An article about geographic distribution regarding primary care for children was published in Pediatrics over the break. The investigators found the following

Between 1996 and 2006, the general pediatrician and family physician workforces expanded by 51% and 35%, respectively, whereas the child population increased by only 9%. The 2006 per-capita supply varied by >600% across local primary care markets. Nearly 15 million children (20% of the US child population) lived in local markets with <710 children per child physician (average of 141 child physicians per 100 000 children), whereas another 15 million lived in areas with >4400 children per child physician (average of 22 child physicians per 100 000 children). In addition, almost 1 million children lived in areas with no local child physician. Nearly all 50 states had evidence of similar extremes of physician maldistribution.

Once again, the data from Alabama are telling. There is a large disparity in distribution of primary care providers for children when Alabama’s performance as a whole (44th) and performance in rural areas (42nd) is compared to our performance in highly populated urban areas (13th – reflects Mobile, Montgomery, Jefferson, and Madison). There are three take home messages from these and similar data that I see

  1. In Alabama the market works just as you would expect. In urban areas where physicians who see a high volume low acuity practice can make a good living, there are a lot of physicians. In rural areas it almost certainly won’t happen, and this is a consequence of our current payment structure (discussed here and here). In Alabama where 45% of all births are funded through Medicaid, not changing Medicaid means not improving the system. The system is perfectly designed to achieve the results it achieves.
  2. Letting more people from urban areas into our medical schools (as we’ve done with the class expansions at USA and UAB) to turn out more docs in hopes that they will move into rural areas by bribing them with loan repayment or threatening them with inability to make a living in urban areas will not work, either. It turns out that physicians can generate their own business regardless of the “need” under the currently structured system and patients will play along (need an imaging study? Additional labs? An operation?) as discussed here and here. The combination of lifestyle and need to generate volume will ensure a continued maldistribution in Alabama under the current payment structure for the next 20 years. In 1956 Kerr White published a study of how healthcare money was spent entitled the “ecology of medicine” which was updated in 2001 by Larry Greene. If such a study were done in Alabama it would be interesting to see what our citizens get for the money. I only hope Governor Bentley understands this.
  3. Although money makes everything better (or allows for the purchase of better antidepressants), even if we altered the payment structure we will not get happy, fulfilled docs in rural Alabama. The other aspects of the infrastructure needed (discussed here, here, and here) are adequate professional support, availability of technology, access to tertiary care,and a team based approach that includes non-physician providers. Particularly, to care for children requires accessibility for the patients as well as physician accessibility to information and tertiary care.

The investigators reached the following conclusion:

The status quo has resulted in a primary care workforce for children that has grown tremendously without elimination of major variations in primary care supply. As demonstrated by the dramatic variation in local child physician supplies across the United States in the face of robust expansion in the child physician workforce, current calls for expansion in medical schools and lifting of the graduate medical education cap should be viewed critically. Unless expansion is targeted explicitly toward serving populations with the greatest needs, it may lead to greater health care inequities, with little improvement in the quality or outcomes of care. Accountability for the public funds that support medical training should start with concerted, transparent efforts to develop, to use, and to evaluate policies aimed at reducing disparities in geographic access to care caused by extremes of physician maldistribution.

With this conclusion I heartily agree.