Major Medical Centers

Robert C. Bowman, M.D.

For most purposes in this web site, major medical centers are defined as medical school zip codes or zip codes with 75 or more physicians.

The determination of major medical center involved multiple reviews of 41,000 zip codes for levels of physicians, trainees, poverty levels, and designations such as Community Health Center or National Health Service Corps or whole county primary care shortage areas.

Medical school zip codes were determined using zip code lists of medical schools, internal medicine departments, family medicine departments, and Masterfile listings of concentrations of physicians in teaching, research, or residency.

If a zip code was determined to be a major medical center zip code, it could not be categorized as an underserved zip code. Major medical center zip codes and zip codes with sufficient physician numbers had lower levels of poverty and higher levels of income. In the following table, the various physician locations and the zip code poverty levels, physician ratios, and physician to poverty population ratios are considered.

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.

Differences and Definitions - more details

Rural Coding - about the RUCA coding and distributions

Variables in the Medical School Database

Correlations at the state level also revealed a 0.7 correlation of state shortages of primary care physicians needed to meet shortage needs when using underserved categories excluding major medical centers compared to a 0.5 correlation when the underserved coding including major medical center locations. Clearly major medical centers serve underserved locations, but distributing physicians and other practitioners outside of major medical centers is clearly a major priority for any nation that hopes to deliver equitable health care to lower income, middle income, and rural populations. The practitioners stuck in major medical centers by a number of health policies are not going to distribute. See Primary Care Retention

The total physician count involved active physicians in the complete Masterfile. The actual count is expected to be more as physicians often have multiple locations and only one is listed using Office Max software by MMSs. Also the physician assistant and nurse practitioner and other providers associated with major medical centers are not included in the count. With all included, the number of zip codes would be higher and the 71% of physicians in major medical centers would be much higher.

A major separation point is that 57% of family physicians are outside of major medical centers while 75% of all other physicians are found inside of major medical center zip codes in 2005. When only active practicing family physicians are considered, nearly 70% are outside compare to the 70% inside for other physicians, including generalist internal medicine and generalist pediatrics.

Major medical center determinations also help understand why geriatrics is not likely to contribute much outside of major medical centers since 85% of geriatricians are found in major medical centers. Obstetrics-Gynecology is also 75% inside.

Health policy greatly favors major medical centers with multiple funding streams from state, local, and federal government and also the highest reimbursement levels for clinical and hospital services.

Major medical centers have significant negotiating power to keep costs low and reimbursements high. Those outside of major medical centers are not able to do so, especially the smallest clinics and hospitals.

A tiny fraction of the funding to major medical centers was able to return solvency to many rural hospitals in the form of Critical Access Hospitals.

So far the concept of shifting a small percentage to primary care or underserved or rural areas outside of major medical centers has not been used. Medicare and Medicaid were turned into major medical center reimbursement programs, except during managed care where Medicaid was doubled and major medical centers had to make significant adjustments. One of the neglected results was a 50 - 60% increase in family medicine and a 45% increase in rural family medicine and in underserved primary care, sending physician distribution to peak levels and temporarily solving maldistributions that have failed decades of health policy and is failing again.

A major problem for the medical school component of major medical centers is lack of state and federal support for health professions education. Lack of this support coupled with increased competition generated by medical schools in the form of subspecialty competition for areas once exclusively within medical schools has meant that medical schools have had to increasingly focus on clinical and research revenues and have less to expend upon teaching.

Major medical centers have mastered all forms of reimbursement, especially National Institutes of Health and Graduate Medical Education. However they have also mastered the forms usually reserved for underserved and rural areas such as the shortage designation process at the state and federal levels, National Health Service Corps, Rural Health Clinics, Community Health Centers, shortage area reimbursement bonuses, and J-1 Visa. Some of these were almost closed with the abuses of some centers and all suffer from the regulations that have been imposed regarding all federal programs. Some of these policies and these regulations (teaching physician) have also fueled an exodus of subspecialties to their own hospitals, making situations even more difficult for medical schools, traditional hospitals, and rural hospitals.

New regulations regarding supervision may even close residency programs in family medicine. Increased regulations regarding billing may close off the volunteer preceptors that help educate numerous residents, medical students, and other students.

The lack of a real primary care system and poor emphasis on public health also has major medical centers doing many of these functions, often at much higher cost and through venues such as emergency care.

Five Periods of Health Policy and Physician Career Choice

Physician Distribution in the United States

Retention Within FP

Physician Workforce Studies

www.ruralmedicaleducation.org