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Person at a cocktail party to me: Do you think the Governor will expand Medicaid

Me to the person: If the past is prelude I think he will consider it for another two years then let the next governor decide, thus allowing many more people to be killed by lack of access to health care in Alabama then will ever be killed by terrorists in Alabama.

The Governor couldn’t decide what to do about Obamacare and poor people so he appointed a task force. His call made it pretty clear that, although Obamacare wasn’t the answer, there were indeed questions that needed to be answered. In the “Whereas” section, for example:

  • Shortages of healthcare professionals in 65 of 67 counties
  • 40th out of 50 states in primary care physicians
  • 594.000 working people between the ages of 50 and 64 wihtout health insurance
  • 10 hospitals closed in the past 3 years
  • etc, etc, etc

The task force met off and on for about 6 months and had one recommendation:

  • Find a way to close coverage gap that makes health insurance inaccessible to hundreds of thousands of Alabamians.

They didn’t specifically say “the medicaid expansion as written into the Affordable Care Act (Obamacare) will solve 90% of the “Whereas”s” but they, by recommending this one thing, got awfully close.

The Alabama TEA Party response was posted on-line last week. Consistent with the national talking points, it goes something like:

We Alabamians pay enough taxes and would rather keep people with mental illness in jails, have hospitals go under, and allow people to avoid health care and die of treatable illnesses because of fear of bankruptcy rather than pay an extra $10 a year per person in taxes because we are TAXED ENOUGH ALREADY.

Fittingly, on the TEA party editorial page was an advertisement for Farxiga. which made the list of Huff Po’s worst drugs of 2014:

But the more frightening news is that patients taking Farxiga in studies done for the FDA were more than five times more likely to contract bladder cancer than the patients who took an older diabetes drug.

Priced at only $10 a day and advertised as first line treatment, I am sure it’ll end up in many physician’s sample closets. Uninsured patients with diabetes, then, who are unable to afford insulin (which is surprisingly expensive) will get lots of Farxiga samples. With any luck, they will contract bladder cancer. Because they are lucky enough to get cancer, assuming the blood in their urine scares them enough to seek care AND assuming they can find a urologist who will scope them on credit, become Medicaid eligible in Alabama. Then they can get insulin for their diabetes and get their bladder cancer treated. Don’t know why the task force didn’t recommend this, instead.

Earlier I spoke of nine things we can do in Alabama as consumers to strengthen rural health care. Having spent a couple of days in Austin at the National Rural Health Association conference, Dale Quinney and I brainstormed and came up with four things the state of Alabama can do to improve the health care delivery system in rural Alabama right now:

The pipeline for rural primary care providers needs to be strengthened rapidly and effectively. There are opportunities to strongly encourage (pressure) Academic Health Centers in Alabama to produce sufficient primary care providers of the right background who are committed to practice in rural Alabama. These providers should include not only physicians who will go into Family Medicine, RURAL pediatrics or RURAL Internal Medicine but should also include mid level providers to be a part of the health care team. Alabama programs are leaders in selective admissions, pipeline programs, and rural tracks in both UAB and USA, wiht examples found here and here. Considerable expansion coupled with measurable outcomes (entrance into primary care specific post-graduate training, entrance into practice in rural Alabama, continued practice at 5 and 10 years) should lead to more providers very quickly.

Enhancing primary care delivery quickly will result in an improvement in health outcomes. The Office of Rural Health/Office of Primary Care or another agency in the Alabama Department of Public Health needs to become a leader in facilitating practice transformation. Physicians in rural Alabama will need more than just computers in their offices to practice in the new age of accountability and quality improvement. The Office should have sufficient staff and resources to functionally coordinate efforts by a myriad of agencies including AQAF, BC/BS, Al-REC and other HIE entities. The goal should be that every primary care practice in rural Alabama has the opportunity to participate in practice improvement activities and deliver measurably enhanced primary care. The goal should be that every primary care practice should be able to qualify for NCQA Patient Centered Medical Home Level 3 status within 5 years

The rules for licensure and practice protocols need to be scrutinized.  There are numerous instances where professional organizations or trade organizations have been allowed to make rules that while making sense on the face, serve to reduce the efficiency of rural practice. This is more true as technology changes.  An example is the Board of Dental Examiners which only tests once a year and does not grant reciprocity such that should a dentist consider relocating to Alabama he or she would have only one opportunity to do so annually. Given the ease of giving a test at a testing center, this seems antiquated. Another is the Alabama Board of Pharmacy’s rules limiting or preventing  telepharmacy, which would be a boon to rural hospitals. A third example is one of Psychiatry. There are acute mental illness needs in every state. In Alabama, these are exacerbated by a chronic shortage of mental health professionals. Several times over the past 10 years we have had natural or man made disasters where voluntary mental  health professionals have desired to come and assist with the acute crisis only to be thwarted by the Board of Medical Examiners. There are many  such instances that need to be addressed. There needs to be attention paid to this rapidly as technological advances have already outpaced many of these rules.

Technology such as telehealth offers tremendous opportunity to transform care delivery but there needs to be a local infrastructure in place. There are many examples of telehealth  and other technologies reducing disparities, eliminating costly transportation, and improving care. For the most part, these technologies are coupled with robust primary care and community hospital resources. It is vital to leverage technology to improve care. It is clear, however,  and supported by data that without the “high touch” component best exemplified in primary care practices outcomes will remain below that of the country and the rest of rural America. There needs to be an office whose responsibility is to assure that technology is leveraged to its fullest but that the outcome is always improved health for the citizens of Alabama.

What it the purpose of a medical school? Seems like a dumb question but it turns out there is not an easy answer. Is the purpose to function as a regional economic engine? University of Alabama, Birmingham College of Medicine certainly does. Is it to provide care for the indigent of the region? Up until recently the indigent in New Orleans would not have had any health care were it not for the presence of LSU and Tulane at Charity Hospital. Is it to assure adequate physician manpower for the region? Clearly the presence of 2 medical schools accepting almost 300 students per year has not accomplished that for rural Alabama.

The American Academy of Family Physicians announced a new tool for those of us who are interested in whether the physician output is the purpose or the byproduct of medical education.

The AAFP’s Robert Graham Center has unveiled a medical school mapping program that allows users to gauge the role of medical schools in promoting and sustaining primary care access within states, regions and localities.

The free Med School Mapper tool can be used to identify counties in which a school’s graduates currently practice, the number of physicians in each county who have graduated from a particular school, medical schools that provide the most graduates to each county, and the percentage of graduates who are practicing in rural or underserved areas.

Using it has led to some interesting discussions around the office.

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.

My previous post has generated a bit of interest among folks smarter and more knowledgeable than I about the health care workforce. I refer you to the post for the full comments. I thought Bob Bowman’s comments were important (and long) enough to warrant a separate post which follows. The one thing I think everyone agrees on is that quality is as important as access and we need to find a delivery system that delivers both:

To understand this situation, one must understand that for near poor, poor, lower income, middle income, rural, underserved, less educated, CHC, lowest health literacy, elderly, oldest of the elderly, and all populations in most need of basic health access that are most complex in evaluation and treatment…(Ferrer, Mold, Rosenblatt, Bowman) Are most likely to see family practice physicians

And are seen in locations with the least health spending, resources, support staff, facilities A few years back the Hartford Currant, the oldest newspaper in the US, singled out doctors from certain medical schools as lower quality using questionable measures. Not surprisingly these were front line doctors serving the most challenging populations that other US docs were less likely to care for.Social determinants shape most outcomes for lower and middle income Americans – decisions by patients, access to care, response to treatment, etc. This is also why pay for performance is a bad idea.Osteopathic information and my own research helped me in this area. In the 1960s the AMA became alarmed about the osteopathic patient care influence much higher than osteopathic numbers. The reason was that over 70% were in family practice or general practice with the longest medical careers (over 35 yrs), the most active, the most volume, and the highest primary care retention (over 90%). This resulted in the most patients seen in the least time. With osteopathic down to 35% FPGP by the 1990s and 18% now, this impact has diminished and the truth is that this was a family practice impact all along

Read the rest of this entry »

The Alabama Rural Health Association is putting together a task force to deliver to policy makers a list of health reform actions that have been taken or will be taken as a result of the passage of the reform package. As a state, we tend to be a little wary of federal initiatives. We as an organization want to inform the gubernatorial candidates what policies are in place so that they can get beyond the political rhetoric. The National Rural Health Association has put together a list of initiatives that are already in the Patient Protection and Affordability Act which will help rural Alabama that we need to be prepared to react to as the opportunities arise. Perhaps one (or all) of the gubernatorial candidates will announce a rural health task force to allow his (all of the candidates are men) adminstration to take advantage of opportunities in a rapid fashion. The law has already been passed so I hope we won’t let politics get in the way of improving the health of our citizens:

Rural Health Care Workforce Improvements (as identified by the National Rural Health Association)

Rural Physician Training GrantsThese grants will help medical colleges to develop special rural training programs and recruit from students from rural communities.  This “grow-your-own” approach is one of the best and most cost-effective ways to ensure a robust rural workforce into the future. Alabama has some very good but underfunded programs

Expanding Area Health Education Centers (AHEC)  – Area Health Education Centers (AHECs) are critical to long-term health workforce strategies in rural America.  AHECs are directly responsive to State and local needs and serve to improve the supply, distribution, diversity and quality of the healthcare workforce, ultimately increasing access to health care in medically underserved areas.  The bill makes a strong investment in the continued success of this program. ALABAMA DOES NOT HAVE AN AHEC

Graduate Medical Education (GME) Improvements – Rural America faces a severe physician shortage, and this bill seeks to partially address this problem by improving GME.  First, it establishes a program for training of medical residents in community based settings by awarding grants or contracts.  This funding would help develop new primary care residency programs in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).  It would do so by creating a demonstration project program for RHCs, FQHCs and other “approved teaching health centers” in non-provider settings for which centers would be eligible for payments for their own direct GME primary resident costs in a manner similar to the payments hospitals would receive for providing similar services.  Additionally, the bill would establish a grant/contract program to train primary care residents in community-based settings.  These programs would recruit and train new residents and faculty, and would either create new programs or operate out of existing primary care residency facilities.  Preferences for this funding would go to programs serving underserved communities. ALABAMA does not have mechanisms in place to take advantage of this at this time.

Redistribution of residency slots – The bill redistributes unused residency slots under the Medicare GME program, enhancing the national capacity for health care provider training.  Not only does this provision protect rural programs from losing their slots, which may be difficult to fill, it also prioritizes the redistribution of slots to rural programs and rural training tracks and ensures additional placements to residents in primary care and general surgery. The funding mechanism was recently announced. Alabama does not have a mechanism to pay for the excess teaching costs associated with these new slots.

National Health Service Corps – The NHSC is critical to addressing the provider shortage crisis in rural America.  This bill includes a significant investment in the NHSC and allows health professionals to fulfill their commitment by teaching, further investing in the future of the health care workforce. The state office that formerly worked with the National Health Service Corps has had significant decreases in staffing.

Undergraduate medical education – Workforce improvements must be made at all stages of the process and a grant program to improve primary care training will enhance the primary care workforce nationally. The Alabama Family Practice Rural Health Board has some resources available to help position us to take advantage of this but they are not adequate.

National Health Care Workforce Commission – The Commission would provide recommendations to enhance the status of the health care workforce across the country.  It would be comprised of health workforce experts and require a balance between rural, urban, suburban, and frontier perspectives.  Additionally, the geographic distribution of the health care workforce would be a priority area for study. The Alabama Rural Health Association has some resources should policymakers have interest.

Important Medicare and Medicaid Improvements

10 Percent Bonus to Primary Care Physicians  – Building on the 10 percent bonus fee schedule payment already offered to physicians meeting certain guidelines, such as those practicing in health professional shortage areas (HPSAs), the bill includes a five-year 10 percent bonus on certain fee schedule evaluation and management (E & M) codes related to office, home, nursing facility, domiciliary, rest home, or custodial care visits. This bonus is available to primary care, general internal medicine, general pediatric and geriatric physicians, nurse practitioners, clinical nurse specialists, or physician assistants for whom primary care Medicare services accounted for at least 60 percent of their charges the abovementioned E & M visits. Alabama Medicaid and Blue Cross should follow suit.

10 Percent Bonus to General Surgeons Performing Major Surgeries in HPSAs – Any general surgeon performing major surgeries in health professional shortage areas (HPSAs) are eligible for an extra 10 percent bonus payment between 2011 and 2016.  Alabama Medicaid and Blue Cross should follow suit.

Medicare Physician Fee Schedule Improvements – Adjustment of the Geographic Practice Cost Indices (GPCI) Formula – For years 2010 and 2011, the “practice expense” component of the GPCI formula will reflect “1/2 of the difference between the relative costs of employee wages and rents in each of the different fee schedule areas and the national average of such employee wages and rents.”    Additionally, the bill includes a hold-harmless provision in the event of an area being adversely affected by this provision.  The legislation also directs the HHS Secretary to analyze a method of establishing geographic adjustments that “fairly and reliably establishes distinctions in the costs of operating a medical practice in the different fee schedule areas.” For the years following (2012 and beyond), the HHS Secretary is required to update the PE GPCI to reflect accurate geographic adjustments based on office rents and other factors.  Alabama Medicaid and Blue Cross should follow suit.

Medicare Rural Home Health Add-On

Because home health is more expensive to provide in rural communities due to distance and the availability of providers, Congress implemented, as part of the MMA of 2003, a 5 percent bonus payment bonus payment to providers supplying home health services in rural areas.  This bonus payment was first implemented in 2004, but because Congress did not extend the program it expired on December 31, 2006.  The health reform bill reinstated this program for the period between April1, 2010 and December 31, 2016.  Instead of the previous bonus amount, however, the bill provides a 3 percent bonus payment.

One-Year 5 Percent Bonus to Mental Health Physicians  – For 2010, physicians offering psychotherapy services will receive a 5 percent bonus payment. Alabama is in a mental health delivery crisis. Te system is broken and needs significant attention. This will help but will not be enough.

Providing Adequate Pharmacy Reimbursement   – The bill includes reimbursement for retail community pharmacies of no less than 175 percent of the weighted average of the most recently calculated average manufacturers price (AMP).  There are many area of Alabama that are not served by pharmacy services

Technical Correction for Critical Access Hospital Method II Billing Reimbursement (Section 3128) – This provision would correct a technical error in current statute relating to CAHs who elect to use the Method II, or Optional Payment Method.  This was in response to the recent CMS Inpatient Prospective Payment System (IPPS) final rule in which CMS interpreted current law to disallow CAHs who bill under Method II from receiving the typical CAH 101 percent reimbursement. Because of reimbursement policies of  Alabama Medicaid and Blue Cross, Alabama has been unable to take advantage of the Critical Access Hospital rules to improve care.

Additional Payments to Hospitals in Counties with the Lowest Medicare Spending – For 2 years, hospitals in the lowest quartile of counties in terms of Medicare spending on benefits will receive additional payments to offset their disproportionately low rates.  These payments will equal $400 million in ($200 million in FY2010 and $200 million in FY 2011) to address geographic disparities for PPS hospitals in the lowest spending quartile of the country.  Alabama needs to be prepared to take advantage of this.

Extension of Important Programs Ensuring Access to Physicians and Other Services Otherwise Set to Expire

–          Extension of Payment for Technical Component of Certain Physician Therapy Caps Physical therapy services are unavailable in many counties of Alabama

Extension of Ambulance Add-Ons Ambulance services are in financial difficulty in many counties of Alabama

–          Extension of physician fee schedule mental health add-on Mental Health  services are unavailable in many counties of Alabama

Extension of Important Rural Medicare Protections  – The Medicare Modernization Act (MMA) of 2003 included a number of provisions important to protecting the fragile rural health care safety net.  These protections are set to expire, and the NRHA is glad this bill includes provisions extending these programs.  They are:

–          Extension of Outpatient Hold Harmless Provision

–          Extension of Medicare Reasonable Costs Payments for Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain Rural Areas

–          5 year extension and improvement of the Rural Community Hospital Demonstration Program

–          Extension of the Medicare-Dependent Hospital (MDH) Program

–          Temporary Improvements to the Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals

–          Improvements to the Demonstration Project on Community Health Integration Models in Certain Rural Counties

–          Extension of and Revisions to Medicare Rural Hospital Flexibility Program

–          Extension of Section 508 Hospital reclassifications

We need to be in a position to take advantage of these in Alabama

Additional Improvements

Strengthening Indian Health Services – The bill ensures Indians below 300 percent of the federal poverty level will not face any cost-sharing when enrolled in the state exchange.  The bill also eliminates the sunset for reimbursement for all Medicare Part B services furnished by certain Indian hospitals and clinics. We need to be in a position to take advantage of these in Alabama

Small Business Tax Credit   – This would create tax credit for small businesses who offer health insurance for their employees.  The credit would be equal to 50 percent (35 percent for tax exempt employer) of an eligible employer’s requirement set forth by the bill through the exchange or a suitable alternative. We need to be in a position to take advantage of these in Alabama

Increases in Funding for Community Health Centers – Community Health Centers are a cornerstone for patient-directed care for populations with limited access to primary health care services.  This critical additional new funding will allow health centers to increase care to millions of underserved patients. We need to be in a position to take advantage of these in Alabama

Expansion of the 340B drug program – The 340B Drug Pricing Program provides low cost drugs to certain facilities.  This bill would expand the program to include Critical Access Hospitals, Sole Community Hospitals and Rural Referral Centers, allowing these facilities to better serve their patients. We need to be in a position to take advantage of these in Alabama

Community Transformation Grants – These grants provide for the implementation, evaluation, and dissemination of evidence-based community preventive health activities. According to the manager’s amendment, at least 20% of these grant funds must go to rural or frontier communities. We need to be in a position to take advantage of these in Alabama

In this country we have had difficulty delivering basic health care to our citizens. We have had a larger problem delivering basic dental care to our citizens. We are almost unable to deliver mental health care given the constraints of the current system. Health insurance reform at this time will not provide the delivery system reform necessary to fix the oral health problem. It may provide resources that will help people get needed mental health care.

The Milbank Fund has published a report on mental health care delivery system transformation. In it they point out that the method of care delivery is important:

A comprehensive health care system must support mental health integration that treats the patient at the point of care where the patient is most comfortable and applies a patient-centered approach to treatment. Integration is also important for positively impacting disparities in health care in minority populations.

A 2008 report by Funk and Ivbijaro cited seven reasons for integrating mental health into primary care. Each must be considered in any effort to design or implement a collaborative approach, partial integration, or a fully integrated model.

  1. The burden of mental disorders is great. Mental disorders are prevalent in all societies and create a substantial personal burden for affected individuals and their families. They produce significant economic and social hardships that affect society as a whole.
  2. Mental and physical health problems are interwoven. Many people suffer from both physical and mental health problems. Integrated primary care helps to ensure that people are treated in a holistic manner, meeting the mental health needs of people with physical disorders, as well as the physical health needs of people with mental disorders.
  3. The treatment gap for mental disorders is enormous. In all countries, there is a significant gap between the prevalence of mental disorders and the number of people receiving treatment and care. Coordinating primary care and mental health helps close this divide.
  4. Primary care settings for mental health services enhance access. When mental health is integrated into primary care, people can access mental health services closer to their homes, thus keeping families together and allowing them to maintain daily activities. Integration also facilitates community outreach and mental health promotion, as well as long-term monitoring and management of affected individuals.
  5. Delivering mental health services in primary care settings reduces stigma and discrimination.
  6. The majority of people with mental disorders treated in collaborative primary care have good outcomes, particularly when linked to a network of services at a specialty care level and in the community.
  7. Treating common mental disorders in primary care settings is cost-effective.

The writers acknowledge barriers, including the traditional mind-body dualism which has led to silo thinking, the problems inherent in attempting information sharing with sensitive information,  and the fact that payment for mental health care is not assured even with the new law. helping is the fact that organizations such as the Carter Center are working to de-stigmatize mental illness

The report points out that vital to improving this care is the Patient Centered Medical Home, the team approach to care (incorporating mental health professionals and primary care practices), and stepped care. In addition, they propose the use of a (proven) model where patients with low health and high needs and low behavioral health needs are cared for in the primary care medical home, and those with high behavioral needs and low and high health needs are cared for in the primary care and specialty mental health setting, all in a coordinated fashion.

The report makes for an interesting read and offers concrete solutions to some vexing problems.

Todays Press Register carried an excerpt of an article from Governing Magazine which contrasted the differences in attitude towards health care reform between Alabama and New Mexico. The article made some interesting points which require some context to fully appreciate.

New Mexico has about half as many people as Alabama (2 million to 4.6 million) and is twice as big (120,000 square miles to 54,000 square miles) so is much more rural. Rurality poses a problem for care delivery for both states but Alabama health care is dominated by several largish cities (Birmingham, Mobile, Montgomery, Huntsville, and Tuscaloosa) that each have a medical school or a medical branch campus. Albuquerque is the only city of significant size in New Mexico. The medical education enterprise in Alabama is dominated by the University of Alabama, Birmingham has as its stated mission “The School of Medicine is dedicated to the education of physicians and scientists in all of the disciplines of medicine and biomedical investigation for careers in practice, teaching, and research. Necessary to this educational mission are the provision of outstanding medical care and services and the enhancement of new knowledge through clinical and basic biomedical research.” The medical school in New Mexico ” Our goal is to provide top-notch clinical services to the residents of New Mexico while being recognized as a respected School of Medicine training doctors for New Mexico.”

Both states are in the bottom quartile of state rankings. The difference is in how the state health officers see the role of health insurance refom in their path to becoming a high performing state. In  Alabama,  Commissioner Stekel sees impending doom. Alabama chooses to insure almost all of its children (97%) but relies on the medical schools to care for the poor adults as a by-product of the education process. As a result there are 100,000 diabetics in Alabama who do not get needed preventive services and either die prematurely or suffer significant disability. 250,000 of its citizens use the emergency rooms as their usual source of care. Although most children have insurance under the current system, 150,000 do not have access to primary care because of a shortage of providers to deliver that care. Commissioner Steckel wishes “more modest approach of incentives for small businesses and pooling had been tried instead.”

The Medicaid commissioner of New Mexico sees opportunity. The per capita numbers may look the same (or even a little worse) but New Mexico Medicaid Director Ingram sees ” it as a tremendous boost to the state economy. Those providers, in turn, will have more money to spend in ways that benefit New Mexico’s economy. Ingram points to a study conducted by the advocacy group New Mexico Voices for Children that found that each dollar spent by New Mexico on Medicaid generated $2.90 in federal Medicaid funds, which in turn generated an additional $2 in extra economic activity as the spending rippled through the economy, ultimately creating a combined “multiplier” effect of $4.90.”

Part of why Commissioner Stekel see impending doom where Director Ingraham sees opportunity may be how Academic Medicine fits into the care delivery system. At the University of New Mexico College of Medicine, many programs exist to enhance care delivery and integrate the clinical offerings into the communities. I saw a very impressive presentation of some of their telehealth activities  at the National Rural Health Association meeting in Miami. I hope that we in academic medicine in Alabama will be offered the opportunity to work with Commissioner Steckel to do the same. 


As I alluded to previously, I was in the nation’s capitol as a part of the National Rural Health Association’s Policy Institute. Many advocacy organizations have such activities, bringing members in from throughout the country to discuss common issues with their members as a group. All 50 states were represented. We had three of us from the Alabama Rural Health Association and visited with the staffs of both of our Senators and 6 of 8 Representatives.

Although the political landscape is still uncertain, primary care (and more specifically family medicine) is on everyone’s mind. From the speakers to the staffers, there is an appreciation for what we do as a specialty and a concern that we will not accomplish sufficient change to enable family physicians to do their job as well as they should. Everyone expressed appreciation for “Family Docs”

The other striking thing is that all of the staffers were aware of the Patient Centered Medical Home and (although some were more convinced than others) were convinced of its potential value. It has been amazing to see how fast this concept has made its way into conversations about health care delivery.

I’ll have more later but if you still are unconvinced about the value of Family Docs, their commitment, and their abilities here’s something for you to look at…

University of Alabama, Birmingham is in the process of selecting a new Dean for its medical school. I have worked in academic medicine for almost 20 years and my father was in academics throughout the period that I was growing up so I understand the ebb and flow of the academic setting. In fact, Wallace Sayre summed up the problems very succinctly by saying “Academic politics is the most vicious and bitter form of politics, because the stakes are so low.”

This is never more apparent when it is time to hire a high-ranking executive in an academic setting. Universities typically use a “Search Committee”  to develop a list of candidates that the Provost (in this case) might choose from. Here is a quote from the University of New Mexico policy on hiring such people:

An effective search committee strategy will do much to facilitate, rather than undermine, an effective search. Keep in mind that the goal when using a search committee is to optimize the effectiveness of the search process from the perspective of all parties concerned-the hiring authority, members of the search committee, colleagues, and in particular, the applicants. Since the search process sets the stage for the future employment relationship, careful attention should be paid in effectively managing this very important phase of the staffing process.” (emphasis mine)

Imagine if  all HR departments had to run potential executives in front of a group of disgruntled folks with their own axes to grind. It would be a wonder if anybody got hired.

The reason this came up is that the Search Committee for the Dean at UAB does not contain a Family Physician, General Internist, or a General Pediatrician. The leadership in Family Medicine asked whether a differently constituted search committee might select a Dean that would place more emphasis on primary care and rural medicine.

It is my opinion that it would not and here’s why. Academic medicine sees Family Medicine as one of a number of competing clinical concerns that they need to balance as they provide education for undifferentiated students.  Traditional academic deans are concerned with maintaining or building revenue streams (typically family medicine is not helpful in this regard), maintaining the educational programs (in which case they need Family Medicine as well as Surgery, Medicine, OB, Peds, and Psych and Pathology  known collectively as the educational “six-pack plus one”), and growing research programs (typically not a Family Medicine function except at the Dukes of the world). Academic medicine in my opinion, does not seen themselves as producers of the physician workforce anymore than Colleges of Arts and Sciences see themselves as producers of the Chaucer scholar workforce. Colleges of Education tend to understand this workforce issue better than most (probably due to the initial charters under which they were founded and state mandates) but now with the charter school movement that might change.

Those of us in academic Family Medicine might see ourselves as producing tomorrow’ s healers but Deans and Provosts see us as  most equal to the others in the “six-pack.”

Medical schools typically don’t care about shortages, workforce needs, unless required to by external pressure. The reason is multi-factorial. One is that there is a lot of give in the system. We graduate 17600 allopathic physicians in this country. There are another couple of thousand osteopathic graduates. We allow almost 10,000 folks from other countries or from Caribbean schools into this country EVERY YEAR to fill the remaining slots. That’s one reason that medical schools don’t worry because this allows US schools to say that the “market” will fix things. We have been unsuccessful in the last 10 years in trying to develop a primary care workforce using a majority non-US grads.

The other reason is that the pipeline following medical school graduation is in the training hospitals and this portion of the pipeline is divorced from the medical schools. Medical schools point to the residencies and claim protection from these types of issues. The residencies point to success in the match as proof that their clinical care is vital and necessary. The way the payment structure is set up all of the grads get jobs, so why should the residencies worry? Of course, when we all get leukemia from CT exposure it’ll be a problem but more business for Oncologists as well.

What makes Deans worry about students attitudes towards a career in primary care? Mandates work for state schools. If the governor or key legislatures say “you gotta make primary care docs”, it happens. As it stands now, some in the Alabama legislature are securing funding fo an osteopathic pipeline as a response to the “shortage” but there are still no mandates in place so it’ll likely fail in this regard as well. This pipeline may have more success because folks educated in rural areas are more likely to go into primary care, all other things being equal.

What else works? Selecting the right students, educating them in a nurturing environment, and paying them (or at least not making them take out and pay loans) for doing the right thing. Paying primary care docs for doing the right thing makes students want to go into primary care. Lastly, making the communities conducive to quality care delivery works (which is why I would like to see collaboration between Schools of Public Health and Colleges of Medicine).

In summary, I suspect that UAB will select a Dean based on the weight of his or her CV and the perceived possibility of extramural funding and/or prestige regardless of the search committee composition. If Alabama wants primary care docs, the Dean will probably not matter one way or another. In fact, one Dean would argue that the Dean’s job is more of a mediator than anything else.  The Governor, on the other hand, will be a different story.