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I got an email from Dale Quinney,  the Executive Director of the Alabama Rural Health Association. He has put together a data set describing the primary care workforce in Alabama (found here). Dale is a data geek, and likes to put data together in interesting ways for folks to use to make value observations. These data demonstrate, among other things, that the primary care workforce in Alabama is old. Of the 3000 odd doctors, not only is the median age 52, but there are about 150 (or about 5%) above the age of SEVENTY. Many of these live in rural areas. Per Dale:

While the median ages are the same (52 years) in 2012 for rural and urban physicians, it is interesting to note that the average or mean ages for rural and urban physicians were higher than the median ages in 2006, emphasizing the older ages in both areas. However, by 2012, the average or mean age for urban physicians (51.4 years) was lower than the median age (52 years), emphasizing the younger ages among urban physicians.
So as with our highways, our schools, our libraries, and other non-sexy stuff, years of inattention have lead us to a primary care infrastructure crisis. For those towns with one (or several) doctors over 70 this  inattention puts all of their citizens at risk of premature death. Dr Starfield offered advice for folks in our situation. She said
At the very least, they can initiate policies to target state funding of medical teaching programs to institutions focusing on primary care training and provide greater financial support (as through loan forgiveness) to physicians who specialize in primary care. They also can encourage or mandate lower payments to specialists for patient visits NOT made by referral from a primary care practitioner. Additionally, they can increase reimbursement rates to providers who demonstrate that they deliver primary care in ways to achieve its benefits; instruments are available to document the primary care orientation of practices.
You listening, Governor Bentley?

I was asked to speak to the pre-med honors society at the University of Alabama about the new health care law (either the Affordable Care Act or ObamaCare depending on your preferred news channel) but that is a story for another day. On the way back to Mobile, being untroubled by an Interstate highway in that part of the state, we decided to take the (way) back roads to eat lunch at an out of the way “fish camp.”  While sitting down at Ezell’s Fish Camp (“The Holy Grail and standard bearer of catfish camps.”) in Laveda Alabama I spy a person walking in with what is clearly a medical office staff who I think I recognize. It turns out that it was Bernita Mims, MD who graduated from our residency and is now working in Butler. It is a very small state!

I later was speaking to the waitress and she reminded me that Karen Manning, MD, a family physician who is one of our community faculty, has an office in Toxey, Alabama (Population 152). As we were driving through Toxey anyway, I stopped by to say hello. Dr Manning has an Rural Health Clinic which she shares with a Nurse Practitioner. I had a long conversation with her a couple of years ago where (as she recalls) I encouraged her to set up the practice and break away from the hospital system that was supporting her at the time. I was able to tour her new office and was impressed by the efficiency of the design, the effectiveness of the staff, and the ability of the office to bring medical care including lab, x-ray, and now ultrasound to a very rural part of the state. I was also impressed by the built-in child care arrangement that facilitates employee attendance and I’m sure accounts for the high employee morale.

As I finished my drive through rural Alabama and hit other towns where we have placed physicians, I was reminded of why I went into academic medicine. As a physician I can only reach so many people but as an academician I can extend that reach. Although we still have profound shortages in this state, at least we as a department are doing our part.

I am here in Washington DC at the Rural Policy Institute put on by the National Rural Health Association. My administrative assistant laughed when I told her that at one time I dreamed of working in DC. She felt that although I would get the policy part, she has not known me to be politic. I will admit that I don’t feel compelled to keep my feelings to myself about other folks’ efforts, especially when I feel like the others are STUPID, but I don’t see how that would keep me out of politics. Instead, I get to go and meet with out delegation, thank them for passing the Affordable Care Act, and answer questions about the state of health care in rural Alabama in the most politic manner I can muster.

I did meet a very interesting person from Mississippi on the flight from Atlanta to DC. She is an administrator at North Sunflower Medical Center in Ruleville, Mississippi. On the map, Ruleville looks like the crossroads made famous in O Brother Where Art Thou where the group picked up Tommy Johnson. She told me they are moving towards electronic health records, have just opened a wellness center for all regardless of ability to pay, are looking to deliver dental services to 11 counties, and currently provide eye care for many Rulevillians allowing them to stay close to home. The North Sunflower  patient satisfaction is at 92%.

Many people say that if you come to a meeting such as this and bring home one thing to do to make things better, it was a good meeting. As the Affordable Care Act is now the law and the Alabama delegation is ground zero for the anti-earmark tsunami, I won’t be taking home any pork. I will get to hear Don Berwick discuss upcoming opportunities to deliver transformative change should the law remain intact. It is now up to the states to implement transformational changes within the infrastructure established within the Affordable Care Act. I hope I can bring back concrete ideas for Alabama to look at as we seek models to use for transforming care. From what I can see, North Sunflower might be a place to look to for such ideas.

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.

Dale Quinney, Executive Director of the Alabama Rural Health Association, sent me the following assorted random facts that point to just how dire the needs are (or just how great the opportunities are) in rural Alabama.

51 of Alabama’s 55 rural counties are currently classified as having a shortage of primary care physicians.  Only Coffee, Dallas, Marion, and Pike counties are not currently considered shortage areas.  (This classification measures the provision of MINIMAL rather than OPTIMAL care.) 


To eliminate all shortage designations, Alabama needs an additional 128 primary care physicians.  402 additional primary care physicians are needed to provide optimal care. 


All 55 rural counties are currently classified as having a shortage of dental care providers.    To eliminate all shortage designations, Alabama needs an additional 288 dentists.  348 additional dentists are needed to provide optimal care.  Alabama’s only dental school currently admits only 55 students each year. 


All 55 rural counties are currently classified as having a shortage of mental health care providers.    To eliminate all shortage designations, Alabama needs an additional 44 psychiatrists.  185 additional psychiatrists are needed to provide optimal care. 


More than one half of all actively practicing primary care physicians in Alabama are aged 50 years or more. 


It is estimated that the number of annual office visits to primary care physicians in Alabama will increase by more than 1,785,000 by the year 2025 – primarily due to the aging of Alabama’s population.  Over 904,000 of these additional office visits will involve rural physicians.  This increase does not consider such adverse factors as obesity with nearly one third of all adult Alabamians currently being obese, not simply overweight. 


Only 20 of Alabama’s 55 rural counties have hospitals that perform obstetrics.  In 1980, 46 of these counties had hospitals performing obstetrics. 


More than one in every five (22.1 percent) rural Alabamians are eligible for Medicaid services.  This is nearly one half ((44.5 percent) for rural Alabama’s children. 


The per capita personal income for rural Alabama residents is $29,170 which is over 21 percent lower than the per capita income of $37,109 for urban residents and over 27 percent below the figure of $40,166 for the nation.  Five rural Alabama counties (Wilcox, Bullock, Barbour, Sumter, and Bibb) are among the 250 poorest counties in the nation. 


The motor vehicle accident death rate in Alabama’s rural counties is 25.1 deaths per 100,000 population.  This rate is only 14.6 for the nation.  30 rural counties have motor vehicle accident death rates that are more than double the national rate with eight having rates that are more than triple the national rate.  While there are a number of reasons for this disparity, the great variation in  emergency medical service among the counties must be recognized as a contributing factor. 


Nearly one in every ten (8.5 percent in 2000) rural Alabama households have no vehicle for transportation.  This percentage is in double digits for 22 rural counties.
I recently gave a “State of the Department”  report to the Executive Committee of the College of Medicine. I took over as Chair in 2005 and have attempted to create a training environment that would facilitate entry of students into a primary care practice with a focus on rural and underserved Alabama.  The template we are working off of is above.
We’ve not done very well in the 4 years since I became Chair.  Only 5% of the students have gone into Family Mediicne and those going into Internal Medicine and Pediatrics have mostly left the state. In the course of the discussion, the non-Family Physician faculty became very defensive and felt that they should not be asked to take responsibility for an outcome that they were unable to influence. In addition, they felt that test scores were an outcome that they should be able to influence and rural students would have trouble keeping up with our current students.
Fortunately, the National Rural Health Association is working on a position paper to counter this argument. In it, they point out that “Medical education programs that include a focus on attracting practitioners to rural settings offer both recruiting and retention benefits to rural communities. In one study, six medical schools that made an explicit commitment to increasing the rural physician supply, that had a defined cohort of students, and that offered a focused rural admissions process or an extended rural clinical curriculum placed an average of 57% of their graduates in rural areas (compared to a 3% of medical students who report intending to practice in rural areas and the 9% of physicians who currently work in rural areas) and, of the two schools for which statistics were available, 79% and 87% of these physicians were still practicing in rural communities from 1 to 20 years after graduation. Implementing similar strategies for 10 students a year in the 125 United States allopathic medical schools would conservatively create an estimated 1139 physicians in rural practice, more than double the numbers expected without these strategies in place.”
This study does not mention test scores but it has been my experience that the NBME exams measure one clinical competency (medical knowledge) and do it on a threshold basis (can you make the minimum on the exam). Maybe we need to assess medical schools differently…


In our (soon-to-be-paperless-but-not-soon-enough) office, we have boxes where messages from patients, abnormal labs, and such are placed by the staff for action by the provider. Because it is not possible for everyone to know where everyone else is at any given time, we have taken to placing paper over the cubby-holes notifying the staff that we will be out until a certain day. If one is going someplace fun, a picture or something else fun is placed on the message as well. As Chairman, my cubby is covered more that most and this past week I used my “Out Reforming Healthcare” message for 3 of the 5 days.

On Tuesday I traveled to Birmingham to meet with the folks from the Patient Centered Primary Care Collaborative and hear Paul Grundy speak to primary care physician leadership as well as Alabama business leadership. His message is always strong and consistent and it is getting more focused.  As a physician who is involved in direct patient care as well as population based care for IBM employees, he is encouraging all employers to stop paying for garbage (his words). From a recent interview:

“40% of the care that’s delivered, according to some folks, is unnecessary and I see it every single day.  I know parts of the country where it costs $17,000 for the last six months of life and others where it’s $127,000 and by the way the patients in the $17,000 category, this particular case in Iowa live longer and are happier with the care than the ones that are in a scenario that is over $150,000.”

He sees transformational change coming and being lead by an empowered primary care workforce. Denmark is being looked at as a model with the number of hospitals reduced by 80%, for example.

On Wednesday I traveled to Montgomery to preside over the Alabama Rural Health Association board of directors meeting. As I have detailed previously, Alabama has an impending crisis regarding the healthcare workforce in rural Alabama. Although this meeting will not make a difference as a stand-alone activity, it is refreshing to get people in a room who are able to agree on a problem, potential solutions, and set in place a strategic planning activity focused in addressing the shortage. In that meeting we committed to focusing resources on FaceBook to recruit young folks interested in rural Alabama (search on FaceBook to find the page yourself), creating a strategic plan to better direct our resources, and finalizing issue briefs on the manpower crisis in rural Alabama health care prior to January 2010. We also committed to doing rather than talking.

Lastly, we went to New Orleans on Thursday to recruit Tulane students into our Family Medicine Residency program. The refreshing thing about this trip (aside from the soft shell crab) was that we spent a lovely evening with students who clearly entered medicine for the “right reasons” and they were committed to Family Medicine. We had a very pleasant visit and hopefully will see them in Mobile during the interview process.

In summary, like Paul Grundy I believe transformational change is coming. I believe it can happen in rural Alabama. The attitude of the students on Thursday confirmed my optimism. It was, however, a long week…

I spent the weekend working on an inventory of health workforce development activites in Alabama and was struck by some very clear needs that we have to deal with as a state if we are going to provide adequate healthcare to Alabamians, regardless of what happens in DC
1) It is incredibly important to develop a health careers infrastructure at the K-12 level on a state wide basis. Many counties are only likely to have physicians return if they were born or spent a significant amount of time in that county. In most of these programs, the children who are trained may take advantage of the opportunity to leave so the programs have to train above need and replacement to take that into account. IN Alabama, we currently have less than 100 students engaged in programs such as this annually.
2) Once rural students and students interested in caring for the underserved are enrolled in medical school, there needs to be predictable funding for the medical school infrastructure at UAB, USA, and possibly AMEC to offer instruction and support in rural and underserved medicine. The current funding strategies in medical education are neither sufficient nor predictable enough to in its current iteration accomplish this.
3) We do not have adequate Family Medicine residencies in Alabama to replace physicians who are retiring, much less address the shortage. These positions should be increased independently of other health manpower activities as residencies predictably place graduates near the program “hub”.
4) Community recruitment and retention efforts and payment reform will need to be accomplished as well to retain these docs in Alabama and not lose them to neighboring states. If there is insufficient reasons for physicians to move to or stay in an area, they will move away

parkerMy friend Josh Freeman and I have had an ongoing discussion over the last 15 years regarding the (un)design of our health system and the fact that every system is designed to get the results it achieves. Based on our results, the current design “bites the wax tadpole” as the Chinese say. Josh has calls for the complete redesign of the system. I tend to agree with Johnathan Cohn in “The New Republic” that one of the things that killed the last effort at serious reform was the fear of the overwhelming that threatening to retool one sixth of the economy all at once invariably brings. I tend to look at HR 3200 as being a little over half a loaf. as does the National Rural Health Association. It is not perfect. It does not going to go far enough to correct payment  inequities that lead to students to select training to become “partialists” rather than primary care specialists. What it does include is increased money to assist with training of generalist physicians and important fixes to the system of paying for this training and increased money for the National Health Service Corps. It also includes some (but still not enough) money to establish the “Medical Home” as a method of care delivery. It could include more on mental health and rural trauma as well but all in all, not a bad start. Now lets see what happens as the sausage gets packed in the skin.

Are we the bestFrom my perspective (and remember, if your only tool’s a hammer, all the world’s a nail) here are aspects of health care reform that are important to Alabama:
1) Access for acute, preventive, and chronic disease services for all Americans (which does not include a pre-exist clause) in places other than the ER. While EMTALA provides coverage for “heroic” care in the ER, it does not allow for the prevention of these very expensive and often preventible episodes. Also, many feel that without universal access any healthcare reform will fail due to “cherry picking” by the commercial carriers such as has historically occurred. This access can occur through commercial plans or a government “Medicare for all” model. If commercial plans are utilized, it is very important to create minimum standards based on quality because (as you are no doubt aware), if these are not created then competition is based on price alone which is why the HMO movement failed. Creating access would allow us to work on the entrenched health problems that dominate Alabama health statistics such as a premature birth (access for family planning), care for diseases such as diabetes (primary care access), and early detection and treatment of cancers such as breast cancer (primary care and specialty care). A lack of a “public option” would leave Alabama an effective single payor system as 95% of people not covered by Medicare or Medicais are covered by Blue Cross/Blue Shield
2) Strengthen the primary care infrastructure and reward coordinated, collaborative care DIRECTED by the primary care physician. We now have enough data to know that people do better and care is cheaper if they have a medical home, if that medical home has the electronic capability to allow prospective recommendations regarding preventive and chronic disease care, and the specialty care is coordinated through the primary medical home. Although many people believe they can coordinate their own care, the evidence is that this is expensive and leads to poor patient outcomes. Additionally, the reimbursement system needs to be restructured away from rewarding episodic “procedural” care towards this type of care management. Lastly, the vast cost of care for a given person is incurred in their last months of life. A medical home can allow patients to have access to an “honest broker” who might be able to reduce these costs through timely hospice referral and effective palliation. The proposals that pay for this through management fees seem to make the most sense to me. Creating this type of payment system would encourage practices to move from an urgent care model (many providers have left private practice in rural Alabama and moved into urgent care type practices) to a model where primary care in rural areas is adequately rewarded. These practices could offer urgent care as a part of the “basket of services” but would not necessarily need the full and costly infrastructure of the hospital.
3) Training of primary care physicians (family physicians, internists, pediatricians) needs to be revamped and adequately funded. Current funding mechanism through Medicare is based on a model of care from the 1960s when training was based on an apprentice model and the poor were the substrate upon which physicians trained. Primary care training should not be primarily hospital based. Additionally, trying to teach learners (premed students, medical students, and residents) primary care is difficult work. Training programs need funding for instructors above what the supervised learners can generate through supervised patient care. HRSA Title VII has been an historic mechanism through which to do this and it is up for reauthorization this year but it may be that the entire method of paying for medical education should be revamped. In Alabama the problem is even more acute as we are a net exporter of physicians and our primary care workforce is rapidly nearing retirement age. Physician assistants and nurse practitioners are important providers of healthcare as well but people want physician directed care.
4) Transformational change must occur which includes universal coverage and movement towards a primary care based system. Attempts at incremental change will lead to failure. Funding concerns, while important, should take into account the current situation and anticipated savings. Paul Grundy, Vice President for Healthcare at IBM is going around the country with a slide show demonstrating how poor the cost/quality ratio is in this country as opposed to other countries as well as how IBM is not creating jobs in this country as a consequence. Up until very recently, healthcare was seen as “an important part of the American economic engine”. I think now we see it is more of a support service which helps us to have a productive economy and that wasteful healthcare spending hurts us all. In Alabama, Medicaid and Blue Cross (included the Medicare plans they administer) cover over 80% of the population. If they can be convinced to embrace such change, it will happen.