Physician Distribution in the United States

Robert C. Bowman, M.D.

Logistic Regression studies - Beyond Evidence Based - over 95% complete data for the 316,752 graduates of the 1987 - 2000 Class years in 2005 locations

Physician distribution is about

The distributional medical students are those normal and not most exclusive (highest income, most urban) and multiply distribution 2 to 3 times. They are most likely to be born and raised outside in more normal American living conditions, they choose family medicine at the highest levels (at average to 3 times average % FM choice), and they are more likely to be found in more normal medical schools (not the most exclusive).

The distributional specialty is family medicine where 53% locate practices outside of concentrations or twice the level of other physicians or primary care physicians. All of the family practice forms of MD, DO, NP, and PA multiply distribution by 2 - 4 times (the family practice PAs have 6 times CHC location rates and 30 times federally qualified rural health clinic location compared to other types of PAs). This is because 45 - 60% are found in practice outside of concentrations along with 65% of the United States population that has only 23% of physicians under the current health care design. The family practice forms remain while all other types decrease with decreased concentrations of physicians, people, facilities, income, and health care coverage.  http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1035

General internal medicine and general pediatrics and the NPs and PAs associated with IM and PD both have 70% inside of major medical centers. All of the non-primary care specialties have 75%  - 92% in major centers or super centers and again the NPs and PAs in these specialties follow these concentrations. 

The health policies that facilitate distribution shift funding and support to patients and health care outside of major centers and super centers. This is of critical interest to the rapidly increasing age 65 and over population that are 70% found in the locations with only 23% of US physicians. Seniors no longer with the luxury of increasing income must move away from highest cost concentrations where health care is found to live in more reasonable cost locations (health, housing, living). These are locations that have insufficient stroke centers and heart attack centers. http://www.jaoa.org/cgi/content/full/108/6/297  But even more important is local primary care as older Americans get less and less mobile. Primary care needs doubles when Americans get older, increase 50% with a cross into age 65, and then double again with age 75 and up. These are HRSA statistics but of course these are very different than medical education experts present regarding primary care versus specialty care needs. The family practice forms of MD, DO, NP, and PA are by far the best source of primary care for age 65 and up. Other physicians and other types of NPs and PAs are simply out of position.

The Physician Distribution by Concentration (PDC) system can be used to divide the United States into zip codes with concentrations of physicians and practice locations that are outside of concentrations.  

 

Inside of Concentrations - 3386 zip codes with 75 or more physicians with 75% of physicians and 35% of the population in less than 4% of the land area.

 

Outside of Concentrations - About 23% of physicians are found in the remaining zip codes with 65% of the population spread over 96% of the land area. Concentrations and percentages of family physicians and primary care physicians were compared across the types of practice locations. http://familymed.uthscsa.edu/research08/pcrmsc/21st_2007/presentations/11%20Categorizing%20Physician%20Locations%20by%20Physician%20Concentrations%20Robert%20C%20Bowman%20MD.pdf

 

Extreme concentrations averaging 1100 physicians per 100,000 are found in super center zip codes defined by the presence of over 200 physicians. These zip codes had half of the nation�s active physicians but had the lowest percentages of family physicians (6.2%) and primary care physicians (28.6%). Super center medical school zip codes had even lower levels at 5% and 26.6%. Major center locations with 75 � 199 physicians represented a neutral ground between super center extremes of physician concentration and locations beyond concentration.

 

Locations beyond concentrations had the least health care resources and the greatest needs. Underserved and isolated areas trailed the nation with one-third to one-fourth of the national average physician concentration of 300 physicians per 100,000 people. Lowest income levels and highest poverty levels are consistent. Numerous locations had significant poverty and few physicians yet did not have apparent shortage designations. Marginal rural and marginal urban locations had less than 75 physicians at a zip code, less than 19% of the population in poverty, and 120 � 150 physicians per 100,000 or half of the national average.

 

The primary care concentrations were highest in the super centers at 230 per 100,000 people even with lowest percentages of primary care physicians. Primary care concentrations are twice the level considered sufficient for the most complex populations. Major centers had half of the super center primary care level or 115 primary care physicians per 100,000. Geometric progression continued as marginal locations were insufficient in urban locations with 55 primary care physicians per 100,000 while marginal rural locations had 37.

 

Family physician practice locations expressed as percentages appear to change dramatically with different types of locations from the lowest percentage at 4% of medical school faculty or 5% in super center locations but  practice location concentrations of family physicians per 100,000 people remain steady at about 30 � 40 per 100,000 or 1 per 100,000 per class year (35 years is a career length or generation of physicians).

 

Family physicians also arise at 1 per 100,000 per class year from the full range of origins from the most rural and lowest income to the highest income and most urban. All other specialties of physicians are more likely to arise from origins associated with concentrations and are more likely to be found in practice in concentrations of income, people, and physicians.  

 

The distributions are consistent with experiential place, lifestyle, socioeconomic, geographic, and role modeling theory expectations. Family physicians are found consistently across all locations except certain medical school locations and the locations with the lowest US support of all. Even so family physicians are twice as likely to be found as medical teachers and twice as likely as other physicians to be found in urban underserved locations.

 

The schools with the highest concentrations of physicians and the lowest percentages of family physicians may not present receptive environments for family practice or primary care. Other physicians increase in concentration as the numbers and concentrations of physicians increase. This results in higher percentages of family physicians found in locations with lower concentrations of physicians. This 65% of the United States depends upon specific admission policies and family practice career choice. As admission, training, and health policy increasingly favor concentrations, fewer find their way to family practice or areas in the most need of physicians. Unfortunately fewer physicians, internal medicine physicians, pediatricians, nurse practitioners, and physician assistants find their way to the 65% of Americans in most need of health care and the economics of health care. Only family physicians and the nurse practitioners and physician assistants that remain in association with family physicians exhibit the optimal health access characteristics most needed by the nation in 2008.

 

Health policy changes are seen in family medicine choices for the 1997 graduating class compared to the 2005 and the 1990 distributions were much the same. Managed Care and Choice of FP or graphic

 

Admissions of highest income, youngest, foreign born, and highest scoring medical students together with health policy that facilitates major medical center location leads to greater concentrations of physicians within Major Medical Centers (with more  developing).  

 

 Types of Medical Students by Distribution Tendencies

Distributional Types and Lower Admissions Probabilities(Humble Origin, bottom 70% origins)

Non-Distributional Types and Higher Admissions Probability

uRural born

uUrban born

uLow or Middle Income

uHighest income

uBorn in the United States

uForeign born current or recent

uInner City

uElite, schools, colleges, medical schools

uOlder, especially with barriers of income, parents less likely professionals

uYounger, especially with no barriers, parents more likely to be professionals and physicians

uNot born in a county with a medical school

uBorn in a county with a medical school

uDiverse/different backgrounds, combinations

uCombinations of the above are most common and all increase probability of admission

uBarriers involving income, education, parent occupation, family structure, environment, no funds for standardized prep and depend upon local, state, and federal government for additional college and career assistance

uParent socioeconomics, occupation, family structure, environment, tens to hundreds of thousands spent on child development, education, standardized testing and college preparation, top colleges where 74% are highest income quartile in origin (Carnevale)

uDisadvantages at critical age 0 � 8 stage, constant challenges after, velocity of learning constant by age 8,  (Hart, B., and Risley, T. Meaningful Differences in the Everyday Experience of Young Children) so it takes years longer to catch up, thus older age at graduation, typically older graduates start toward a medical career in early teens and work years before and after college to gain admission

uMajor advantages at age 0 � 8 stage, can maintain advantage with less effort, tens of thousands spent by parents on their children beyond public investments, youngest at college and medical school entry, least life and health experience prior to entry, more likely single, more likely science and disease focus compared to people focus

uLower scoring on standardized tests at age 8 to admissions, often a pattern of improvement from admissions to USMLE 1 to clinical, medical school may be the first level playing field of their lives. See also

Education

uHigher scoring on standardized tests until admissions and then possibly some decline from MCAT to USMLE 1 in relation to others catching up (strong in Asian and somewhat in Hispanic types, both the most concentrated next to MMCs) Veloski, J. Callahan, C Xu, G  Hojat, M  Nash, DB Prediction of students performances on licensing examinations using age, race, sex, undergraduate GPAs, and MCAT scores.Acad Med S28-3075 (10 Suppl)

 

For tables of class compositions and distributional outcomes see Medical Schools and Distribution

Health Policies

Basically a normal distribution would result in better physician distribution, but not 90% of health resources expended in 3386 zip codes.

Distributional or favoring physicians and practitioners outside of major medical centers

Current policy rewards exclusive careers and locations with the most lines of reimbursement and the top level of funding in each line.

Non-Distributional or favoring physicians and practitioners inside of major medical centers

Difficult to change since the current policy design favors 75% of physicians and 90% associated with medical schools and medical associations

uSlow steady consistent increases in reimbursement for physicians outside of major medical centers such as primary care and family physicians

uAbrupt or steady increases in reimbursement to physicians inside of major medical centers such as subspecialists and hospital support physicians

uSlow steady movements of health care funding to lower or middle income populations including improved health care coverage, eligibility, rural and small hospitals, Community Health Centers not in major medical center zip codes

uPolicies that continue to move funds into major medical centers. Major medical centers are particularly good at maximizing revenue streams, even those targeting location outside of major centers and served areas (bonuses, designations, Community Health Centers, and now J-1 Visa)  

uDespite attempts to impact training and location, medical students, residents in training, National Institutes of Health dollars, and Graduate Medical Education dollars rarely leave major medical centers

uLow levels of federal and state funding for medical education, forcing medical schools to retain and maximize existing resources, barriers regarding Medicare regional carriers and delays in policy implementation involving those who might establish training outside  

uLimitations of graduate medical education positions such that more are encouraged to choose family medicine, the only career that locates outside of major medical centers with 57%, 70% for direct patient care family medicine.

uUnlimited GME positions for the physicians that locate in major medical centers (all except FP) that move funding to major medical centers, faculty to major medical centers, and keep physicians in major medical centers

uExpansion of medical schools during periods of emphasis of primary care, family medicine, and restoring equity in the nation

uExpansion of medical schools during periods of emphasis of subspecialization and the lowest choice of family medicine in decades

uAccreditation and training funding that allows flexibility in how curricular objectives are accomplished. Focus on more active student and resident participation in health care decisions, procedures, and patient management. Replication of established models that have proven their ability, not forcing replications to some different hybrid form. Partnerships between government and major medical centers and middle and lower income populations, especially involving training in rural and underserved areas and Community Health Centers. 

uAccreditation and training funding that forces medical schools and residency training locations to be in the most urban areas by size or subspecialist or revenue stream restrictions. Health policy punishes leaving major medical centers for training by loss of revenue or lack of GME funding. There are no real incentives for Community Health Centers or anyone outside of major medical centers to participate in training. There are many incentives now for non-academic and private physicians to cherry-pick the least complex Medicare, Medicaid, and previously indigent patients who once were teaching patients.

 Doctors Are Where Patients Aren't http://www.dailyyonder.com/doctors-are-where-patients-arent/2009/02/12/1924

Physician distribution involves distribution of physicians to rural locations, to primary care, and to lower income locations and populations. Physician distribution is a key measure of health access in the United States.

 

 

Important Focused Questions and Issues Regarding Distribution

Physician Workforce Studies

Medical Schools and Distribution

Bright Future Rankings

Flawed Physician Workforce Beliefs

www.ruralmedicaleducation.org

Wolf Grey 3s jordan 3 wolf grey jordan 3 wolf grey wolf grey 3s coach factory outlet online retro jordans wolf grey 3s cheap jordans wolf grey 3s louis vuitton uk michael kors outlet louis vuitton outlet louis vuitton outlet sport blue 3s louis vuitton outlet jordan 3 wolf grey kate spade outlet sport blue 6s coach factory outlet coach factory outlet