Differences and Definitions

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Rural Coding - about the RUCA coding and distributions

Differences in Primary Care Types with Respect to Health Policy    Health policy can impact different types of physicians and locations. Including different types of primary care as a single group can be confusing. There are differences in career choice factors. There are also differences in the types of students choosing family medicine, internal medicine, and pediatrics. (Xu 1996)¹ Also there are major differences in the locations of the three major types. Family physicians are found outside of major medical centers at 57%. Office based general internal medicine and pediatrics physicians are found inside of major medical centers with 69%. (Bowman 2006)2  Health policy can influence physicians, facilities, or patient care inside or outside of major medical centers. Some types of physicians are dependent upon different programs. Medicaid is critical for general pediatrics and family medicine. Family physicians outside of major medical centers or in lower income areas are dependent upon Medicare and Medicaid. Health policy has involved new funding as in the creation of Medicaid and Medicare. More commonly in recent years health policy has involved movements within budget “firewalls.”

Primary Care Retention Differences  Perhaps the major difference in primary care regarding health policy involves primary care retention. Family medicine remains 99% active, 98% within family medicine, and 90% in office based practice. Pediatrics loses residents and graduates to other careers and inactivity but the greatest losses are to subspecialization. About 66% remain in office based generalist practice. General internal medicine losses were 50% but the indications are that over 80% subspecialize now (Garibaldi 2005) 3  with the potential for more to be lost over time. Medicine pediatrics losses are just as severe with only 14 remaining in the Masterfile with medicine pediatrics as the primary specialty out of over 150 who matched into medicine pediatrics in 1987. Nurse practitioner losses are about half to inactivity and include significant shifts to hospital, emergency, geriatrics, and women’s health, all in major medical centers. (Primary Care Retention)4  Physician assistants working with family physicians have declined from 40% to 28.5% in the past ten years with more changes to come. One major factor in all of these primary care losses is better pay and better support for those who leave primary care. Physician assistants can boost salary by 10% just by leaving primary care.   http://www.aapa.org/research/index.html 5

Only one specialty remains in primary care through all of these health policy related changes: family medicine. About 1% move to sports medicine or geriatrics and 1% go to a variety of careers. The major losses include academic family medicine, military, administrative, and hospital careers leaving 90% in office based primary care. Retention Within the Specialty of Family Medicine 6  Family medicine endures health policy changes without departing primary care, especially changes that involve decreased support for primary care, rural locations, underserved areas, and all areas outside of major medical centers. Family physicians increase in concentration as health care facilities and other physicians decline and as populations grow less dense, lower in income, lower in health care coverage, lower in education, and more diverse. Family physicians are half of Community Health Center physicians and 61% of those in rural centers. (Rosenblatt 2006) 7   Family physicians increase from 30% of all rural physicians to 56% in isolated rural areas and 67% for isolated rural areas of lower income. (Family Medicine Physician Distribution⁾⁸

Older Age and Distribution  Older graduates choosing family medicine, those with life experience before medical school, are critical for supplying rural and underserved areas. Osteopathic graduates have 40 – 50% older graduates compared to 22% for allopathic schools. The six osteopathic public schools have offered superior opportunities for older graduates interested in family medicine and have responded with the top levels of distribution in the nation. Duluth and Mercer have done much the same. Accelerated family medicine programs grew to 12 programs and 132 graduates were tracked. About 56% were older, rural location rates were over 4 times the national average (50%) and underserved location rates and rural plus underserved location rates were triple the national average of 6.5% for US MD Grads. Accelerated programs were terminated and only 6 osteopathic public schools were created from 1972 to 1978, more evidence for lack of supportive health policy in the nation for the most distributional programs.

Age and Choice of Family Medicine

Differences in Medical Student Types    Birth origins impact career and location choice. Each medical student has a probability of choice of family medicine, rural practice, and underserved practice that varies by birth origins. Family medicine choice is closely related to rural and underserved choices and rural and underserved populations are more likely to choose family medicine as well as rural or underserved locations. Birth origins also reflect medical students who know their final career choice. Health policy impacts are less likely for those who know their final career before medical school or early in medical school training. Those deciding late in medical school or in residency can be influenced by health policy. Those most likely to know their final career are at the extremes of socioeconomics, age, birth origins, and medical schools. Highest MCAT medical students and Asian and foreign born students plan subspecialty careers. The top MCAT schools are exclusive selections of these students. These students are the least likely to be found in family medicine. The older medical students, rural born students, lower income origin students, lower MCAT scoring students, and collections of these students in schools such as Duluth, Mercer, and osteopathic schools are the most likely to be found in family medicine and this does not change much with health policy. The broad 70% in the middle are more susceptible to health policy changes. (Bowman 2006)2

Those changing choice with recent health policy also reveal much about the need for health policy support. Black and Mexican American students had greatly increased family medicine choice in the peak 1995 – 1997 years. Currently these students may not feel confident in a choice of family medicine or primary care. This continues even though they are the most aware of significant health access problems in the nation.  (AAMC Minorities in Medicine) ⁹

For recent graduates of 1987 - 1999, underserved distribution is 3.5% for urban underserved, 2.9% for rural underserved, 6.5% for US MD Grads, and 7.0% for active 1987 - 1999 physicians from all sources.

Understanding Physician Distribution to Rural Locations  In the recent time periods, only two groups distribute consistently to rural areas: rural born students and family physicians. The percentage of rural born students for a state, nation, or medical school can predict future physician workforce. About 10% of current medical students are born in rural areas, about 10% of physicians are in rural areas, and there is a 0.9 correlation between the percentage of rural born student admissions and the percentage of rural physician graduates of a medical school. The percentage of rural born students can be used as a measure of the potential for distribution. Family practice and general practice percentages share a strong 0.65 correlation with rural practice location, but there are states, medical schools, and populations that have higher and lower correlations. There is also variation over time periods. These strong and consistent correlations have been possible only during the 1975 – 2000 period. Before this time period, career choice was more unpredictable. After the creation of Medicare, Medicaid, family medicine, and newer medical schools; physician distribution was more consistent. Family and general practice physicians have remained 30% of total rural physicians for each graduating class since 1975. A consistent 24% of family physicians are found in rural areas. (Birth Origins Database from American Medical Association Masterfile Database Using OfficeMax Practice Locations)⁸

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Understanding Physician Distribution to Underserved Areas Outside of Major Medical Centers

Two groups of medical students distribute to rural areas: medical students of humble origins and family physicians. Lower income origin, rural born (also many are lower income by birth), and older medical students (delayed by barriers of income and education) are humble origin types and are those from outside of major medical center areas or excluded or different in important ways from the typical medical students and major medical center way of life. They do not have optimal parent income or education, child development, education, neighborhood, private schools, college preparation, top colleges, easy access to the best college advisors, easy access to professionals for advice, and the usual path to medical school. They all have half to 10% of the probability of admission to medical school. When they do manage to survive American education and gain admission they are found in underserved areas at the highest levels, particularly when choosing family medicine. Family physicians are found in underserved locations in 2005 at 14 – 40% from the highest income urban types to the most rural lowest income different types (Native American females). Family physicians consistently supply 12 – 14% of the physicians in underserved areas outside of major medical centers for each graduating class since 1975 or twice the 7% level (6.5% for US MD Grads). Family medicine does this despite donating 11% of the most distributional types with 27% or more rural or underserved probability to academic or military careers. (Bowman 2006)2

Understanding Rural Definitions and Distributions  The percentages of rural born allopathic medical students (US MD Grads) for each class year were determined by RUCA 1.1 coding. (WWAMI Rural-Urban Commuting Areas) 10 This was within 1 – 2 percentage points of nonmetropolitan percentage throughout the time period. The percentage of rural born students acts as a baseline measure of the potential for distribution for a medical school, a state, or a nation. Medical schools and states that admit more rural born students also admit more older and lower income students and graduate more family physicians.

Understanding Limitations in Location Choice and Facilitation of Distribution  Family medicine choice allows full expression of the potential for distribution. Other choices limit locations to major medical centers and largely urban and higher income areas with health care insurance coverage. Family physicians have only 43% major medical center location. Any other choice means major medical center location for 69% to 90% of graduates and lower levels of distribution. Family medicine choice allows rural and lower income students to maximize their distribution potential. Also even urban born and higher income students have twice the national average for distribution with choice of family medicine. Without family physicians, the nation’s potential for distribution is markedly diminished.  (Family Medicine Physician Distribution^{) 11}

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Physician Workforce Studies

Major Medical Centers - definitions and tables regarding US physician distribution

www.ruralmedicaleducation.org