 90% of health resources expended in 4% of the land area compared to 10 � 15% expended in 30,000 zip codes with 65% of the population.

Also the origins of the physicians found in the most exclusive super center and major center locations can be tracked. The physicians with the most exclusive careers and locations are most likely to arise from the most exclusive origins.

Policy, Birth Origins, and Family Medicine Choice Graphic - emphasizes layering by policy

Family medicine choice is shaped by policy influences as in increases in the 1970s and 1990s and decreases all other periods including the last decade. Modifying the policy response up or down is a function of birth origins, age, and type of training. 

Five Periods of Health Policy and Family Medicine Choice in US MD Graduates - includes the major policies that impacted career choice

Further studies illustrate the impact of experiential place as some were more likely to move toward and away from family medicine under supportive (1990s) as compared to destructive (2000s) policy with regard to health access.

Further studies indicate that the US graduated peak primary care at about 300,000 Standard Primary Care years from about 24,000 graduates in the 1998 class year. "Primary Care" annual graduates increased to 28,000 by 2008 but the primary care delivery estimates fell to 200,000 SPC years due to massive losses of primary care retention in IM, NP, and PA with 1000 fewer family medicine residency graduates (loss of 25,000 SPC years). The end result was that family medicine increased in share of primary care delivered with 75,000 SPC years or about 40% of primary care since other forms declined in primary care contributions. Once again more graduates delivering less primary care is not a primary care solution for the nation.

 Physician assistant primary care retention, internal medicine primary care retention, medical student choice of the permanent primary care form of family medicine - all indicate the impact of policy on primary care delivered. Only those with different perspectives or agendas other than most needed health access can fail to comprehend the failure of policy, the failure of flexible primary care forms, and the failure of US health care without a basic health access foundation.

The Standard Primary Care Year

Promises of primary care are one thing. Actual delivery of primary care is another. Studies fail miserably for the purpose of national health access workforce when they fail to consider entire populations of practitioners. Most studies only consider active full time graduates. These studies miss the most important determinants of actual primary care delivery.

Four Factors Integrated into a Comparison of Primary Care Contributions

Graphic illustrating rural SPC year contributions

�         The number of years in a career, usually 27 years for age 38 � 65 (nurse practitioners, foreign origin international medical graduates) as compared to 35 years for age 30 � 65 contributions (US origin physicians, physician assistants)

�         The percentage remaining in primary care for an entire career on average for all graduates in a class year � 10% for internal medicine, 25% PA, 33% NP, 50% PD, 90% for family medicine

�         The percentage that remain active and in the United States delivering primary care, not part time or inactive graduates  - 60% for nurse practitioners and foreign origin international medical graduates compared to 70% for physician assistants and 85% for physicians

�         The volume of primary care delivered compared to other forms of primary care � this can be compared to a standard such as the top volume delivered by family physicians � 100% FM, 95% PD, 86% IM, 70% PA, 60% NP.

Another problem with workforce is that measures of past contributions fail to anticipate future workforce. Numerous recent studies indicate deficits of tens of thousands of primary care physicians, but the question remains, �Which primary care physician?�  The same situation involves proposals for more nurse practitioner or physician assistant primary care � which type, who remains, how active, how long.

This is a huge problem in the United States as primary care graduates melt away from primary care with each passing year.  Estimates of future primary care contributions are needed such that future primary care delivery can be estimated. This must be specific to each source of primary care based on entire populations and specific to the class year of graduation.

One simple method is to multiply years in a career times primary care retention percentage times the percentage remaining active times the volume of primary care percentage compared to family physicians (35 years times 90% in primary care times 86% active times 100% for family physicians results in 27 Standard Primary Care Years).

2009 Grad Future Primary Care Contributions Over the Next Decades

The Standard Primary Care Year can also be used to estimate rural or underserved workforce in rural Standard Primary Care Years or underserved SPC years. This is possible as each source of primary care has a definite rural or underserved percentage that remains steady over time.

Graphic illustrating rural SPC year contributions

Some calculations are needed for the NP and PA forms that involve multiple specialties. The FP mode is the portion making the superior rural and underserved contributions. With NP and PA grads leaving the family practice mode during training and at graduation and each year after graduation, they are departing primary care, rural, and underserved contributions. Instead of a simple primary care loss, there is a combined primary care and rural loss.

A second method can be used to calculate the Standard Primary Care year over an entire lifetime in the career of a physician or non-physician. This can include the changes in the percentage that are active and the percentage remaining in primary care that also change over a lifetime. A graphic captures this best with the years in a career from age 30 to 65 on the horizontal axis and the vertical access representing the year to year primary care contributions using the product of primary care retention percentage, percentage active, and percentage volume.

The area under the curve represents the Standard Primary Care Year contributions specific to the specialty and to the class year of graduates.

Graphic Illustrating the Standard Primary Care Year

This method tends to capture the greater contributions in the first years with lesser contributions in later years.

Graphics also included in the Ten Myths article in pdf form at

http://www.adfammed.org/documents/Ten_Biggest_Myths_Regarding_Primary_Care_in_the_Future_with_graphics.pdf

This gives a visual depiction of the different primary care contributions of the different sources of primary care.

The major determinant of primary care contribution is primary care retention. With 90% retention, family medicine contributions are greatest. Internal medicine graduates with 10% primary care retention contribute the least. Nurse practitioner contributions are lower due to 8 years delay in entry (complete nursing school, nurse practitioner training, 8 years experience as a nurse practitioner), the relatively constant 60% active seen in nurse derived careers, lowest volume at 60%, and only 33% remaining in primary care. Physician assistants come out with relatively the same Standard Primary Care year contribution, but the contribution begins at an earlier age, involves slightly more volume and activity, but loses ground with lower primary care retention at 25%. Foreign origin international medical graduates lose the most workforce with only 10% remaining in primary care, only 27 years remaining after delayed entry, only 60% remaining active in the United States, and 80% of the volume of a family physician. This is a significant loss as 45% of all internal medicine residency graduates are foreign origin IMG.

 It is readily seen that the contributions of foreign origin international medical graduates is minimal. They have half of the workforce of US origin graduates due to 23% of primary care lost in delayed entry and 30% lost after graduation. Studies that only consider only the FIMG IM graduates active and in the United States miss the significant losses before and after. One solution for increasing workforce for little or no additional cost is to replace foreign origin international medical graduates with US origin graduates. This basically doubles the workforce contribution. Also without family medicine choice, graduates of US as well as international schools are not likely to deliver most needed health access. Medical School Type and Career Choice and Most Needed Health Access

The 3000 family medicine residency graduates each year at 25 SPC years per graduate will deliver 75,000 SPC years of primary care. The 8000 internal medicine graduates at 2 SPC years per graduate will contribute 16,000 SPC years. Both of the above figures are adjusted for the FIMG graduate component. The 7000 PA graduates will deliver about 25,000 SPC years. The 7000 NP graduates will deliver about 25,000 SPC years. The 3000 family medicine residency graduates will deliver more primary care than the 22,000 flexible primary care graduates � the combined total for IM, NP, and PA.

When it comes to primary care, remaining in primary care is the most important factor. Health policy now drives flexible forms away from primary care in this destructive policy period.

 Standard Primary Care Year Contributions for 2009 Graduates  See More Detailed Table Regarding Individual Medical School Graduates at Match 2009 Estimates of Future Primary Care

 Health Access Failure in Design: Flexible Primary Care Instead of Permanent

Beyond Policy Declines: Other Influences Moving Primary Care Up or Down

Confirmation of Physician Distribution By Concentration and the Standard Primary Care Year � MEPS Studies and Community Health Center Studies and Physician Assistant Studies

The PDC coding system and the Standard Primary Care Year studies predict multiple times the contribution in primary care for family physicians compared to other sources. Studies by Ferrer confirm multiple times greater contributions in ambulatory care by family physicians. In these studies family physicians had 2 � 4 times greater contributions. The point of the article was equitable distribution of family physicians to all populations of all ages or all socioeconomic and geographic origins.¹ Also it is important to understand that there are fewer family physician graduates in practice compared to internal medicine generalists or nurse practitioner graduates. The multiple times primary care contributions of family physicians are confirmed in actual practice. Future separations are more likely for ambulatory care as rates of departure from primary care are faster for IM, NP, and PA although blurring is likely since more and more desperate Americans will go  to specialists and specialist NP and PA forms just to find health care at all. The cost of health care from deficient primary care has many more mechanisms than are currently counted.

The studies of Rosenblatt and Hart published in JAMA indicated family physicians as the most likely practitioner for Community Health Centers.5 Given fewer family physicians compared to internal medicine and nurse practitioner graduates, once again the multiple times contribution of family physicians is noted. Also the distribution confirms multiplication of rural rates to higher levels. Those in top concentrations will note different patterns, but nationwide family physicians remain 2 times more likely to be found in urban most needed locations and 3 times or more for rural needed health access.

The physician assistant studies confirm the family practice mode advantage. The family practice physician assistants have remained 30% in rural locations with other PAs at 15% or less in rural locations. The PA rural average is 15% but continues to fall as departures from primary care, family practice, and rural locations continue. The family practice physician assistant has 6 - 7 times the CHC location of other PAs and has 30 times the federally qualified rural health clinic location rate of other PAs not in family medicine. (AAPA data source)13

Most needed health access is a function of the broad generalist mode and family practice is the last remaining broad generalist, when graduates remain in family practice.

Experiential Place and Health Access

Cutchin discussed the concept of experiential place with regard to rural practice. Those with life experiences most connected to rural experiences were most likely to be found in rural practice as physicians.^18-20

Coding systems are often developed upon extremes. Rural experiential place would often be interpreted in terms of population density with lowest population density most dramatically rural. At the other end of the spectrum are the most urban origins. Experiential place can involve concentrations of people.

The author develops experiential place in a number of dimensions. Density of population is just one dimension. Life experiences in concentrations of people are just one dimension of concentration. Density of income is another that is relevant to physician practice location. Physicians with lower and middle income life experiences as indicated by birth origins have two or more time greater probability of being found in a wide variety of underserved practice locations as physicians. Origins involving concentrations of income also are least likely to be found in underserved locations, the locations with lowest income levels. Experiential place is not just rural or lower income. Experiential place can be the most exclusive urban locations or the most exclusive income levels. Exclusive social organization is also found with exclusive origins.

Multiple dimensions of exclusive are very relevant for physician practice location as the most exclusive are half as likely to be found in rural practice, in underserved practice, or in family practice.

Another dimension is the generalist lifestyle. Rural, lower income, and middle income people are more likely to live in locations with generalists. The occupations that they come in contact with tend to be nurses, teachers, public servants, and generalist physicians such as family physicians. Their children are most likely to become these basic serving professionals. Teachers, nurses, public servants, and family physicians are the major role models for lower and middle income children. When home repairs are needed, people learn to make do or fix things themselves or call in someone with multiple different skills. Social organization levels are lower, people skills are more highly valued, and people are more independent. Also studies that consider lifestyle may not capture the lifestyle preferences of physicians in terms of career choice so much as they capture experiential place with the interlinkage of lifestyle.

Role modeling is often distorted to consider medical school experiences, but with regard to generalist versus specialists choices, experiential place is a primary consideration. All of the types of physicians raised in lower and middle income locations (those most likely to choose family medicine, rural, and underserved careers) also have different role models in the basic front line serving professionals - teachers, nurses, public servants, and family physicians - generalist role models from birth to admission to fit the generalist lifestyle and generalist career choices.

At the opposite extreme is the specialist lifestyle. In the most urban and highest income areas, people are more socially organized, more interdependent, and more anonymous. The role models are highly specialized. Even basic service personnel such as for repairs are specialized personnel. Schools and colleges attended by children of concentration involve more specialized personnel. Their neighbors, family members, and other contacts throughout life are more specialized. They experience few in family practice and potentially fewer in primary care as many skip to specialized services.

Experiential place becomes a unifying theme for the career and practice location decisions for physicians as they proceed from birth origins to education to neighborhood environments to college to medical education. Themes and theories abound in the areas of concentrations versus lack of concentration or exclusive versus more normal in income, in people, in physicians, in generalist versus specialist lifestyle, and in the variety of life and health experiences that shape a physician.

Inside of concentration origins versus outside origins (income, people, physicians, resources)

Generalist versus specialist

Most recent life experiences shaping the current life experience

Socially organized compared to less organized

Race, Ethnicity, Gender issues      Minority family physicians distribute according to their origins, magnified for optimal health access

Lower Probability of Admission Is Associated with Increased Probability of Most Needed Health Access Careers

Family Physicians Traced to Birth Origin and Admission Probability

Rural Physicians Traced to Birth Origin and Admission Probability

Underserved Physicians Traced to Birth Origin and Admission Probability

As admission probability increases with origins associated with concentrations (more exclusive) the probability of family practice, primary care, rural, and underserved careers decreases. Family medicine changes from 25% to less than 5%, rural career choice changes from 20% to less than 4%, and underserved career choice changes from 18% to less than 5%. Underserved career choices are better compared to physician concentrations (or lack thereof) regarding income but the findings are the same across concentrations. More exclusive and less normal is associated with failed health access. More normal and less exclusive results in higher probability of health access.

Admission Probability and Experiential Place: Admission Ratios and Physician Origins

Short Presentation Comparing Admission Probability to Probability of Most Needed Health Access Careers

Elementary My Dear Health Access: The Elements of Experiential Place Related to Basic Health Access Begin with Family Structure, Nurturing, Child Development, Early Education, and Opportunity in America

Life experiences begin before birth. To understand why the United States is dividing into rich and poor, one must understand the divisions involving birth to admission, especially those that impact education.

The Broad Generalist Family Practice Form and Health Access Contributions

The broad generalist family practice form is the universal health access solution. Any that are graduated that are more specialized or narrower in scope result in less health access contributions. Broad generalists have over 2 times greater urban needed health access contributions and over 3 times needed rural health access contributions.

Broad generalists can adapt to the widest range of needs involving women�s health, minor surgery, endoscopy, emergent care, hospital care, mental health, geriatrics, and other needed areas.

Broad generalists can cover call for one another to support the local health care system.

Broad generalists arise from more normal origins, more normal training, and more normal distributions of health resources. They are more likely to be older with more life and health experience that are essential for health access.

Rural Workforce Has Multiple Solutions, Not Just Rural Origin Admissions

Too many studies focus on rural origin as a solution for rural workforce. This also makes it easy for medical workforce experts to demonstrate that there are not enough rural origin students to cover rural workforce needs.²¹ This also makes it easy for medical education leaders to believe that rural workforce solutions do not exist.

Rural origins are too narrow a definition in a nation that has great variations from most rural to normal to most exclusive. Only about 6% of the physicians entering the US workforce have rural origins but substantially higher percentages have lower and middle population density origins.

Actually rural origin is not the most likely source. Family physicians have three times the rural location rate with birth origins only two times odds ratios. Older graduates have 30% higher rural choice. Lower and middle income origin students also have greater rural choice. Graduates of most allopathic public schools and nearly all osteopathic schools have higher probability of rural careers.

The only way not to graduate rural physicians is selection focus on the most exclusive highest income and most urban origin children (from US and from international origins), is to focus on the most exclusive training environments training in top concentrations of resources and specialists, is to focus on exclusive career selection, and is to design or tolerate policy that sends 90% of funding to 4% of the land area in top concentrations. This is of course the current design in admission, training, career choice, and policy.

Rural origins and family medicine choice are both required for Jefferson Physician Shortage Area  Program graduates as the exclusive nature of training reduces the probability of rural location. Also Pennsylvania state workforce is a negative influence on rural practice location.

Rural origin is a 2 times multiplier, family medicine is a 3 times multiplier, and exclusive school is a 0.5 times multiplier. This cancels the rural origins and leave the 3 times factor in place. Across the nation rural origin plus family medicine results in 43% rural location rates that are not reduced by exclusive school graduation. It is only in the allopathic private schools that rates of rural origin require rural origin plus family medicine to reach greater than average rural distribution.

Columbia has teamed with Mary Imogene Bassett in Cooperstown NY to train medical students. Columbia admits medical students that consistently have 0.5 to 0.7 odds ratios of rural or underserved distribution, Columbia only graduates about 1 family physician so the career choices of graduates are actually 0.7 odds ratios of distribution, Columbia has younger graduates and normal age for 0.8 odds ratios of distribution, Columbia training is associated with 0.5 odds ratios of distribution although a "rural location" might help. Of course Mary Imogene Bassett is actually isolated rural, but has over 300 physicians, only 2% family physicians, less than 20% primary care, significant graduate medical education and faculty, and top levels of specialists and subspecialists. The Columbia medical students will train in a rural location that is little different from New York City in training environment and in the types of physicians experienced.

Asian family physicians are interesting. These are physicians with the most urban origins in the nation that are choosing family medicine. The origin factors do result in some decrease in rural location and Asian physicians do tend to come from more exclusive schools. Also 30% of Asian family physicians are found in California, a location with 4% rural population. Asian medical students are the youngest medical students which is another decrease for family practice choice and rural location. The Asian family physicians do have about 8% rural location which is less than the 10% average for the nation or the 18% average for urban origin family physicians nationwide, but considering most urban origins and more exclusive school of graduation and younger age (0.7 odds ratio), and California practice locations there is still increased rural location rate. Often the race or ethnicity or geographic origins is less important than other origin factors and age.

It is important to consider origins, age, career choice, training, and policy together. Also some consideration is needed for state workforce such as Pennsylvania and California when the programs are local or state in nature.

Bivariate Versus Multivariate Studies

Bivariate studies are about the only studies that will fit in today�s word limited journal articles but they fail in many ways. As noted above, Asian physicians represent about 3 or 4 different origin factors. Osteopathic graduates of the 1990s represented greater rural origins, the oldest students, and 40% in family medicine as well as training differences. When comparing osteopathic to rural location there is a 2 times odds ratio of rural practice location. When comparing origin, age, career choice, and osteopathic training the contribution for osteopathic declines to 1.5. Studies of family medicine departments, Title VII, family practice student interest groups, role modeling, controllable lifestyle, or other independent variables compared to primary care, family medicine, underserved, or rural outcomes are similarly flawed.

Studies that include bivariate graphics are prone to distortions. Graphics usually involve bivariate comparisons. Studies rarely consider multiple variables as they take much more time and effort, typically exceed the word limitations of major journals

Compare origin, career choice, and practice locations in graphics below or a powerpoint video to sequentially compare origins and practice locations

Subspecialist Origins to Practice Locations    note fewer from lower and middle concentration counties and dominant super center location

Internal Medicine and Pediatric Origins to Practice Locations   internal med and pediatric origins are exclusive as are practice locations

Hospital Support Origins to Practice Locations    again exclusive origin and practice location

General Types of Specialties by Origins and Practice Locations     finally some tendency for more normal in origin and practice location

Family Physician Origins to Practice Locations              dependent upon a broad range of origins, the greatest distribution beyond concentrations

This can be repeated by type of training, by age of graduate, and other origin factors to get a better representation with proper controls.

Studies must have proper controls.

Health access demonstrates this, but cost and quality factors also require multiple controls.

This is a stretch for a basic concept, but with more study the relationships are easier to see. Cost, quality, and access have the same solutions. Contrary to primary care assertions, the solution is not primary care. The solution involves lower and middle income children that become the patient, the nurse, the health care team, and the administrator. These are more important factors than physicians or primary care physicians for most quality impact.

National Rural Health Association Annual Quality and Clinical Conference   Health Cost, Quality, and Access Have the Same Solutions    Robert C. Bowman, MD, A.T. Still University, School of Osteopathic Medicine Arizona    http://www.ruralhealthweb.org/index.cfm?objectid=6A183A9B-3048-651A-FE048E671102A334

Health care quality = patient factors + health team factors + system factors + physician factors

When health care quality is compared to physician factors alone, the physician factors get too much credit or blame. These flawed studies include the Institute of Medicine studies.

Higher status patients may indicate physician problems. The equation is

Health care quality = patient factors + health team factors + system factors + physician factors

But because the higher status patient is more likely to be health fluent, is more likely to make better decisions (cancels out patient factor) is more likely to have a top health care team and system (cancels out health team and system factors)

Health care quality = patient factors + health team factors + system factors + physician factors

Then the equation reduces to

Health care quality = physician factors

For lower status patients there is a different story as lower status is associated with severe deficits in health care literacy, barriers of income and education and coverage, health care teams of lower quality and resources, and system factors of lower quality and resources.

Health care quality = patient factors + health team factors + system factors + physician factors

The physician is the least of the worries but of course the physician is often blamed for the poor outcomes that are really a function of patient and design.

Regional differences involve different patient, health team, system/environment, and physician factors

With 63% of physicians from exclusive allopathic private schools for the 40 zip codes in Massachusetts that are half of the physicians in the state, these are very different and most exclusive situations with consequences for cost, quality, and access

Proper studies require proper awareness, and proper design for proper interpretation.

This is also why studies that indicate primary care linked to health care quality are often flawed. Correlations between generalists and health care quality are 0.4 correlations. Correlations between child poverty, poverty, child well being, distributions of income, employment ratios, voting rates, and middle class measures all indicate 0.5 to 0.9 correlations with health care quality. Quality is about the patient factor most of all for the general population and especially for lower and middle income populations.

The task is no easy venture. Defense expenditures, deficits, and entitlements are complicated by declining tax revenue sources. Studies comparing the United States to other nations would seem to support different priorities involving nurturing, child development, early education (child well being), deficit reduction (better future), public security, housing, reduction of energy costs, basic health care access, and improvements in primary care.

Among the potential benefits of better investment in children are

Increases in the Service-Oriented Pool of Professionals - Nurses, public servants, teachers, and family physicians are more likely to arise from lower and middle income peoples and the nation needs enough to supply all of these and more, not have competition for the few remaining or be forced to select those with lesser quality potential.

Better Quality, Efficiency, and Effectiveness - Better nursing, public servant, teaching, and primary care physician quality as more are able to become serving professionals and they make better serving professionals and they are a better match up of serving professional to those that they serve.

Better Quality from the Student/Citizen/Consumer/Patient Side of the Quality Equation - Better students, patients, and health care interactions from improvements in children who make better decisions in education and life that lead to better employment and better health care coverage with all phases of the patient side of the equation improving health care quality

Best Validity in Complete Populations of Physicians or Non-Physicians with Problems Increasing for Evidence Based, Selected Populations, or Single Schools or Programs

The medical literature has fallen in love with complex meta-analysis and evidence based studies. These methods have significant limitations in areas such as the basic selection of studies to use.

There are methods that have much greater potential for accuracy. When studies involve complete populations of hundreds of thousands of physicians, there are fewer errors that can be made. Sampling bias is minimized. The limitations are in the data and the coding. 

Career choice is available at over 90% levels in secondary databases such as the Masterfile. Birth data and data on medical school allow the calculation of age at graduation at nearly 100%. Techniques can enhance the validity of the data. For example physicians graduating before the 2001 class year can be captured in a database collected in 2005. This allows time for graduates to complete training, complete initial transitions and obligations, and move to representative careers and locations for proper study. Use of graduates that are too recent is a common problem as 20 � 40% are listed as not classified or still in residency training. This is a particular problem for international graduates that are delayed in entry to the United States or have already returned to home nations for practice. A few studies have counted physicians as serving in United States primary care that delivered no workforce at all in the United States.

Birth origins data is not the same as high school location of graduation, but birth origins data is similar. Also there is a similar continuum of life experiences found when comparing birth origins to high school origins as in Nebraska studies. The higher status populations may have life experiences in different cities and states, but have a similar experiential place from birth to high school. Children of more humble birth origins tend to remain in the same locations about 40 � 50% of the time from birth to high school and those that move tend to be found in nearby locations or similar locations in the same state or in an adjacent state.

Also birth origins reflect more about parent influences. Children born in Washington DC that are admitted to medical school already reflect a number of concentrations related to their parents and upbringing. Children born in a county with a medical school are born in a location with concentrations of physicians. Indeed many are themselves children of physicians and professionals that are concentrated in such locations.

Birth origins consistently reflect higher probability of admission and lower probability of health access career choice or else the pattern is lower probability of admission and higher probability of health access choice.

Debates can continue about birth origins, but validity is about consistency. With 95% of US allopathic graduates listed in the Masterfile with a birth origin plus 70% of osteopathic physicians, already a substantial group can be coded. Also international graduates can be coded in meaningful ways by birth origins in 50% or by their medical school or country of origin.

Foreign origins, most urban and highest income origins, and other origins associated with top concentrations consistently reflect higher probability of admission and lower health access contributions.

Rural, lower and middle income, older graduates, and origins outside of physician concentrations consistently reflect lower probability of admission and higher probability of health access careers for those gaining admission.

Unlike anecdotal remembrances that often distort the memories of medical school leaders, complete data analyzed using logistic regression demonstrates consistency.

Memories are fallible and also reflect what a person wants to believe. It is easy to believe that rural origin medical students fail to choose rural practices because most do fail. However rural origin medical students do have 2 or more times greater rural location rates even though 75% are found in urban practices. The proper studies involve odds ratios generated using complete populations.

Workforce leaders may want it to appear as if physicians cannot be distributed for purposes such as supporting more funding for medical student tuition.²² They may want to deflect criticism or evade responsibility for rural health access by targeting a simplistic solution such as rural origin admission²¹ rather than more comprehensive efforts illustrated by those who do understand accountability and social responsibility.²³

Most commonly leaders are just not aware of the solutions that have been documented in numbers of states and nations as they have been raised, educated, and trained very exclusively and far from the normal everyday lives of people in need and those who serve them.

It is also common to associate higher standardized test scores with better physicians even though studies have not demonstrated this finding.

What is found is that colleges, medical schools, students, and career choices associated with higher standardized test scores are also associated with lower health access career choices.

Also assumptions are commonly made about admission of students with greater probability of health access careers.

�         Assumptions based on race or ethnicity or origin alone are poor assumptions. Each race, ethnicity, and origin yields physicians that are consistently associated with combinations of concentration (income, people, physicians) and others that are least connected to concentrations or have a mix of origins. Race and ethnicity are often utilized, but also tend to distract from more important factors with regard to health access workforce or workforce for the most concentrated physician locations.

�         Assumptions about poor performance in medical school based on standardized test scores are also incorrect. Studies can predict higher rates of academic difficulty for students of more normal origins, but these studies even used by experts cannot predict the individuals that will have academic difficulty. Exclusion of 30 students just because 5 or 10 of these students will have academic difficulties is a great wasted of human potential.

�         Assumptions of increased health access probability also must be corrected. Studies can illustrate the types of physicians that will distribute where needed, but not the individuals who will deliver most needed health access.

�         Assumptions regarding gender are flawed. A number of states have more female rural family physicians compared to males. This is because fewer males and more females from rural origins gain admission. Gender is assumed to result in lower productivity. Because female entry into the workforce is relatively new and different, this is mostly not studied. Also females tend to have different patients, different specialties, and different billing codes. Women�s health is often lower volume, but has higher Relative Value Units. Choice of visits or RVU makes a big difference.

But there are important principles to understand. When medical education in an entire nation moves steadily toward more exclusive in birth to admission, in admission, in training, and in policy, there is little hope for health access and primary care. Children with combinations of concentration and the higher scores that are most common to such origins are least likely to choose health access. When the system permits a �market forces� progress ever more exclusive, there are fewer and fewer options for more and more in the nation that are left behind.

Most of all physicians should do no harm. Medical, medical education, and workforce leaders must remember this just as physicians in practice should practice this. The nation does need researchers and subspecialists. The nation needs well trained physicians. But the nation also needs basic health access workforce.

When a nation fails in the basics, if fails in cost, quality, and access.

The move from no health access to some health access is one of the most important considerations. Without access, health care cannot begin. With the move to some access, there is some cost and access improves infinitely. With increases in needed basic health resources, there is the potential for improving quality. With over 2 trillion dollars expended annually, it is easy to forget that for about 2 billion dollars, the United States can produce the primary care that it needs for those left behind. In fact it may have no choice but to directly fund most efficient primary care to allow other improvements such as increased access to be implemented.

If universal access was immediately implemented without sufficient health access professionals (nurses, non-physicians, physicians) there would be chaos and increased costs with less rise in quality. This would be due to the release of pent up demand. But if the nation first addresses sufficient primary care and makes selections that remain in primary care, expansion of health access can also proceed. This is the beauty of the 1965 � 1978 era when increases in federal funding were directed toward rebuilding health access infrastructure and resulted in a quadrupling of primary care graduates from 1970 to 1980. One of the failures of managed care was a failure to have sufficient primary care available.

National health designs require much study, especially of the past natural experiments of the nation.

The United States has had all of the health policy natural experiments, the statewide health access efforts, the medical school efforts, the decentralized program efforts, and the wide variety of admission and training successes that document the principles that result in health access. Most of all the United States understands how to concentrate physicians and health resources. Frankly to understand failure in health access, it is important to understand the production of top concentrations of physicians.

When nations understand concentrations and distributions, then they are in a best position to design health care for an entire nation. Until then, the health care will serve the exclusive and limit care for the rest of the nation.

It will always take time for the most important understandings. Exclusive parents will always think that their children with exclusive scores deserve the opportunity to be a physician. Of course what they do not know is that children raised exclusively may not have the qualities or characteristics that would make a good physician. When children have not had to overcome much to gain admission, when they have not suffered, when they have not had to deal with uncertainty while not knowing the ultimate outcome, they have not been prepared well for a medical career that involves the ability to understand suffering, the ability to deal with uncertainty, and the ability to accept what can and cannot be done.

The nation does not need more exclusive children. It needs better physicians in areas such as diligence, service orientation, awareness, empathy, and communication skills. Only testing involving communication skills demonstrates the ability to screen out poor quality physicians before they become physicians.²⁴ The nation needs to admit medical students that will go to serve the 65% of the nation left behind in health access. It need not admit those with the least that have highest probability of failure, but it must also not move steadily toward most exclusive.

Sufficient academics with great people skills can make a great physician.

Great academics without great people skills does not make a great physician.

For people in rural and underserved populations the consideration of great physicians is far beyond the current situation. They need physicians that will be accessible to them.

For the rural and underserved facilities trying to provided more and more care with less resources, particularly because they are paying more and more for locums, recruitment, and retention costs � then need basic health access physicians and nurses. This is the one thing that the United States appears to be avoiding at the current time.

Misuses and Misunderstandings Regarding Standardized Testing

Studies demonstrate that Standardized tests at the college admission and medical school admission level are poor predictors of performance. Only a year or two after testing the ability to predict performance deteriorates. One reason is clear. Medical students are much more than their scores and their scores often reflect their parents rather than who they are. Scores do not measure communication ability, people skills, organization, the ability to master new material, or the complex decisions made by physicians. Scores have been known to be flawed in predicting complex performance for over 80 years.²⁵

The students identified by average scores have only a few percentage points of academic difficulty difference compared to higher scoring students.

No admissions test or battery of test actually compares to actual medical school performance as a predictor. Once medical students take their first competitive test exam with classmates, the very poor 0.2 to 0.3 predictors of performance prior to admission are destroyed by 0.6 or higher correlations with the first exam.

Studies Do Not Demonstrate Higher MCAT Scores Associated with Better or Best Physicians or Medical Schools

Studies demonstrate that physician quality problems involve communication skills.²⁴ Studies fail to demonstrate highest scoring students with advantages. Once again scores are a tiny part of a physician.

From the perspective of most Americans that are in need of health care, graduates of schools with higher MCAT scores are the lowest probability solution and likely the individual physicians with the highest MCAT scores are similarly lowest probability solutions for their health access problems.

Higher Scores Are Associated with Decreases in Health Access Careers

Each of the factors related to higher probability of admission to medical school is also related to higher MCAT scores and is also related to lower probability of family medicine, primary care, rural, and underserved careers.

When medical schools rank students by top scores for interviews or for acceptance and when they bias interviews by allowing interviewers to know scores, they are biasing admission away from health access.

When schools set a threshold for scores and academic suitability and admit medical students based on other characteristics such as service orientation, people skills, and other characteristics individual to the student (not related to the parent), schools are preserving health access career choice and are also more likely to admit students with a broad range of needed career choices as well as a broad range of needed physician characteristics.

Narrow biomedical focus is not a good policy for physicians that must care for entire populations requiring a wide range of physician backgrounds as well as generalist and more general career choices.

Workforce Research Requires Awareness and a Broad Perspective, Not a Narrow Focus Specific to Funding or Defense of Medicine or Specialty

Physicians, physician leaders, and workforce researchers immersed in top concentrations of physicians, resources, and people have a most difficult time grasping the health care needs of 65% of the US population outside of concentrations of physicians, outside of the current design, and outside of decent health care coverage.

Studies in workforce are far too easily biased by specialty focus. Studies must involve complete populations of physicians.

Medical practice is about a higher priority placed on patient needs than the needs of the physician. Medical education, medical research, and workforce research need to have the same values. Workforce research based on databases controlled by a narrow group, with studies initiated by a narrow group, analyzed by a narrow group, and published by a narrow group is not a good design for an entire nation in need of health care.

About Birth Origin Studies

 About 95% of the graduates of United States allopathic medical schools (US MD Grads) can be traced to birth origins in the United States (city, state) or another country (foreign born US MD Grad). Physicians can be compared to census data to generate ratios of admission or probability of admission. These can also be compared across the same origins to physician career and location choice involving underserved areas, family medicine, and primary care.

Birth Origins, Admission Ratios, Career Choice, and Distribution

Linear relationships for admission and for distribution are seen across population density categorizations of birth counties. The physicians from the birth counties with lower concentrations of income, population, and physicians are more likely to choose family medicine, primary care, rural, and underserved locations. Lower and middle income origins are more likely for the lowest density origins along with military base birth. Foreign origins are associated with counties with concentration that consistently have medical schools and top concentrations of physicians, income, professionals, and people.

Distribution is complicated by the fact that fewer are admitted from humble origin counties. Those most likely to gain admission have origins in the most densely populated counties and are the least likely to distribute to primary care, rural, and underserved locations.

Birth county methods are strong in that 95% of US MD Grads can be matched to birth in a defined county, type of county, or foreign nation; however variations are involved. In rural counties, the variations are small. In large urban counties, birth origins are more variable. Lower income origin physicians cannot be separated from higher status origin physicians and foreign born physicians exist only in an entirely separate category without known US location prior to medical school. Birth origin to physician distribution relationships are also distorted by the state and local level by higher poverty levels. States with higher poverty will have more physicians in underserved areas, using the current underserved category. State and regional comparisons can be made, but must be adjusted for local workforce in rural and socioeconomic dimensions.

Birth origins, especially when nearly complete, are a nice control for the origin factors in a global overview for national workforce. Proxy variables can be created that represent origins involving income, geographic origin, and parents. Data such as parent income, parent origins, and MCAT scores is not readily available for more than individual medical schools. Another problem is that multi-school studies have been undertaken, but the schools are not representative of all medical schools. Usually the exclusive schools have the funding to undertake detailed data collections.

Research is about consistent results that help explain areas such as health access. Birth county income or population density, birth in a city or county with a medical school, and comparisons of types of medical schools by training are readily available and provide consistent results.

Origins must be integrated with training, career choice, and policy.

In the 1970s the nation quadrupled primary care production and massively increased needed health access with a doubling of physicians at one of few time periods of emphasis in primary care, emphasis of family medicine, increased funding for lower and middle income populations, and rebuilding of health care infrastructure. Primary care and specialty care needs were both addressed. The current expansion fails completely for primary care with active destruction of existing primary care due to poor support in health access policy. Because health access is much lower in cost, small percentages shifted from the top concentrations of health care result in major improvements. Critical Access Hospital funding took only a tiny fraction of hospital funding to stabilize hundreds of threatened rural hospitals that were paid too little to maintain operations.

Apportioning sufficient resources is a most important consideration in the design of a national health care system. The United States is not going to increase health funding, nor should it at 7000 per person per year or 2.4 trillion dollars. But it must shift funding to balance health care within the United States across all populations, across the wide variety of health care needs from prevention to acute to recover, across all ages and employers and methods of health care coverage.

One of the greatest challenges facing political and medical leadership is the problem of imbalance in primary care versus specialty care. There is really only way to restore the balance. Health funding must be shifted from top concentrations of physicians to support primary care and lower and middle income populations. As in the 1960s and 1980s, this shift of funding is actively opposed by systems, teaching hospitals, and medical schools that resist any losses or perceived losses of funding, even for the most essential health care of all moving patients from no access to some access.

 Most of all to gain some understanding of the entire situation, there must be awareness. The major problem for the United States in health care as well as banking, economics, education, and other areas is that people in 4% of the land area that are immersed in the top concentrations that shape politics, leadership, the media, health care, higher education, education, and more are relatively unaware of the situations facing people in 96% of the land area with 65% of the population, usually lower and middle income Americans. Perhaps one of the saddest situations is the elderly who must move away from the most costly top concentrations to become 70% of the people that are outside of concentrations of physicians, but they are also in most need of health care and are less and less mobile with increasing age. Again few realize that the elderly more than quadruple needs for primary care as they move from 50 to 65 to 75 years of age. Studies also indicate that older Americans are out of position for the heart attack and stroke resources that they need.²⁶

The US health care design fails most for the elderly even though financially they have universal access to care. Because only 23% of physicians are found in zip codes with 70% of the elderly, they are also left behind. As the older Americans double, they will find that all of the types of physicians that are most likely to be found serving this 65% of the nation have been eliminated with changes in admission, training, and policy. The leadership of older Americans, also found in top concentrations, is also unaware of the situation (or benefits from the current situation). In either case change is unlikely. Meanwhile the elderly will double and the oldest of the elderly will increase greatly � all in locations that have the least US investments in health care.

The US initial design for Medicare and Medicaid was health access and restoration of rural, lower and middle income health care was involved, but as with any of the federal programs, the more organized manage to convert health access interventions to vehicles to concentrate health resources in top concentrations rather than broad distributions.

Medicare and Medicaid expanded to release pent up demand, but eventually change to concentrate more resources in fewer zip codes. The initial health access design failed as higher paid hospital and specialty services increased in number, in higher cost, and in greater percentage of annual increase during rampant inflation. The concentrations involved locations with concentrations of physicians and hospitals and facilities. Failures in underserved populations, rural populations, rural health care, rural facilities, and primary care were soon evident by the 1980s.

The nation has yet to realize that the only way to reliably increase health access is to increase health care funding to lower and middle income Americans and increase the funding of the basic health access professionals that are most likely to be found in lower and middle income America. Of course this is a huge problem as the nation has utterly failed in basic health access careers and has policy that actually destroys basic health access, converting primary care to specialty care in thousands each year in internal medicine, nurse practitioners and physician assistants. Decades of work to build up health access and primary care have been wasted in a few years.

Once again there is failure to realize that basic health access and primary care take decades of planning and coordination. Also some level of protection is required from those that would profit off of conversions of primary care to specialty care that generates more revenue under current policy. Specialty care has always been able to arise from primary care or related specialties. Nations that insure a health access foundation have versatile workforce. Nations that destroy their health access have brittle health care systems that are unable to adjust to the constantly changing health care demands of diverse populations and world situations.

A nation prepared with sufficient basic nursing and sufficient health access with health resources distributed has already accomplished the most important preparations for pandemics or disasters. A nation with insufficient basic nursing (getting worse) and with more difficulties graduating enough nurses (faculty shortages, age 31 average age of nurse graduation, 7000 lost a year to nurse practitioner workforce) with insufficient primary care (converted to specialty care) and with declining primary care production (getting worse) and with the population concentrated together in close proximity (locations with already much higher communicable disease rates) and with known delays of a week or more for any reasonable outside assistance to arrive and with emergency services in just a few locations along with 90% of health resources in 4% of the land area is about as poorly prepared as a nation can be. Lessons should have been learned in all of these areas in the past 100 years and experts have given warning, but the nation continues to concentrate health resources where they will be least efficient and least effective, especially when most needed.

Readers are not expected to comprehend all of this at first reading. There has been too many distortions and misrepresentations by the media and major journals in the area of primary care alone. CNN has failed in major ways. JAMA and other articles support foreign origin international graduates as workforce when they supply the least workforce and the lowest levels of primary care per graduate of all sources. Nurse practitioners, even when they remained in primary care at high levels were unable to generate much primary care per graduate and with declines to one-third remaining in primary care, the contributions of nurse practitioners are minimal to most needed health access. Health access funding is regularly abused sending funding to locations with top concentrations of funding. When there is understanding of the basics, the flaws of the current design are more and more evident.

These are all critical to understand because health is a most basic infrastructure requirement for an efficient and effective nation. Few remember that it was health care reforms that reined in costs in the 1990s and allowed the nation�s economy to catch up, recover, and take off on one of the longest durations of steady economic progress. Few understand the crippling effect of health care costs on government at all levels from school districts to federal budgets. Very few understand that US health care design is one of the major factors that divides the nation into rich and poor.

Understanding will take time, reflection, consideration of multiple perspectives, and careful consideration of bias build up for decades. There are too many basic principles and concepts to understand regarding true health access, true primary care, distribution patterns of physicians and resources, origin factors, and health policy impacts. The author has immersed in multiple data sources for a decade. The data will be presented and explained and related to the entire picture regarding health access. Over and over the theme will be 65% left behind (or more). The rural populations, the urban underserved populations, the elderly, lower income Americans, Native Americans, Hispanic Americans, African American Americans, middle income Americans, self-employed Americans, Americans victimized by the health care coverage design, Americans spending far too much in out of pocket costs (health care, transportation), Americans forced to utilize urgent and emergent care over and over, Americans marginalized by hospitals that shorten stays to dump health care responsibilities on overwhelmed outpatient services, Americans that pay more and more to brokers who take more and more health care dollars from those desperate for needed workforce while actually delivering no health care at all, Americans putting off health care for too long � all are left behind.

Unifying Physician Workforce Studies Across the Great Divide

Much is missing in physician workforce studies because there is too much emphasis on what happens during medical education and too little emphasis on before and after. Before medical school includes birth to admission:  nurturing, child development, education, opportunity, higher education, preparation, and admission. After medical school is about policies in any number of areas at a number of levels of government.

Studies often consider birth to medical school or medical school to practice, but rarely across the great divide.

Birth origin studies help to understand admission, admission probability, the path to admission, and the beginnings of health access.

Policy enables or prevents health access. Supportive primary care policy facilitates improvements and efficiency all along the pathway to health access. Destructive policy in primary care insures that each step results in a loss of health access - from college to medical school, from medical school to residency, from residency to practice, and during practice.

Why Birth Origins Are Underestimated

Birth origins are available for complete populations of physicians and do represent origin points to allow consideration of origin, training, career choice, and policy.

Few give birth origins much thought, but they do represent a number of factors related to parents, early life experiences, and upbringing.

Most importantly they are consistently collected dating back before the 1950s.

Coding using birth origin zip codes or counties consistently represents career and location choices. This is a most important consideration for any variable. The variables are consistent using county income, population density, various geographic coding methods, and quartiles.

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14.          Physician Assistant Income: Changes in Inflation-adjusted Total Annual Income from Primary Employer 2003-2004 and 2004-2005. AAPA; 2005. http://www.aapa.org/research/index.html. Updated Last Updated Date. Accessed November 2006.

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Principles of Health Access Summary Points

Steps to Health Access

Basic Health Access Concepts To Review

The Basic Table - Taxonomy, Themes, and Theories Related to Experiential Place and the Principles of Health Access