Facts Important in Basic Health Access

Policy support for basic health care for lower and middle income Americans is essential, and lacking.
Policy support for primary care facilities and health care team members is essential, and lacking.
Policy support for primary care practitioners is essential and lacking.
Primary care training program graduates must remain 90% in primary care for entire careers and deliver at least 25 years worth of primary care to even begin to resolve health access difficulties with the current numbers of primary care graduates.

Health care funding associated with physicians in the United States is distributed 90% to 3400 zip codes in 4% of the land area to locations with concentrations of physicians, nurse practitioners, nurses, and physician assistants. The remaining 65% of the population spread across 96% of the land area with only 20 � 25% of physicians and non-physicians receives only 10% of health funding related to physicians as these zip codes have the most basic health access professionals that are paid the least to do the most with the fewest resources and support personnel as well as caring for the most complicated patients. The only reliable sources to resolve deficits are health professionals that share origins with the 65% of the population left behind, graduates older with life and health experiences prior to training, family practice broad generalists who remain for 35 years in the family practice broad generalist mode. Only family physicians remain in family practice, primary care, rural, and underserved careers at highest levels. Nurse practitioners and physician assistants steadily depart primary care and this results in losses of primary care, rural, underserved, and most needed health access. NPs, PAs, employers, and large systems all benefit financially (according to current policy) by departures from family practice and primary care.

Various estimates of missing, delayed, or insufficient health care insurance or financial coverage range to 30% of the US population. By combining the various sources, it is likely that about half of the US population has some barrier to finance that impairs or delays or reduces needed health care. Only a minority can access the care that it needs, when it needs it, without significant barrier. There are few protections for overutilization with too much cost, quality problems, and compromise of needed health care for those in need of basic health access. This also is the result of the US design for health care.

The US has grossly insufficient basic health access nurses and physicians to care for its population. Resolution of the 1 million shortage of nurses in 2020 and the accumulated deficit of producing half enough primary care for two decades will take 35 years or a generation of physicians or nurses to resolve once the United States finally begins producing enough nurses who stay in nursing and enough primary care physicians who remain 90% in primary care with 90% active with 90% of a top volume primary care physician for 35 years of a career. This is a production of 35 years x 0.9 active x 0.9 remaining in primary care x 0.9 volume = 25 Standard Primary Care Years. The US will need about 300,000 to 350,000 Standard Primary Care Years of graduates to address primary care and basic health access needs and this workforce will need to be able to distribute to rural and underserved locations. See Health_Access_Report_Card.htm for grades with regard to primary care and health access.

A requirement for 325,000 SPC years (about what the peak primary care production of the 1998 class year was) can be met by 12,000 to 13,000 graduates that can meet the 25 Standard Primary Care per graduate parameters. The following numbers of annual graduates are required to meet this need

162,500 internal medicine residency graduates (20 times current levels of 8000 graduates a year) at 2 SPC years per graduate with 31 years of a career, 0.75 active, 10% remaining in primary care, and 83% of the volume of a family physician (the 45% foreign origin IMG internal medicine reduces the years, activity, and volume. Low primary care retention is a function of internal medicine

130,000 US origin internal medicine residency graduates a year (35 years, 0.86 active, 0.86 volume, but 10% primary care retention)
80,000 to 110,000 annual physician assistant graduates (12 to 15 times current levels) but most would need to remain in family practice mode and all physician assistants would need to have supervision by physicians (35 years times 0.7 active for a career times 0.7 volume times 0.25 - 0.3 primary care).
70,000 to 100,000 nurse practitioner graduates a year at 3 to 4 SPC years per graduate (27 years, 0.6 active, 0.6 volume, 0.3 to 0.4 primary care retention) but most would have to remain in family practice mode for their entire careers and supervision is commonly required by physicians.
65,000 total Internal Medicine, Nurse Practitioner, and Physician Assistant graduates or three times more than the current 22,000 at a level of 5 SPC years per graduate (double the current primary care retention likely requiring substantial primary care reimbursement increases with decreased specialty care reimbursement)
13,000 family physician graduates a year at 25 SPC Years per graduate at 35 years times 0.9 primary care retention times 0.86 active times 1.0 volume While this is 4 times the current level or 3 times the 1990s class year peak, the entire primary care production would require just 13,000 graduates a year. This is far less than the 8000 internal medicine, 7000 nurse practitioner, 7000 physician assistant, 3000 pediatric, and 3000 family medicine production or 28,000 graduates a year. This is a great savings in training costs with a maximal primary care outcome, a maximal distribution of basic health access, and a maximal distribution of the economics of health care. This is also exactly what is needed for rural populations, underserved populations, Community Health Center populations, the elderly, and the 65% of Americans left behind by the health care workforce design as family physicians, controlling for origins and training, are 2 to 4 times more likely to distribute to all of these populations in most need and the populations that are growing and in need of most care.

Remember that only when the nation actually reaches sufficient primary care production at 300,000 or more does the clock start ticking backwards from 35 years to 34 years to 33 years required for adequate return of basic health access. Movements toward primary care and basic health access are most difficult with current policy that facilitates movement of flexible primary care graduates (IM, NP, PA) to specialty and hospital careers.

The only locations with saturations of primary care in 2005 were super center and major center locations with over 75 physicians and 400 to 5000 physicians per 100,000 people in zip codes or adjacent zip codes and 100 to 250 primary care physicians per 100,000. The US has the fewest nurses and health access physicians found outside of top concentrations of physicians, non-physicians, and health resources with 65% of the population in zip codes with only 60 � 150 physicians per 100,000 and 30 � 60 primary care physicians per 100,000. These zip code determinations also included considerations of adjacent zip codes for a more accurate representation of local primary care access. Even super center and major center locations are less likely to have primary care saturations as these are locations with dependence upon internal medicine, nurse practitioner, and physician assistant primary care with half of active graduates moving away from primary care in the past decade.

The sources of primary care that have contributed the most graduates per year for the last decade and for the next decade have contributed the least primary care per graduate and will continue to contribute the least primary care per graduate and shrinking levels of primary care per graduate for the next decade or more

with internal medicine at 8000 graduates, 2 SPC years per graduate, and 10% of graduates planning to begin in primary care (and departures each year after graduation continuing)
with nurse practitioners at 7000 graduates, 3 � 4 SPC years per graduate, and 33% remaining in primary care (and departures each year after graduation continuing)
with physician assistants at 7000 graduates a year, 3 � 4 SPC years per graduate, and 25% expected to remain in primary care for a career (only 28% start in primary care and departures each year after graduation continuing)

In a time period of grossly insufficient primary care production, the most numerous primary care graduates should deliver the most years of primary care per graduate. In the United States the best source of primary care at 25 SPC Years per graduate and the only source with equitable distribution to all populations in the United States, has been reduced to the lowest annual graduates at 3000 graduates per year. If family medicine were increased to the 8000 annual graduates a year found in internal medicine, the United States would begin to recover primary care capacity about 20 � 30 years after this level of family physicians was reached.

The United States primary care production was over 20 Standard Primary Care Years per graduate for the 1960 � 1970 class years of graduates. The Standard Primary Care Years per graduate for IM, PD, FM, PA, and NP has fallen steadily to only 6 SPC years per graduate and should continue to decline steadily to 4 Standard Primary Care years per graduate.

Workforce deficits in primary care capacity take generations to resolve as primary care improvements have required decades for awareness building, consensus, social organization, specific policy changes, changes in the students admitted, changes in training to emphasize health access, changes to graduate more family physicians, and changes in policy such that primary care is supported at a sufficient level. The United States at the current time

lacks basic awareness regarding the nature of the deficits and the consequences,
does not even understand who actually delivers primary care and as such is unable to reach consensus regarding the efficient and effective way to address basic health access and may even choose yet again to produce more primary care graduates that deliver less primary care per graduate (IM, NP, PA),
continues to admit the most exclusive students and those least likely to end up in basic health access careers,
has leadership that considers primary care �not marketable� (because of policies set or tolerated by these leaders) or less than necessary (absolutely necessary for most Americans and for those left behind, less apparent with smallest percentages in locations where medical leaders are concentrated)or less complex (more complex)
American medical schools as well as the graduates of Caribbean and International Medical schools that come to the United States admit the most exclusive students that are least likely to end up in basic health access careers, train students away from health access, train students in environments least favorable to basic health access and primary care, graduate the fewest into the family medicine careers most needed for basic health access recovery, fail to support changes in policy to increase family medicine, increase primary care retention, and support basic access to health for lower and middle income Americans left behind.

Graduates of the few health access medical schools that admit, train, and graduate optimally for health access deliver 50 � 100 times more rural primary care and underserved primary care compared to the top 20 schools that receive the top rankings and prestige ratings based upon their Medical College Admission Test scores, researcher efforts, or exclusive career choices of their graduates. The United States supports these exclusive schools with top levels of clinical, research, and graduate medical education revenue. The United States tolerates smallest class size, the least support, and the most challenges facing schools who remain steady in pursuit of health access. Not surprisingly medical schools have moved steadily toward most exclusive in intention and have moved away from basic health access if for no other reason other than survival.

Medical schools and medical school zip codes have the lowest percentages of family physicians and primary care physicians, a clear indication of lack of commitment to basic health access. In some states such as Massachusetts nearly half of the physicians are found controlled by medical school zip codes and basic health access is difficult with 2% family medicine and less than 20% primary care in 40 zip codes with half of the physicians in the state. With over 60% allopathic private school graduates, including concentrations of graduates from the schools contributing the absolute lowest primary care per graduate, it is not a surprise that health access can be challenging despite the top concentrations of physicians in the United States. Also basic health access is not likely to improve despite state efforts as the medical schools and associated large systems can do much better under United States health policy by focusing all efforts on subspecialty, hospital, research, and graduate medical education efforts rather than basic health access.

The range of medical school admissions probability extends from 8 � 10 times greater probability of admission for Asian Indian origin medical students that have the most urban, highest income, most likely to be professional and physician parents that reside in closest proximity to top concentrations of physicians (census and medical education association data) to 5 times lower probability of admission for Americans of lower income rural origin or Mexican American origin.

Policy, medical student origins, and training shape family medicine choice. Exclusive policy, exclusive origins, and exclusive training move medical students away from the basic health access choice of family medicine. Asian Indian medical students are the most exclusive in origin with combinations of concentration. Asian Indian medical students are more likely to attend exclusive medical schools and eastern medical schools. Asian Indian people in the United States are least likely to be found around family physicians or the generalist lifestyle. The Asian Indian medical students had 2% family medicine choice during optimal policy in the 1990s. This low rate of choice was shared by other American medical students with the most exclusive origins and training.

The populations with the highest probability of family medicine choice were rural in origin, lower income in origin, and first generation to college. Mexican Americans had 19% family medicine choice and lower income rural origin choice neared 30%. Vietnamese, also a third group representing first generation to college had over 20% family medicine choice, as do most lower and lower middle population density origin medical students.

Best estimates now are that family medicine choice is in the 1 � 3% range for the medical students from the largest metro areas that dominate admission in the United States, even those from Omaha and Lincoln and suburbs in the Midwest that had over 10% family medicine choice a decade ago.

Policy, exclusive preferences in admission, lack of health access training, and fewer family medicine graduates complicates basic health access for most states, most American people, and the elderly that are also dependent upon primary care and family practice. The elderly will double in the next 20 years and they share location patterns with lower and middle income Americans away from concentrations of physicians. The lower and middle income populations left behind in the United States are growing, their local physician levels and primary care physician levels are shrinking (or not growing), the funding that might help restore basic health access is going to locations with concentrations of physicians, the physicians that they most need are being produced at the lower and lower levels, the nurse practitioner and physician assistant graduates are leaving the family practice mode that is the only NP and PA component that serves them well, the cost of delivering health care keeps rising, the complicated regulations associated with health care delivery are increasing, the graduates emerging from health professional schools are not prepared for complex primary care delivery, and their care needs are growing more complicated.

Sort Counties by top population density - What is the Countdown for the Fewest Counties to get to half of the physicians in the United States in the following specalties

50% of gen psychiatrists can be found the 103 most densely populated counties

50% of all internal medicine residency graduates in 106 counties internal medicine residency graduates in ultimate concentrations graphic

50% of neurologists are found in 110 counties

50% plastic surgeons in 113, 50% of pathologists in 117, 50% dermatologists or cardiologists in 118

50% of office based internal medicine primary care in 121 and 50% of office based Pediatric primary care in 121

50% of ob-gyn physicians in 127

50% of US physicians in 129 - mean value - indicators of average or better distribution below

50% of gen surgeons in 139 urology 146 Radio 156, ER 158

50% of US population in 227

50% of family physicians in 283, office based FP in 290 - once again family physicians are the only ones that distribute according to the population rather than according to concentrations of people, income, and other physicians.

Sort by top concentrations of physicians in each specialty. When approaching physician distribution by concentrations of physicians in a specialty

50% of internal medicine physicians are found in just 61 US counties out of over 3000 US counties

50% of office internal medicine in 71 counties

50% of US pop can be found in 160 counties

50% of office family medicine found in 184 counties

Pick your concentration, family medicine is about distribution.

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