You are currently browsing the category archive for the ‘Rural workforce’ category.
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.
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.
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
- 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.
- 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.
- 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.|
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…
My 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.