Primary Care and the National Health Service Corps: Finding Physicians “Who Will Go Where No One Else Will Go”

Roughly 65 million Americans live in places where there are at least 2,000 potential patients for each lonely physician. No surprise, these tend to be impoverished rural regions, or depressed inner cities. We call them “underserved areas.”

If we paid medical schools to train more primary care physicians, would they migrate to these areas? Probably not. Experience shows that if we increase residency slots, physicians continue to flock to the same popular, well-served areas where most prefer to settle: Manhattan, Boston, Boca Raton. . .

It should come as no surprise that relatively few med students elect to set up a practice in rural Mississippi, Detroit, or the South Bronx—unless they are returning home. As I have written in the past, research reveals that students coming from low-income communities frequently feel a commitment to those communities.  

Many—not all, but enough—want to go back. But these days, given the sky-high cost of medical school tuition, combined with the nearly perfect test scores and GPAs that med schools require, very few students who attended public school in a small town in Tennessee wind up becoming M.D.s. 
Yet health care reform guarantees that waiting rooms full of formerly uninsured low-income patients will be looking for health care. According to the Harvard Medical School, an additional 17,000 primary care health professionals will be needed in underserved areas. Skeptics suggest that reformers have promised more than we can possibly afford. How will we funnel more general practitioners to areas where there already are too few physicians? How much will we have to pay to lure them there?

Most of reform’s critics have never read the Affordable Care Act, and so have no way of knowing what rich funding the legislation provides for the National Health Service Corps (NHSC)—or what that will mean for family practice. Like many Americans, they may never have heard of the Corps.
A government program created in 1970 with an eye to distributing physicians more evenly throughout the country, the NHSC offers scholarships and forgivable loans to med school graduates who agree to work in places where they are most needed for a few years after graduating from school. (If you ever watched “Northern Exposure,” the quirky television comedy/drama which tells the tale of a young doctor who lands in a very small town in rural Alaska, you’re familiar with the Corps.)

Over the years, the NHSC has proven itself in the ways that count. Very few students renege on their commitments, and more than 60 percent of NHSC clinicians have continued to devote part or all of their careers to serving the underserved, well beyond their original commitment to the Corps.

                    Health Care Reform Gives the NHCS a Transfusion

When the Obama administration came to D.C., it earmarked generous funding for the Corps in its initial 2009 fiscal stimulus package. The 2010 Affordable Care Act then built on that investment. All told, Washington will be putting nearly $2 billion into the NHSC over a five-year period—a sum that should create more than 12,000 additional primary care physicians, nurse practitioners, and physician assistants by 2016. (This is only one way that the Affordable Care Act swells the ranks of primary caregivers. For more, see this Fact Sheet on primary care and reform.

 In 2010 alone, nearly 5,000 recent medical school graduates accepted federal grants to pay off tuition and school loans averaging $150,000 per student. The awards came with contracts that obligate the young doctors to remain in what are typically rural areas for three to five years.

The new funding for the Corps marks an extraordinary turnaround for a much-needed, but badly battered program. Ten years after the NHSC was created, the idealism of the early 1970s gave way to a political climate that was not so friendly to low-income families. As economist James Galbraith pointed out in his 2009 book, The Predator State, in the 1980s, the U.S. began to suffer from “compassion fatigue.”  We started to “lose interest in the poor.”

President Reagan was elected in 1980, and, according to the National Advisory Council on the National Health Service Corps the NHSC soon “fell victim to a policy sea-change in Washington.  . .  driven by the twinned goals of reducing the size of the Federal government, and limiting its ‘intrusion’ into activities that could be better handled at the state and/or local level, the Administration cut the NHSC’s budget, and cut it again. It became apparent that the Program was slated for dissolution by 1990."

The indifference of the 1980s left the NHSC “a shadow of its former self.”  By 1990, its “budget was $50 million – less than a third of what it had been in 1980. The primary effect of the budget cuts of the previous decade could be seen in Field Strength: as fewer scholarships were awarded (only 40 in 1988) and the pipeline dried up, the Field Strength fell by two thirds as well (from the peak of more than 3,100 in 1986, the NHSC would be able to field barely 1,000 in 1991."

In the early 1990s, funding picked up. “By 1994 the NHSC had a budget of $124 million and awarded 429 new scholarships and 536 new loan repayment contracts,  Field Strength had grown by more than 80 percent to 1,867."

In the second half of the 1990s, however, the NHSC again found itself under attack. The Clinton administration was moving steadily to the right, and the Health Services Corps was not particularly popular with the base that New Liberals were wooing—suburban voters. Meanwhile, the number of uninsured grew. In 1999 the NHSC had a Field strength of 2,439—which met only about 12 percent of the need for 20,000 primary medical, oral, and mental and behavioral health clinicians in underserved areas nationwide. Of 2,439 health care workers in the field, just 1,327 were primary care physicians. Roughly half were African-American or Latino; the NHSC was attracting a more diverse group of doctors, but 1,300 just wasn’t enough.

Flash forward to the Bush years: “From 2003 through 2008 funding for the NHSC was cut by $47 million, over 27 percent of a budget that was already insufficient in FY2003."

For decades, the NHSC has been hanging on, waiting for health care reform—and finally it arrived. The $1.5 billion that the Accountable Care Act set aside for the Corps marks a final win for Ted Kennedy.

At the same time, the Obama administration realized that the NHSC would need ongoing funding. This is why, when Obama announced his fiscal 2011 budget in February 2010,  the National Health Service Corps benefited from an increase in funding with the President allocating $169 million (up $27 million.)
But of course the story does not end there.

Predictably, conservatives who have launched a new war on the poor (not to be confused with a war on poverty), would like to gut the NHSC. The House Appropriations Committee has proposed eliminating $141.925 million in discretionary FY 2011 appropriations for the Corps, while maintaining $290 million in mandatory funding, which would mean that some 2,365 health professionals would no longer be able to receive NHSC dollars.

I doubt the House will succeed. More importantly, the fact the Appropriations Committee cannot whack the $290 million in mandatory funding is just one example of how difficult it would be to “de-fund” health care reform. That $300 million is part of the $1.5 billion that the Affordable Care Act promised the NHSC over five years. It appears that conservatives cannot touch it.

                                  Money Is Just Not Enough

But money alone will not provide the recruits needed to provide continual primary care in those areas where, as the NHSC puts it, “few choose to go.”  Much turns on medical school admissions committees reaching out to a larger pool of applicants.

Not long ago, the Washington Post wrote about a young doctor who had signed up to work in a small, unincorporated Virginia town just “a few miles from the real-life Walton’s mountain.”  According to the Post she “embodied the traits that President Obama extolled in stump speeches about reform. She earned straight A's through Richard Montgomery High School in Rockville, Maryland, [a D.C. suburb known for its corporate headquarters] and graduated from Johns Hopkins University with a 3.7 grade-point average. She was one of two students in her graduating class at Northwestern University's Feinberg School of Medicine who chose to become a family practitioner rather than one of the high-wage specialists the school is known for producing.”

But in 2010, as she approached the end of her three-year contract, this NHSC recruit was not at all certain that she wanted to stay. She enjoyed her work, but according to the Post, she was “unprepared for the daily inconveniences of rural living: well water in the clinic's kitchen sink that smells of rotten eggs; being unable to use the iPhone's Epocrates app, which helps doctors identify and prescribe medicine; the dial-up Internet that crawls along on a single computer shared by the clinic; the 40-minute drive to a grocery store. . .”

“‘I don't think I'm a rural kind of person,’ she told reporter Darryl Fears. ‘I like having stuff around. I like the ability to go out to dinner and do cultural things.’" She added that “the National Health Service Corps should make rural offices more friendly to technologically savvy young doctors if it wants them to stay.” But the truth is that her sleek new iPhone won’t pick up a signal deep in the woods, and that is where the patients who come to her clinic live.

The Washington Post reported that as this young doctor tried to decide her future, “Deborah Anderson, an assistant administrator at Central Virginia Health Services, watched anxiously. Doctor turn-over in rural Virginia clinics creates a void in services,” the reporter explained. “Patients who develop a relationship with doctors feel rejected and are reluctant to bond with new doctors.”

No doubt, this bright and caring NHSC recruit contributed to the health of the community during the three years that she has spent there. But the town needs a family practitioner who will stick around. Before she arrived in the summer of 2008, there was no full-time doctor. “We had to let patients go," say M. Denise Williams an older doctor who works three days a week, and sees 20 patients a day, but just cannot take on a larger case-load.

As a result, “patients have been very hesitant and angry," Anderson confided. The typical question they ask new doctors is, 'How long are you going to stay?' They are very reluctant to get to know new doctors. Sadly, a revolving door undermines the trust essential for a strong doctor- patient relationship.”

                                   Class, Income and MCATs

When I spoke at a Mayo Clinic conference on medical education two years ago, I came away with a better understanding of why so few physicians want to work in the remote Virginia town that the Post describes, even if it is “surrounded by trees as tall as skyscrapers, emerald soybean farms and vineyards.”  Today, medical schools are selecting applicants from a fairly small cohort of relatively affluent students who grew up in our cities and suburbs. Little wonder that they don’t choose to settle down in the poorest section of rural America.

Speaking at Mayo’s conference, Dr. John Stobo, senior vice-president for health and health services at the University of California, was one of several speakers who suggested that if we want to correct the mal-distribution of physicians in the U.S., “we need to pick our medical students from a larger pool that does a better job of reflecting the diversity of the patient population.”

As I reported at the time, Stobo went a step further, suggesting that we might want to put less emphasis on grades and Medical College Admission Tests (MCat) scores.  Relatively small differences in GPAs (say the difference between a 3.4 and a 3.9 on a four-point scale) don’t necessarily measure intelligence, he observed. As for MCATs, Stobo pointed out that we know that they discriminate against low-income students. See this study on MCats which reveals the strong correlation between MCAT scores and social class.

Moreover, while superb MCATs correlate with higher family incomes and high grades in preclinical [i.e. classroom] work, “they do not correlate  with clinical performance. And to a certain extent, higher scores correlate with characteristics probably not desirable in most physicians (less interpersonal skill, empathy),” notes a reader commenting on The Future of Family Medicine. When it comes to treating patients, low-income students with lower scores do just as well or better. (For evidence, the reader points to John Delzell's blog "Education in Medicine" where Delzell reviews the literature on this topic.

Nevertheless, these days most admissions committees set the MCAT bar very high, and this helps explain why the vast majority of our doctors in training represent a small percentage of the population. Imagine a five-step income ladder. In 2005, 55 percent of those admitted to U.S. med schools came from families who had managed to arrive on the very top step.(In 2000, only 50 percent  came from the top of the ladder). Another 25 percent were raised in households that lived just one step down from the top, what economists define as the statistical “upper-middle class.”  Only about 3 percent grew up on the bottom step, while approximately 8 percent came from lower-middle class families doing their best to keep their balance on the fourth step—just one step up from the bottom.

Typically students who gain entrance to med school went to excellent private or public high schools in suburban or urban areas, earned impressive SAT scores, and went on to study at expensive top-tier universities. When they apply to med school, the lucky ones have the stellar grades and scores needed to be admitted to an increasingly exclusive medical elite.

                   Young Doctors Return To the Places They Know

When they finish their training, it is understandable that the majority of these young doctors will settle in urban and suburban areas much like the places where they grew up. This is where they want to raise their families. The idea of going to work in an underserved area might be appealing, at least in the abstract, but these young physicians are less likely to feel comfortable in an unfamiliar culture, trying to serve patients who they don’t readily understand. (Let me be clear: this does not mean that committed doctors cannot overcome cultural barriers. But it is hard. When communication is a problem—even though both the doctor and patient each speak their own versions of English—distrust can easily build on both sides of the equation.)

By the same token, research shows that medical students who choose to serve “underserved and rural populations” also pick places where they feel at home.  They are “less likely to be children of professional, high income, and highly educated parents” observes Dr. Robert C. Bowman, director of Director of Rural Health Education and Research at the University of Nebraska. 

In a paper titled “Comparing Physician Distribution and the MCAT” he analyzes demographic data on students who chose Family Practice after graduating sometime between 1987 to 2000. His work reveals that these students “have origins just like the regular people that they serve. They are from a broader range of people types, as a result they understand the people and their needs, and they serve the people. Service-orientation is also a part of who they are.” 
“This is not a matter of choice,” Bowman adds. “It is who family physicians are and where they came from, and perhaps more importantly, what they have learned long before they were called ‘medical student.’”

Bowman argues that reliance on MCAT scores when considering students for admission undermines the goal of recruiting primary care doctors who will go where others choose not to go—and put down roots: “Basically everything that would help distribute physicians more broadly is defeated by reliance on the highest MCAT scores. . . “Students with the highest MCATs do not choose family practice or rural practice.”

“MCAT is no different than the SAT and ACT regarding income, ethnicity, and urban bias.” Bowman continues, “and the cumulative impact of ACT/SAT and MCAT is likely. The problem is not standardized testing, but over-reliance on standardized testing. The standardized tests are also the least valid on the students most likely to distribute well. Studies on those choosing primary care note a clear discrimination bias in the MCAT, likely a result of income differences.” Meanwhile “the rapid increases in admissions of those of higher income (see yearly data past decades from AAMC), also indicates that medical students are increasingly unlikely to choose family medicine and rural practice.”

“No physician would use any medical test with the specificity and sensitivity of the MCAT,” Bowman concludes. “Multi-school studies note that MCAT subscores of 8, a total of 25, and a GPA of 3.0 give maximal opportunity for diversity without increasing academic failure to a great degree.”

                          It’s Not the Money, It’s the Mission

We often assume that if we paid PCPs more, we could lure them to rural Mississippi or the Bronx. Certainly low-income med school applicants need scholarships and programs that will repay their loans if they wind up working where they are most needed—otherwise most could never afford to go to medical school. But according to a study physicians published in the November 2010 issue of the Journal of Public Health, money is not the key factor motivating them to go home.

On The Future of Family Medicine, a blogger who identifies himself as “Chris, a 4th year medical student entering family medicine with an interest in health care policy,” reports that “When researchers analyzed interview responses from primary care physicians in Los Angeles County, California concerning their reasons for practicing in their particular geographic location, only about one-fifth  of those practicing in underserved areas in the county selected their practice location because the choice meant that they received federal aid in repaying loans, which seems to indicate that federal funding is a minor player in [attracting and retaining] primary care physicians in such areas”

“Digging deeper into the numbers of the study reveals that those physicians working in underserved areas were most likely to do so because of mission-based values,” Chris observes, defined as: a “‘sense of responsibility or commitment to a particular community, a defined patient population, or a moral obligation’ and self-identity (including ‘language, personal, family, cultural, socioeconomic, and geographic backgrounds).”

 A 2003 study of a rural physician workforce in Florida confirms these findings, “noting that physicians from rural backgrounds and physicians who were exposed to rural experiences in medical school and residency were more likely to practice in underserved rural areas..”   Where a student trains matters: “A 2009 study in the Annals of Family Medicine firms up the connection between training and practice:  it looked at training residents in community health centers (CHCs) which serve a large number of uninsured and underinsured patients. Researchers found that family medicine residents who trained at CHCs were four times more likely than their colleagues to go on to practice at CHCs.” (It is worth noting that the Affordable Care Act provides funding to double the capacity of CHCs. More primary care residents need to be trained there, rather than in the basements of academic medical centers where, too often, they receive little support.)

“So,” Chris asks, “what does all this mean? It would appear that prior experience in an underserved community and a sense of responsibility to that community is truly the major motivator in where a primary care doc practices. It means that medical schools and residencies need to partner with CHCs to encourage graduates to work with the kinds of populations that frequent them. Even more importantly, it confirms what we should have known all along: the best medical school candidates are those who already enter with mission-based values and who self-identify with those communities that most require family physicians. . .

“Opportunities to train with an underserved population best stimulate those who already want to work in that setting. It’s up to medical school admissions committees to select medical students who fit that bill.  Easier said than done, but we can’t hope to rely on loan repayment opportunities and training alone to funnel more students into family medicine.”

                     How Medical Schools Can Team With the NHSC

Last year Academic Medicine, the Journal of the Association of American Medical Colleges, published a paper which asked: “Do Medical Schools Have a Responsibility to Train Physicians to Meet the Needs of the Public?” The piece was subtitled The Case of Persistent Rural Physician Shortages.

“Yes,” said the author, Roger A. Rosenblatt, responding to a study published in the same journal earlier in the year: “Which Medical Schools Produce Rural Physicians? A 15-year update.”

The update, by Dr. Candice Chen, et. al,  showed that the situation has not improved since the mid 1990s. Indeed, ever more affluent medical students are showing less and less interest in primary care. And here, let me submit that raising salaries by 30 percent still probably wouldn’t persuade a young physician from Greenwich Ct. to settle in Arkansas.

Some have argued that schools should address the problem by expanding  class sizes, but Chen and her colleagues argue that simply admitting more students , without explicitly emphasizing primary care or rural health,” may well “result in more physicians choosing to practice in urban centers, worsening the rural–urban maldistribution.”

Rosenblatt agrees. “The convenient conclusion for the traditional academic health center is that student preferences and market forces are exerting their invisible and inexorable force on medical students, and that the ultimate choice of practice location cannot be easily affected by medical schools themselves.

“Convenient, but incorrect,” he adds.  “In a series of methodologically impeccable studies across two decades, Howard Rabinowitz and his colleagues have demonstrated that a variety of medical schools across the country have been able to create rural training tracks.” 

He points to Jefferson Medical College and asks “can the formula discovered be replicated?” Yes, “in actual fact, by adopting two interventions. The first is an admissions process that affirmatively encourages acceptance of qualified students from rural backgrounds . . .The second is a longitudinal curriculum that helps to protect this cohort from the siren song of the dominant medical ethos, by providing them with appropriate role models and satisfying intellectual experiences that reinforce their early predilections.”

The culture of a medical school is critical. A school where professors openly disdain primary care, while putting a premium on research, is not going to produce very many family practitioners eager to help the underserved.

Writing on the Future of Family Medicine, “Chris” goes further, suggesting that we should reward medical schools that create a culture which nourishes students with a mission:

The Robert Graham Center (RGC), which is backed by private foundation money, “is already producing objective data on how well medical schools and training centers are fulfilling their ‘social mission’ (that is to say, how well they are meeting the health care needs of the public),” he writes. “The RGC uses geographical information systems mapping tools to display these results visually.

“Knowing that, I propose a more effective use of federal money to improve the primary care services in the United States: create a national database of registered physicians and their specialties and locations of practice; then, instead of tying the majority of a medical school’s funding to the amount of research it produces, tie a large portion to the percentage of each school’s graduates who end up working as primary care physicians in underserved communities.”

This seems, to me, a compelling idea. . . Medical research is essential, and will always be the major focus at some academic medical centers.  But if millions of Americans don’t have access to the fruits of that research, one can’t help but ask: why do we pour so much money into studying disease, and so little into improving the delivery of health care?

The National Health Services Corp is back on its feet. It now can make medical school affordable for a larger slice of the population—though it will continue to need additional funding. But medical schools themselves also should be reaching out to a more diverse pool of students who are likely to enter primary care, not just by admitting low-income and median-income students, but by providing them with the mentors, the curriculum, the clinical experience, and the respect that will remind some of why they wanted to go to medical school in the first place, paving the way home.

36 thoughts on “Primary Care and the National Health Service Corps: Finding Physicians “Who Will Go Where No One Else Will Go”

  1. Good article, Maggie.
    One other important issue in causing maldistribution is that the atmosphere in medical schools is stacked in favor of creating doctors who will prefer to work in specialties and to work in sophisticated medical centers predominantly found in urban and suburban areas.
    Medical schools are usually part of large research institutions, and are staffed with teaching physicians who are academic doctors working in those institutions. Any outside clinical experience usually comes in the urban centers that the schools are in, and from clinical teachers who are doctors working in other sophisticated urban medical systems. Equipment is cutting edge. Complex medical problems often outnumber more routine illnesses and well patient care in the clinical population.
    In this setting, it is not surprising that most med students, even many who started with an interest in primary care, quickly learn to think that the most interesting things in medicine, and the things that are associated with the highest respect and prestige as well as incomes, are specialty areas and tertiary care. Sore throats, well babies, and old people with lists of minor complaints are for lesser beings working somewhere outside the domain of the big centers and ivory towers where the truly exiting and prestigious work is done. This is actually reinforced when doctors in training rotate out to spend some time in overcrowded, understaffed, underequipped, and often shabby “outreach” clinics in impoverished areas of the cities the centers are in.
    I do believe that selecting students from the backgrounds that characterize areas of need is one important way to address health care distribution issues. A second important way, for the small cities and rural areas that often cannot get people to come to work, is placing more medical schools and more training programs physically in those areas, as is being attempted in some places now.

  2. I think that in looking at issues of distribution of health care services in the US, there are two issues which I believe are completely separate.
    One is the problem of getting people to live and work in rural and semi-rural areas that are less developed and more remote than major urban centers or resort like “garden spots.” I think the solutions that this article suggests are very helpful for that issue.
    For poor areas of large cities the problem is different. It is certainly possible that a doctor can work in Harlem, the South Bronx, East LA, or Compton and live in Brooklyn Heights, the Upper West Side, Santa Monica, or the Hollywood Hills, enjoying all the cultural and lifestyle amenities. Patients can be referred to the exact same large urban hospitals that doctors practicing in affluent neighborhoods use. The problem here, I think, has less to do with getting doctors to the regions — there are thousands of surplus doctors living within a short drive or train ride — but more to do with our country’s weak commitment to health care for low income people. The very low rates of payment for Medicaid in most states, the large numbers of uninsured patients, and the fact that many low income people with insurance, including Medicare, are in fact underinsured with out of pocket costs they cannot afford, make working in these areas carry a financial penalty for doctors compared with being underemployed in overstaffed practices with patients who have the ability to pay. In addition, the chronic low level of payments for services causes facilities to be poorly staffed and maintained and short of equipment and facilities, and for what equipment and facilities they do have be poorly maintained or outdated, making working there professionally frustrating as well as financially unrewarding.
    Choosing medical students who come from these neighborhoods may help some, but will not address the real problem. To fix health care in low income urban neighborhoods, we need comprehensive payment reform. The key is to pay enough for the care of the poor so that, on an hour by hour basis, doctors and health centers are not making 20-30% as much money as their neighbors “across the tracks,” while working in underfunded clinics where practicing good care is a constant battle. I believe that if, with relatively the same time commitment, a young doctor living in the West Village can make 30% more being busy in a well equipped and staffed clinic in Brownsville than as an underemployed junior member of an overstaffed Midtown practice trying to churn a living out of too few patients, many of them will choose the train ride to a neighborhood they wouldn’t live in but may be willing to work in. Right now, a doctor making that choice would probably make 70% less and have to scramble every day to find the supplies needed to do her work.

  3. people who live in rural areas lack many other things we urbanites enjoy like culture and the intellectual stimulus of major universities. these things come with density. folks who opt for rural areas have fewer of these things — along with fewer noisy and nosey neighbors and less crime and pollution.
    you say there’s already a physician shortage, but analysts like Wennberg say otherwise, tho there may be distribution issues. they also say that there’s a link between the size of the total physician population and the size of the nation’s medical bill. in short, if you get more, you’ll have to pay more.
    some incentives to induce docs to go to rural areas may make sense, but the spirit of today’s budget debate suggests it might be wiser to frame the debate by also talking about areas that seem to have too many doctors– as suggested by the resulting bills.

  4. Maggie:
    May I suggest alternative solutions already exist beyond those you suggested above?
    First, there are a number of existing health care distribution centers already in many of those small towns and rural areas. Walgreens, CVS and Walmart are all now in the health clinic business and will soon be in a position to provide a systematic solution that does not need to rely upon re-selecting and training more people from rural areas to enter medical school.
    They will each be rolling out integrated systems of care connected by telemedicine in the very near future, bringing a thoughtful solution to market better, faster and less expensively than approaching this problem as one of medical school recruitment and training.
    (I write as a former adjunct medical school faculty member whose medical school broke that barrier decades ago in recruiting medical students from rural areas directly after high school.)
    Secondly, may I suggest we have trained tens of thousands of care givers at public expense who are presently blocked from giving care by restrictive state laws that grant government protected monopolies to physicians? Think military medical corpsmen and women; physician assistants, nurse practitioners and many others–including “Dr. Mom,” who with electronic connections, can bring top flight medical knowledge and skills to small towns and rural areas without having to move their or wait from medical schools to ramp up unneeded production.
    For years, I successfully recruited physicians to small towns and rural areas throughout the Midwest. This is not the solution to the problem in the 21st century.
    Ron Hammerle
    Health Resources, Ltd.
    Tampa, Florida

  5. Geat piece. It is worth noting that NHSC and the Community Health Centers, along with Maternal & Child Health Title V, Ryan White Care Act, are under the Health Resources and Services Administration (HRSA.gov).
    Despite years of strong bipartisan support, recent growth under George W Bush and Barack Obama, expansion under ARRA (stimulus) and under PPACA, the Community Health Centers are also threatened with draconian cuts (rather than planned expansion) by the House Republicans. See:
    http://www.dailykos.com/story/2011/02/15/945212/-More-about-Community-Health-Centers

  6. Getting primary care docs to practice in underserved areas is tremendously important. Med schools’ heavy reliance on MCAT’s in the admissions process is perhaps the most important factor driving this issue.
    But, think of it from the schools’ perspective. There are far more young people that want (or think they want) to be doctors than there are spots in school for them. How do you fairly and objectively assign these spots, knowing that patients lives and students’ futures hinge on who these scarce opportunities are assigned to? Also, schools cannot afford to have any students dropout in their 2nd, 3rd, or 4th year, since a new applicant cannot be slotted in at that time – if that happens the university loses a six figure stream of tuition income and society loses a physician. While most B students who get 25’s on the MCAT’s would probably do fine in med school and be great doctors, some portion of them wouldn’t cut it and there would be adverse consequences to that too. Also, to give that B-avg & 25 MCAT student a seat, you’d have to take one away from an A-avg & 30+ MCAT student. There is already a small amount of affirmative action that happens in the admissions process, but it helps candidates only if they are right on the cusp of getting in or not. So, yes, it’s true: generally, those who do well on the MCAT’s are science geeks from rich families who don’t know what it’s like to be underserved and have trouble communicating with ordinary people. But, if you don’t use the MCAT to evaluate, what do you use instead? Maggie, I think you’ve framed the question brilliantly, but I don’t think you’ve answered it (nor have I).
    Incidentally, I’m a former foster kid who will be attending a top-15 med school in the Fall. I bombed the MCAT on my first try, but I aced it the second time, after I lived and breathed studying for it over two intense months of studying. I hope funds are maintained for the National Health Service Corps, since I hope to repay my loans that way. I’ll probably practice primary care in an underserved urban area in my hometown or perhaps in the rural area that’s an hour drive away. Eventually, I’ll want to practice in the underserved urban area near my family. Like the young doc in your story, I too like restaurants and cultural stuff; having spotty Internet would drive me crazy.

  7. Great piece Maggie- Correct-The selection of students with values that match desire to work in underserved areas is key.
    Dr. Rick Lippin
    Southampton,Pa

  8. Ron & Jim
    Ron– You write: . “Walgreens, CVS and Walmart are all now in the health clinic business and will soon be in a position to provide a systematic solution that does not need to rely upon re-selecting and training more people from rural areas to enter medical school.”
    Retail medicine at a Walmarts or CVS is not a medical home. It is a place where people stop in for care from someone who has never seen them before and probably will never see them again.
    Typically, the uninsured and underinsured use this form of retail care, paying out of pocket.
    (It is worth noting that is the type of medicine that Rick Scott’s new company has been promoting in Florida.)
    “Entrepreneurs” like Scott love the idea– they hope to make a fortune on retail medicine.
    But under heatlh care reform , as more and more Americans have comprehensive insurance that will cover continuous care, they will be looking for–and deserve–a medical home where they, and their families can be seen by doctors and nurse-practioners, working together, and providing care to these families over many years.
    No amount of Health IT can subsitute for this type of continuity.
    The reform bill also doubles the capacity of
    Federally Qualified Community Health Clinics, and for many patients in rural areas, these will be their medical homes.
    The CHCs will be staffed by nurses, nurse practioners and doctors, and specialists will be available or will take referrals from the CHCs (You won’t find many specialists working at Walgreens.)
    Finally, I wonder if you and your family get most of your care at Walgreens??
    Low-income people living in rural areas deserve the
    same level of care that you would want for your family. And under reform, they will have the insurance that covers this care.
    I am very glad that federal regulations require that health care workers be licensed
    Jim–
    If you read the post carefuly, you will see that I am Not talking about increasing the total number of physicians.
    The problem is not that we need more docs; we need better distribution of docs.
    To achieve that goal we need to admit more kids from low-income famlies In Place Of the Kids from high-income families that we are admitting now.
    Virtually everyone looking at medical education today says that med students should better reflect the diversity of the population.
    Reserach constantly shows great disparities in the level of care that people receive, based on their race and income.
    More white, African American, Latino, Native American doctors would begin to solve that problem.
    Further reserach shows that students from those low-income families are much more likely to Want to be in primary care and Want to practice in areas where they can help people like the people they grew up with.
    And while their MCATS are lower, as clinicians they are as good–or better than–the high income students with higher MCATs.
    We’re also talking about replacing some specialists with primary care docs.
    When Wennberg and others talk about an over-supply leading to higher medical bills, they are talking about too many patients going to a specialist instead of a primary care doc.
    Under reform, it’s likely that in many cases, patients will need a referral from a primary care doc before seeing a specialist. And the primary care doc will be encouraged to diangose and treat, if he can, rather than referring the patient to a specialist. (Bonuses for providing a medical home.)
    So, we’ll need fewer specialists, more primary care docs and nurse practioners working with them.
    Both you (living in a city) and a low-income family living in a rural area will be more likely to get most of your care from that
    combination (nurse-practioner and primary care doc.)
    As for the notion that people who live in rural areas don’t have access to many of things found in cities– museums, intellecutal stimulus, etc.
    These things are very, very different from health care. Access to a museum is not something that we, as a society, can or should provide to everyone. (Though I think museums should be free or nearly free, and so open to anyone who wants to travel to a city.)
    Access to high-quality health care is something that we, as a society, have decided is a basic right.
    CMS (Medicare & Medicaid) provides much of othe fudning for med schools–those are tax-payer dollars.
    In return , med schools have a social responsiblity to produce doctors eager and willing to care for all sorts of Americans in different parts of the country,
    Let me put it this way: try to imagine yourself the father of a four-year-old who has been hurt in an accident.
    Don’t you think you should have a medical home that you trust–and where you & she are known–where you can take her? (You might have to drive a little further than you do in D.C., but the care should be there.

  9. Why would med students want to do rural primary care when Maggie puts up post after post claiming that they are “overtrained” and can easily be replaced by nurses?

  10. Sheryl: Maggie doesn’t think physicians are overtrained, nor that they can be replaced by nurses. She believes that too many physicians go for the least needed specialties in areas that have the least need because that’s where the money is.
    Big difference.

  11. Sheryl–
    If you read my posts,you will find that in the cases you seem to be referring to I was talking about primary care physicians who spend most of their time simply referring patients to specialists (rather than treating thed patients.)
    Understandablly, often these PCPs are , disstisfied with their wor. Meanwhile observers see them as “over-trained” to serve simply as a referral service.
    (I could give you a better reply if you cited a particular post [posts] on a particular date [dates] as well as quotes. Then I could explain what I was trying to say (if not as clearly as I wished) in context. A broad somewhat sharky attack just isn’t very helpful . . .)
    But I can say that I have always argued that we need primary care physicians as the spine of universal coverage.
    At the same time,, nurse-practioners can also do many (not all)of the things that PCPs do.
    This is why more and more PCPs like to have nurse-practioners in their practice.

  12. First, there are a number of existing health care distribution centers already in many of those small towns and rural areas. Walgreens, CVS and Walmart are all now in the health clinic business and will soon be in a position to provide a systematic solution that does not need to rely upon re-selecting and training more people from rural areas to enter medical school.”
    Uhh Walmart does not exist in the kinds of rural areas discussed in this article. Walmart stores are generally found only in population areas > 50k which is hardly rural.
    Furthermore, the “urgent care clinics” in CVS/Walgreens are a joke. They give vaccinations, do rapid strep tests, and give out simple antibiotics. Thats all. They cant test you for diabetes, refer to you to a vascular medicine specialist, or start antihypertensives. They are practically worthless. Nobody wants to work at those clinics anyways, they have a hard enough time just recruiting simple nurse practitioners to work there.
    “They will each be rolling out integrated systems of care connected by telemedicine in the very near future, bringing a thoughtful solution to market better, faster and less expensively than approaching this problem as one of medical school recruitment and training.”
    Telemedicine has crappy reimbursement. Medicare/Medicaid only pays around $5 for a telemedicine consultation because there’s no physical exam involved. Furthermore, theres a lot of medical malpractice involved when you “diagnose and treat” someone without doing a physical exam on them. Telemedicine will only be utilized across national borders for 3rd tier countries with nonexistant health systems.
    “(I write as a former adjunct medical school faculty member whose medical school broke that barrier decades ago in recruiting medical students from rural areas directly after high school.)”
    I know who you are. You are not a medical doctor and have very little insight into the real problems with rural healthcare. You’re a so-called “health IT” expert who knows nothing about practicine medicine.
    “Secondly, may I suggest we have trained tens of thousands of care givers at public expense who are presently blocked from giving care by restrictive state laws that grant government protected monopolies to physicians? Think military medical corpsmen and women; physician assistants, nurse practitioners and many others–including “Dr. Mom,” who with electronic connections, can bring top flight medical knowledge and skills to small towns and rural areas without having to move their or wait from medical schools to ramp up unneeded production.”
    This is a joke right? Nurse practitioners are already allowed to open up their own clinics in 10 rural states with ZERO supervision or oversight by doctors. Guess how many NPs have actually taken that step to open up a rural clinic? Its only 7-10. Far less than 1% of the nurse practitioners in these states choose to open up their own practice or work solo. Therefore, your “solution” fails.

  13. Jason–
    Thank you very much for your comment.
    You write: “Walmart does not exist in the kinds of rural areas discussed in this article. Walmart stores are generally found only in population areas > 50k which is hardly rural.’
    “Furthermore, the “urgent care clinics’ in CVS/Walgreens are a joke. They give vaccinations, do rapid strep tests, and give out simple antibiotics. Thats all. They cant test you for diabetes, refer to you to a vascular medicine specialist, or start antihypertensives. They are practically worthless.”
    Yes– this is what I was trying to say to Ron.
    Everythign you are saying confirms what I have read in studies about these retail clinics.

  14. Condemning rural and low income patients to treatment by e-mail or by youtube or through minimal care centers at profit based businesses that already have bad track records in their concern for the welfare of the public would be an important first step in what appears to be the goal of many “market based” reformers — creating a two tiered health care system in which there is one standard for the rich and another for everyone else.
    Solving the distribution problem requires creating a health care system that provides a high level of care for everyone, whether they live in Cut Bank, Watts, or Rancho Sante Fe.

  15. Hey Maggie,
    Great blog post! Thank you for referencing our blog: Future of Family Medicine – we are excited about sharing your post with other fellow medical students!
    Match day is in a couple of weeks… hoping to continue the upward trend in US grads matching into family medicine. So far, the DO and military matches both showed upward trends in numbers of those interested and matching. Hopefully the NRMP match will add to family medicine’s success this year!

  16. Pat S.– Responding to both of your comments.
    Your first comment (March 3 12:49) highlights a couple of points that I
    left out of the post. (Believe it or not, I actually do “cut” these posts to try to make them shorter!)
    But what your say is extremely important.
    First, you point out that: “One other important issue in causing maldistribution is that the atmosphere in medical schools is stacked in favor of creating doctors who will prefer to work in specialties and to work in sophisticated medical centers predominantly found in urban and suburban areas.”
    Yes, I allluded to this very briefly, but the truth is that in many med schools both professors and many students look down upon “primary care.”
    Students who came to school with that idea in mind often succumb to the cultural pressure which says “You’re too smart for that.”
    Secondly, you write: ” do believe that selecting students from the backgrounds that characterize areas of need is one important way to address health care distribution issues. A second important way, for the small cities and rural areas that often cannot get people to come to work, is placing more medical schools and more training programs physically in those areas, as is being attempted in some places now.”
    Yes, Some medical schools are setting up satelite sites in rural areas– an excellent idea. We do Not needc to expand academic medical centers in NYC, Boston, LA, etc. etc.
    On your second comment:
    First, regarding pay, I totally agree that doctors who treat Medicaid patients and other poor patients are underpaid.
    But under reform, Medicaid reimbursements for primary and preventive care will be lifted to equal Medicare reimbursements.
    This represents a major step forwardd.
    Specialists will still be paid about 70% of what they would receive for a Medicare patient. Though in New York, many specialists won’t take Medicaid patients for any amount of money becuase they “don’t want to deal with them.”
    On where docs live: .
    In New York City you’ll find Latino and African American doctors working and living in or very very close to the South Bronx, Harlem, Washington Heights etc. These inner city neighborhoods are far more varied than many people think. Some wonderful architecture, great renovations, relatively safe areas although the majority of the population is non-white.
    To many of these doctors, being a doctor serving a community means being part of the community. They would lilke to improve the community itself. (See the book “White Coats, Clenched Fists.”)
    And if they grew up in a core inner city, they are comfortable there.
    Also many of these docs who grew up in majorityy/minority low-income neighborhoods would definitely Not Want to live in Brooklyn Heights, the Upper East Side, or much of the West Village.
    Nor would I. Not places I would want to raise my children–different values, different culture. (I also wouldn’t want to live in Santa Monica or the Hollywood Hills.)
    My daughter lives in Brooklyn, and because she’s having a child, she & her husband are looking for a new apartment– but not in Brooklyn Heights.
    We’ve talked about why they don’t like it . .
    Twenty or twenty-five years ago, it was different, but now Brooklyn Heights represents a very materialistic culture–everyone shopping all of the time People we used to call “Yuppies” –and their very spoiled kids.
    I like the Upper West Side, but liked it better 15 or 20 years ago. When I moved here, the neighborhood was maybe 50% white, 50% African-American, Latino, new immigrants from many other places. I wanted my kids to grow up in a very mixed neighborhood.
    Now my own building has become “gentrified” to the point that when leaving the building 8-year-old children step back from the door and wait for the doormen to open it for them!
    They think of the doormen as servants.
    We have no African-American doormen (I’m pretty sure many people in the building would object if we hired one) ,and no African Americans living in an 18 floor building with 7 or 8 apartments on each floor.
    New York City is probably the least racist city in the country, but still apartheid remains alive and well.
    Real estate brokers don’t bring African Americans to look at apartments here.
    A few years ago, a Latino who is a friend came to visit me. Someone on my floor saw him in the hallway, and called down to the door to warn that there was someone who “doesn’t belong here” wandering around in the building.
    I’ve been in my apt. for 24 years, and love it, but no longer go to meetings of the building. My husband and I are friendly with just a few people in the building–and we’re friendly with the doormen,the super, etc. who are very nice to us (in part because we don’t treat them as servants.)
    Finally, if I were an African American or Latino doctor I definitely would not want to live in this building–or most of the buildings in this increasingly exclusive part of the Upper West Side.

  17. mdstudent31, Pat, Dr. Steve B.
    mdstudent31
    Good to hear from you. I was going to send you a head’s up that I had quoted your blog–just hadn’t gotten to it yet. I recommend “Future of Family Medicine” to everyone and hope you will share the post wtih fellow med studens.
    Very glad to hear about the upward trend of US grads matching into family medicine.
    In the post I don’t think I mentioned that older med students (31-34) are much more like to pick family medicine. Bowman suggests that this may be because they are more mature–have thought more about what they want to do.
    I do think med schools should take a very close look at older applicants. Twenty-two or twenty-three seems young to begin training to be a doctor
    It might be useful if more students took a few years in between undergraduate school and med school (or law school) to gain a little more experience in the world, find themslves, travel, work a couple of different jobs, see more of the world,learn more about people . ..
    Being pre-med as an undergraduate is hard. Med school is very hard.
    A break in between could help. Otherwise, many students come out of med school feeling that they’ve spent their twenties working non-stop, under pressure, being abused . . .
    Pat– You write: “Condemning rural and low income patients to treatment by e-mail or by youtube or through minimal care centers at profit based businesses that already have bad track records in their concern for the welfare of the public would be an important first step in what appears to be the goal of many “market based” reformers — creating a two tiered health care system in which there is one standard for the rich and another for everyone else.”
    Exactly, And it should come as no suprise has gotten into the retail medicine business. .
    Dr. Steve B.
    Thank you.
    Yes, I know the conservatives also would like to cut CHCs (probalby think they could be replaced with clinics in Walgreens.)
    I plan to write about CHCs at some point in the future. We have some very good ones here in NYC.

  18. Maggie —
    I did not mean to imply that doctors SHOULD live in gentrified or wealthy neighborhoods, rather to say that in large cities the doctors are certainly free to choose to live in whatever type of neighborhood they prefer no matter where they work. Unlike the situation in rural and semi-rural areas out here in flyover country, choices of lifestyle amenities are not part of the picture in the distribution of health care in large cities. Part of it has to do with cultural preferences, but a lot of it has to do with money, plain and simple, and the lack of it both for doctors and for operation of facilities in low income neighborhoods.
    I am aware of the attempt to improve this as part of the ACA, and hope it stays in effect. But that is just a beginning of transforming financial issues in medicine to deal with the needs of poor and working class Americans.

  19. Pat–
    I understand that you weren’t telling docs where they Should live.
    But I believe that in inner cities we need docs who really Want to treat low-income patients–and be part of their communities.
    Docs who live in NYC’s most affluent communities just don’t want to spent their days in core inner-city neighborhoods.
    You are also right that much of where most doctors live has to do with money, plain and simple.
    And even if we raise payment for primary care docs caring for low-income patients, they are not going to be able to afford a small to medium-sized apt. where they might raise one to two children in NYC’s most affluent neighborhoods. .
    In the city, these apts now cost $1.8 million to $3 milion –plus $2,000 to $3,000 in monthly maintainance & taxes.
    Prices are comparable in many cities on both coasts.
    If a primary care doc and her/his spouse have a very good eye for real estate, are willing to live in an apt, during a one-year renovation, overseeing the wrok themslves, and have managed to save $500,000 toward a downpayment (or have parents able to provide the downpayment) they could pull it off.
    But most young docs who actually want to work in low-income neighborhoods are not in that situation.

  20. “I believe that in inner cities we need docs who really Want to treat low-income patients–and be part of their communities.”
    Maggie —
    I think doctors, especially those who grew up in inner cities or other low income environments can easily do a fine job of relating to patients in a personal chemistry and cultural sense as well as diagnosing and treating their medical issues competently without actually living in the community as long as they don’t mentally “forget where they came from.” Bringing their expertise to bear in treating patients should be more than sufficient without also expecting them to be part of their community. It is also quite understandable and, I think, normal to not want to subject a spouse and children to inner city living if you can afford something better even if you lack the income for a co-op in one of Manhattan’s most exclusive neighborhoods. Given the shortage of doctors willing to practice in inner city neighborhoods in the first place, I think you’re asking too much of them.

  21. “creating a two tiered health care system in which there is one standard for the rich and another for everyone else.”
    OK, lets set this straight right now. EVERY SINGLE HEALTH SYSTEM ON EARTH GIVES BETTER CARE TO RICH PEOPLE THAN POOR PEOPLE. End of story.
    UK? Rich people buy supplemental private insurance which covers more than what the NHS covers.
    Canada? Rich people pay out of pocket for private appointments and get seen much faster than people on the public healthcare system; furthermore they pay out of pocket for specialist referrals and dont have to wait for PCP approval.
    You get the idea. The ONLY way to create a “one tier, equal access healthcare system” is to absolutely BAN all private healthcare. That doesnt happen in ANY country, even the most ardent socialized medicine nations in Europe dont do that, and neither will we.
    Rich people will ALWAYS get better healthcare than poor people, period. The focus should be on ensuring that everybody has some kind of MINIMAL FLOOR level of healthcare access, because thats a reasonable goal to achieve. It is UNREASONABLE AND IMPOSSIBLE to mandate that rich people get the same care as poor people.

  22. I read the post and the comments in detail. It seems odd to me that we get a wished for set of positions vs a here’s the way it really is set with almost no middle ground. Sad because both sides have good points.

  23. Barry–
    I’m not expecting anything– just commenting on the fact that many people actualy like returning to their roots–and like inner citites.
    This is not about “subjecting wife and spouse” to an inner city–it’s about a couple choosing an inner city.
    Here’s what one professional couple says a about Harlem:
    “Harlem Culture: Historic and ahead of the curve. Best suited to young-spirited culture mavens, our all brownstone bl”ock in the heart of one of New York’s most intriguing emerging neighborhoods is surrounded by the kind of mom and pop businesses fast disappearing from other parts of town, such as rootsy inexpensive restaurants serving Caribbean, Latino, American Southern and African cuisine. This neighborhood of historic brownstones, some built by acclaimed architects such as McKim, Mead and White, is bursting with jazz haunts, famous spots from the 1940’s as well as no sign “neighborhood secrets,” which is quite the trend in New York these days. Cultural institutions on surrounding blocks include the Apollo Theater, the Studio Museum and the Schomburg Center for Research in Black Culture, the Maysles Independent Cinema, innovative live theater at the Gatehouse, the Magic Johnson movie theater complex which includes the renowned Hue-Man Bookstore, and a new crop of edgy, still affordable designer boutiques. We’re also near Columbia University and C.C.N.Y. You’ll find maps, guidebooks and a long list of our personal recommendations in the apartment.”
    On the Bronx:
    My wife and I have degrees from Columbia and Yale and we love living in the Bronx. . . .
    Another coupleL “We were The Bronx long before the Manahattan/Dumbo refugees started opening their eyes to all the Bronx has to offer. Beautiful parks, diversity, some of the best food in the five boroughs that will not bust your budget, art deco architecture, humongous apartments, great people and a whole lot of love. . .”
    As for Washington Heights,
    Columbia University’s Pediatric Center advises young doctors:
    “An apartment in Washington Heights offers a young doctor the opportunity to live among his or her patients, and to see the world that they see. This largely Latino neighborhood is rich in culture and history …”
    Is it unsafe? Not necessarily, but “you do have to be aware of your surroundings.”
    In other words you have to be steet-smart. When I moved to the Upper West side in the 80s it was also a place where yhou needed to know where you were. For instance, when my children were very young, I didn’t let them walk on Riverside– bordering a park, and too few people on the street.
    They grew up street-smart, and now could live anywhere.
    Bottom line: different people prefer different surroundings. Some want homogeneous neighborhoods for themselves and their families, some value diverity and a multi-cultural setting a place to raise children.
    I moved my children out of Ct’s suburbs (Fairfield county) to the Upper West Side in the 80s not because I had to but because I wanted to.

  24. Jason Thompson:
    First, you are wrong about Canada. Canada does in fact ban special treatment of people who can pay more. There are exceptions for services that are not covered by Canadian Medicare, but otherwise the only choice is for people to leave the country — a choice that is not associated with better results.
    Second, in other countries, people do not get BETTER care by paying more, they get special amenities — better rooms, better food, more privacy, shorter waits, and so on. The quality of care is identical. In one article I read about German health care, a wealthy person who had chosen to stay in the normal national health care system rather than take the option — chosen by only about 5% of people — to get private luxury care commented that he did not think it was worth paying a large extra premium for a better lunch.
    This is in fact shown clearly in data. In other advanced countries there is no significant health outcome advantage for people choosing to bypass the public systems for high cost private care. Outcomes for various classes of disease are the same regardless of ability to pay. In the US, however, health care outcomes are significantly worse for the uninsured and for people in many states’ Medicaid systems, and very high deductible insurance leads to worse outcomes.
    What I mean by two tiered health care is not hospital rooms that resemble the Ritz versus four bed wards, it is an increased risk of dying from routine treatable disease because of lack of access to health care, which is the outcome that so called “market based” health care models for the US are heading toward. Lack of insurance, very high co-pays, and very high deductibles lead to people getting sicker and sometimes dead. Ironically however, as long as we do not plan to allow people to die on the sidewalk, those changes do not save money, since high costs of managing patients in ICU’s who could have been managed with a $3 generic antibiotic if they had presented on time more than cancel out the putative savings from making large numbers of people avoid getting health care except in extreme conditions.

  25. Jason–
    Please see Pat’s comment.
    As he indicates (based on medical reserach) you are
    simply wrong.
    I have read the same reserach, and also have very close friends and relatives people who live in France,
    Germany and Canada.
    I also recall interviewing a 40-soemthing pediatric oncologist from Germany who explained that he had chosen the public program (even though he could afford the private program) becuase the difference had “nothing to do with quality fo medical care.”
    As Pat says, the difference is all about amenities.
    Pat S.–
    Thank much for your well-informed comment on healthcare for the wealthy in other countries. . .
    Joe–
    Quite often, the truth does not lie in the middle ground.
    For instance, invading Iraq was not a “pretty good idea that has worked out pretty well.”
    A few people still think it was a very good idea, well worth the cost –measured in human blood as well as dollars.
    A great many Americans agree that it was a terrible idea, based on lies, and everyone involved has paid an impossibly high price.
    But in this case, as I pointed out, Roy & I are talking about very different types of large hospitals.
    Some of those that he is talking about are for-profits. Others are academic medical centers that do, in fact, put $$$ ahead of patients, and over-treat many patients.
    I am talking about hte medical centers that have served as the models for the large multi-specialty centers that the reform legislation calls for.
    These are places where docs are not paid fee-for-service– thus they are not rewarded for volume.
    They are rewarded for better outocmes and great efficiency (shorter stays, patients see fewer specialists, undergo fewer tests and treatments, and patient satisfiaction as well as physician satisfaction is higher.)
    I suspect that Roy woudl agree with me about hte hospitals I am talking about, just as I agree wtih him about the hospitals he is talking about.
    We might disagree on what the health reform law encourages–Roy’s specialty is superb investigative reporting.
    But I’m not sure how much time he has spent reading and studying the Affordable care act. That’s
    more my specialty.

  26. Ideally one could shift the incentives. Say higher per-same-type-of-encounter (cpt, Inc, etc coding as already used), based on census track of doctor’s practice site and/or patient. Higher for inner city and rural. Lower for park avenue and beverley hills. There is already enhanced reimbursement for certain kinds of practice (fqhc higher then mediciad mill or solo doc without certificate of need; higher with higher level of. Patient centered medical home certification) so model exists. And UK has this for GP’s serving in lower class areas. Along with Maryland type all payer this would be very positive next step reform.

  27. Dr. Steve B–
    I agree that PCPs working with low-income patients, who, by defintion,have more medical and psychological problems, should get higher pay.
    But I also think that higher pay won’t draw the docs who would be best with these patients.
    I still think we need to admit different students to med schools who actually WANT to work with these patients. That’s key. And I don’t think money creates the compassion, patience, and psychological stamina (ability to withstand disappointment) needed to work with low-income patients.
    But higher pay would make it possible for docs who actually want to work in that setting to spend the time with individual patients that is needed to do a good job.

  28. I agree with Maggie – higher pay is necessary but not sufficient. Requiring all medical schools to have departments of family medicine or at least primary care would help decrease some of the pressure against choosing primary care.
    I hope the new student loan repayment programs in the PPACA are not repealed, they could go a long way towards increasing the number of doctors working in poor areas.
    Love working in the Bronx! I don’t know why everyone wouldn’t want to work here. Amazing patients from all over the world, colleagues who share my values, co-workers from the neighborhood.

  29. This is not that complicated. It is the money. Raise the salaries to 200k. Still not enough docs? Raise the salaries in 50k increments until you have docs beating down the door to get in. It will happen.
    Impossible,I hear you say. Fine, then live with the shortage. “We’ve just got to get the demographics right, poor docs, old docs, minority docs, docs on a mission.” Rubbish. Raise the salaries or forever live with the shortages. Next case.

  30. Pingback: Obamacare isn’t creating a doctor shortage, it’s solving it | Maggie Mahar | FREE Article Distribution, Press Release Distribution, News Distribution - No Registration! Submit a Free Article or Press Release | BUZZSTAKE

    • Thanks for putting this piece out there. I hope that HealthBeat readers will take a look at it.

  31. Great blog you’ve got here.. It’s hard to find excellent writing like yours nowadays.
    I seriously appreciate individuals like you!
    Take care!!

    • Rosa–

      Thank you! If you would like to get an e-mail every time I post something new, just clip on “Subscribe” on the first page of the blog (right-hand side)