Doctors Are where Patients Aren’t
Dr. Robert Bowman, M.D. describes the broken design of American health care:
physicians are concentrated in locations and careers that fail to serve
the majority and the most urgent medical needs.
Projected growth in U.S. population 2005-2020: red line=people
over age 65, blue line=under age 65
So you are now 65 years old. You and your peers are pioneers of longevity, having lived longer than any generation in American history. And you are expected to live one or two more decades still. Your tasks now, as an older American, are to preserve your health, minimize health care costs, minimize your cost of living, and maintain enough assets to support yourself.
In the past few months, your situation likely has become far more complicated with collapses of investments and pension funds. The net assets of older Americans are tied to home equity, but homes are declining in value and more difficult to sell.
Older Americans — typically with fixed incomes, lower incomes, and lowering incomes –need lower costs of living and lower health care costs, too, yet the elderly generally need more health care and more complicated health care. Just the sorts of health facilities they need most — basic health care clinics, stroke centers, and heart attack centers — are heavily concentrated in the most costly locations in the nation.
Most of the nation’s health resources are located, of course, where there are high concentrations of physicians — about 4000 ZIP codes in the United States. But the majority of elderly Americans (70%) live outside of these regions of best access, as do 65% of all Americans.
Because cost of living tends to be higher in these same 4000 ZIP codes, many older Americans are forced to move away from the sources of health care that they most require.
The current geographic design of American health care is not a good fit for older Americans, especially for the elderly who live in rural areas.
Health care design we have now dictates that most Americans and their families must drive great distances for complex medical needs. But elderly Americans tend to have the least mobility. Greater distances mean more out of pocket costs for health care.
Older Americans have Medicare and Medicaid coverage, but these programs are insufficient to support many forms of health care, even the most basic medical access. Older Americans now face the prospect of fewer physicians, and fewer physicians who can afford to take them in as patients. The same flawed design hampers 65% of Americans left outside of concentrations of physicians. Citizens with the most complex health problems have the least support – only 10% of the nation’s health resources and only 23% of physicians.
Health Professional Shortage Areas, July 2008 — only the
areas in white have sufficient numbers of health
A new coding system illustrates the problems with the current health care design. This coding system divides ZIP codes into locations with concentrations of physicians and health resources and locations outside of concentrations. Note these important discrepancies:
• Locations with Concentrations – These are the 3386 zip codes with at least 75 physicians. They comprise 4% of the land area and contain 35% of the U.S. population, yet here are 47% of family physicians, 70% of internal medicine physicians, 75 – 92% of specialists, and over 90% of the nation’s health resources (medical schools, research dollars, residents in training).
• These locations with concentrations have 300-5000 physicians per 100,000 residents (The national average is 260 physicians per 100,000 residents).
• The ZIP codes with medical concentrations are clustered together, making access to health care difficult. These are the only locations with sufficient physicians and primary care. Fewer older Americans live in these areas; more young adults with highest incomes or those heading to highest income levels live in these areas.
• Nurse practitioners and physician assistants who work with specialists are also concentrated in these locations and are increasingly moving to these same physician-rich areas.
• Locations Outside of Concentrations – The ZIP codes with fewer than 75 physicians are a group of 18,000 urban ZIP codes and 18,000 rural ZIP codes. In these physician-poor areas live 65% of the population.
Only about 5 – 10% of the physicians in locations where doctors are most concentrated are family physicians. Most family physicians (53%) depart these concentrated locations after training. The physician assistants and nurse practitioners that remain associated with the family practice mode share family practice distributions. But only 8 – 30% of other physicians depart doctor-rich areas.
It is easy to understand why the U.S. health care design has failed to meet our real needs. Existing health care leadership has suggested that primary care is not marketable as a profession. Medical leaders tolerate dysfunctional primary care and publish articles about its collapse. For the most part, they represent the viewpoints associated with internal medicine and they come from areas where the concentration of medical practitioners and facilities are high. Conversely, low percentages of family physicians (only 4%) and primary care physicians (only 20%) live in communities with medical schools. Those family and primary care physicians who do work in these environments typically are hired at the lowest levels of administration.
In the past, the United States has been able to make primary care available in numerous ways. A decade ago the nation optimized primary care and health access by boosting family practice residency graduates to 4000 graduates a year. There were major improvements in health policy, and market forces shaped increased support for a permanent primary care choice. Now choice of a permanent primary care career is made most difficult by health policy.
Nearly 63% of Americans over age 65 consult family physicians. A nation that fails to produce family physicians is ignoring realities – diminishing the numbers of practitioners who provide the largest portion of health care for most Americans. Family physicians are 2 – 4 times more likely to be found serving older Americans, the poor, the near poor, lower and middle income Americans, and rural Americans.
Family Practice Physician Assistants share the locations of family physicians. They are 30 times more likely to be found in federally qualified rural health clinics compared to other physician assistants. They are 6 times more likely to be found in Community Health Center locations, and are 2 – 4 times more likely to be found in all rural locations. But family practice physician assistants have decreased from 54% of all physician assistants in 1984 to 26% currently. Only 20% of physician assistants now begin in family practice now, compared to 22% who serve in surgical subspecialties where they receive highest pay and benefits served up by the American health care design. Younger family practice physician assistants in states such as South Dakota are also likely to be part time while older graduates with higher primary care concentrations are retiring. Physician assistants are moving steadily toward hospital and specialty careers and locations with concentrations of physicians, income, and people.
Family Nurse Practitioners share the optimal distribution patterns of family practice forms. Nurse practitioners are found in rural areas at the highest percentages (20 – 25%) and make superior contributions to all locations outside of concentrations of physicians. Family nurse practitioners are now accepted and are heavily recruited across the wide range of health care. About 6% of nurse practitioners are found in cardiology with significant movements to other internal medicine subspecialties.
Most important to understand is that family physicians have remained in primary care practice, serving the elderly, rural populations, lower and middle income Americans, and all of those who live outside of the areas where doctors are most concentrated.
Major solutions for care of the elderly, for the nation’s health access problems, for physician distribution, for distributions of health care funding, for care of the 65% of Americans most in need of health care are much the same. The United States must graduate more family physicians and must figure out how to get nurse practitioners and physician assistants to choose the family practice mode.
To understand retention, it is important to understand why humans depart primary care careers. The formula for departure is easy to understand. It is because they are human. Just $10,000 more for a specialty, hospital, or hospitalist career is enough to get internal medicine, physician assistant, and nurse practitioner graduates to depart primary care. It is this design that destroys primary care, health access, and care to most needed populations. The impacts are seen on production and retention of graduates.
The current design needs changing. The initial Medicare and Medicaid designs favored primary care and those in most need of health care; the nation quadrupled primary care production from 1970 to 1980 and redistributed health care — to poor Americans and older Americans, to rural areas where more elderly and poorer Americans live.
But the current design for health care favors only 35% of Americans associated with top concentrations. Medicare and Medicaid once redistributed health resources to those in most need of care. Federal programs have been changed into vehicles that concentrate health care away from the 65% that need care and the 70% of older Americans that share their location and their fate
Dr. Robert C. Bowman, M.D., founder of the Rural Medical Educators Group of the National Rural Health Association, is a physician and long time health education policy advocate. He is professor in Family Medicine at A.T. Still University School of Osteopathic Medicine in Arizona. See this listing for Dr. Bowman’s selected references on the topic of concentrations of health care professionals.