Monday, November 29, 2010

Compromised public health ethics across the pond: Britain too!

Not long ago, I wrote of the “consumer alliance” between the American Academy of Family Physicians (AAFP) and the Coca-Cola company (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). In that piece, I also noted the close relationship between the American Dietetic Association (ADA) and Hershey’s. For the record, I did not believe that these were, um, healthful, for the American people. I cited the work of Howard Brody, who looked at the ethics of the conflict of interest specifically in the Coca-Cola/AAFP case (and yes, there is definitely a conflict of interest whether or not that conflict results in prejudicial outcomes).

It turns out that this kind of arrangement is not limited to the United States. Indeed, Dr Alex Scott-Samuel, Director of EQUAL (Equity in Health Research and Development Unit) in the Division of Public Health at theUniversity of Liverpool, brings our attention to an article in the British newspaper the Guardian. It reports that in the United Kingdom, the “…Department of Health is putting the fast food companies McDonald's and KFC and processed food and drink manufacturers such as PepsiCo, Kellogg's, Unilever, Mars and Diageo at the heart of writing government policy on obesity, alcohol and diet-related disease”, an apparently far more malignant development.

The potential advantage of a government-run national health system is that it can insure that health care is provided for everyone, as I have often lauded. The public health role, however, is one that is even more commonly a public one, even in the United States, but in the UK the influence of the Department of Health over public health policy is even greater than in the US because they do not have independent state governments with their own health departments and health policies. We are, of course, familiar with the “fox guarding the henhouse” method of making public policy, which seemed to have reached its apex in the GW Bush administration with the big oil companies writing energy policy. Or maybe not; recently we discovered from a recent NPR investigative report (we need more of those) that the noxious Arizona immigration law was actually written by the private, for-profit prison industry as a way to increase business! (“They even named it. They called it the 'Support Our Law Enforcement and Safe Neighborhoods Act.’")

Is, then, the public’s health just another example of this type of “consumer alliance” (I really love this term!) – the British call them “responsibility deals”, more enigmatic, perhaps, but not more accurate – or is it another matter? Clearly, as demonstrated by the BP oil spill in the Gulf of Mexico, energy policy is critically related to health. And a law that makes it illegal for a person, a US citizen, to stop an offer humanitarian life-saving help to someone they find wandering and half-dead in the Arizona desert, not to mention imprisons and deports those who are not legally here, impacts on their health. Certainly these policies impact the rest of their lives.

Maybe it is because this is happening in the UK that makes it stand out. Maybe because some of us, myself included, have seen the UK and other European countries (and certainly there are many differences between European countries) as more focused on the health of their citizens. I know that there have been any number of problems with and criticisms of British health and social policy, including those of Julian Tudor Hart (“the inverse care law”[1], Medical Student Selection, December 14, 2008) and Sir Michael Marmot (the “Whitehall studies”, Health Outcomes: The interaction of class and health behaviors, May 9, 2010), and continued by current public health experts and scholars. I guess that the presence of the British National Health Service and its universal access have been so overwhelmingly positive in this regard that I have regarded such criticisms as those of people who “don’t know how good they have it”. Let me be clear: I never doubted that the concerns were valid, but rather that they may minimize the good things present in the system; in the same way I know that those in US cities with public hospitals are correct when they point to the underfunding, second class care, and inequities that they suffer, but at least, unlike where I live, they have public hospitals.

This initiative is, clearly, malignant. It is unquestionable “conflict of interest” for those whose interest is in selling more of their products, however unwholesome they may be, to be involved in the writing of public health policy around the use of, and advertisement of, those products. And, moreover, they will certainly ensure the insertion of policies that benefit themselves at the same time as they harm the public’s health. Note that it goes beyond food (and junk food); not only does the “food network to tackle diet and health problems includes processed food manufacturers, fast food companies,”, but “The alcohol responsibility deal network is chaired by the head of the lobby group the Wine and Spirit Trade Association.” Wow. One consumer advocate noted "This is the equivalent of putting the tobacco industry in charge of smoke-free spaces." It’s quite an achievement. Even Philip Morris couldn’t get to chair the cigarette control board!

Obviously, that this is occurring shortly after the Conservative Party has taken control of the British government is not a coincidence. It is part of a very successful strategy to transfer not all most, but virtually all, wealth and power to those who are already most wealthy and powerful. In the US, despite the control of the White House and both houses of Congress by the supposedly more progressive Democratic party, this consolidation is proceeding apace, clearly helped by Supreme Court decisions such as Citizens United that essentially removed all limits on corporate contributions to political campaigns.

Having input from corporations that stand to benefit from legislation or policy is one thing, as long as it is balanced by input from consumer groups – and the welfare of the people is the final criterion for making a decision, not maximizing corporate profit. In this case, the case of the public’s health, the decision should be clear cut.

[1] Tudor Hart, Julian, “Three decades of the inverse care law”, Br Med J, 2000 Jan 1;320(7226):15-8.

Tuesday, November 23, 2010

Lung Cancer Screening: Benefits, Costs, and Opportunity Costs for the Public Health

In a rather unusual action, the National Cancer Institute (NCI), a division of the National Institutes of Health (NIH), issued a press release on November 4, 2010 announcing preliminary findings from a research study that, at that time had yet to be published (it since has been). This bulletin, Lung cancer trial results show mortality benefit with low-dose CT, announces that a large, multi-center, randomized controlled trial (RCT), called, the National Lung Screening Trial (NLST), has found that regular screening of current and former heavy smokers with low-dose chest computed tomography (CT) scanning aged 55-74, compared to screening by regular chest x-ray, led to 20% fewer deaths from lung cancer. It is unusual in that it is there is no associated published study in a journal describing these results (the statement says that it is being “prepared for publication in a peer-reviewed journal within the next few months”); the only concurrently published article is a description of the methods of the NLST study, with discussion of previous screening studies for lung cancer, is the “National lung screening trial: overview and study design” published in the November issue of Radiology and made available November 2, 2010.

The study comparing these two screening tests – x-ray and CT – appears very strong. Because it is randomized, there is no significant difference between the pre-existing characteristics of those assigned to CT versus chest x-ray screening, and because the end point is death, it largely eliminates one of the most important confounding issues in prior studies called “lead time bias”. This means that if a more sensitive test identifies cancer earlier in its course, the time between diagnosis and death will be longer even if the death itself is not forestalled. (E.g., you have cancer and one test finds it at 55 and you die at 60; another test could find it at 50 and you die at 60; finding the cancer earlier didn’t make you live longer.) It is also a very large study (53,000 people) and well designed in many other ways, so that a 20% reduction in death is important. There is an excellent FAQ for this study, including graphics of lead-time and length-time bias, at the NCI website

So is there any problem? Will lung cancer, the biggest killer among cancers, become like breast cancer, where a screening test can find the cancer earlier, lead to earlier and effective treatment, and decrease mortality? Not exactly. In addition to a 20% reduction in mortality being far less than the reduction in breast cancer mortality from mammography, lung cancer is not breast cancer; we know the cause of the vast majority of cases: smoking. The authors, and the NCI, emphasize that such screening, even if widely adopted, is no substitute for stopping smoking or increasing efforts to get people to stop smoking. The real question is what is the benefit of spending huge amounts of money (while there is no statement of cost of screening in either the NCI brief or the Radiology article, estimates are as much as $12 billion a year -- 30 million screened at $400 per CT screening with interpretation, including follow-up exams -- to screen people who smoke, or smoked, heavily for cancer in pursuit of a significant, but relatively small, reduction in mortality? Moreover, there is no estimate of the potential risk of repeated CT scans (even low-dose, such as studied) and the degree to which the existence of a screening test might decrease the interest of smokers in stopping. (If this seems perverse, it is almost certain to happen; it happens every time news of a possible preventive intervention is announced: some people decide there is no need to stop their risky behavior.) Thus, to save 1 in 300 lives (about 100,000 of the 30 million screened, or 0.039% of the US population), not even considering quality of life (generally low for long-term smokers with cancer who have other conditions such as chronic lung disease), will cost about $40 per every person in the US per year.

How do we evaluate cost-benefit? In the current political environment, the popular theme is “don’t spend public money”, but there is always the implicit caveat “except if it benefits me” – and in this country we have over 300 million “me’s”. Dr. Robert Bowman, who has previously contributed to this blog, describes for us the potential alternative uses of not only the ongoing cost of screening, but even the cost of the study itself:

· The $250 million for this one study involving CT screening for lung cancer is about what the United States spent for all Agency for Healthcare Research and Quality (AHRQ) health care cost, quality, and outcomes research in 2008. (AHRQ is the main government agency looking at these issues, including “outcomes”, particularly important as I have previously discussed; it is obviously funded at a lot less than the $30 billion for NIH.)

· $250 million is the entire sum that the Health Resources and Services Administration (HRSA, the government agency that funds workforce research, training programs in primary care, dentistry, physicians assistants, pipeline programs, etc.) could scrape together to address emergent needs for primary care workforce this year.

· $250 million, if used to train family doctors at about $30,000 cost per Standard Primary Care provider, would produce 8333 Standard primary care years of workforce in family medicine graduates, or about 333 FM physicians serving their entire careers and improving cost, quality, and access where it is most needed.

And the $12 billion?

· The $12 billion a year spent on CT screening for 30 million current or former smokers could graduate 16,000 family physicians a year.

· $12 billion a year, expended each year for the 30 years required to actually build any workforce (i.e., a generation), if applied to family medicine would supply the entire nation enough primary care for all locations and populations in need of primary care. Sufficient primary care for over 90% of Americans in all needed locations would begin 30 years after reaching 16,000 annual graduates and would be maintained with continued funding of 16,000 annual graduates
. (Indeed, compared to less-efficient spending on training programs, such as internal medicine, that yield far fewer primary care years per dollar spent, this $12 billion is actually is a savings of a few billion dollars!)

Or, if we are concerned about lung cancer, using this for tobacco control campaigns, both the "stop smoking" kind and the legislating non-smoking venues, cities and states.

Dr. Bowman continues:
"The US continues to fail, time after time, in the most basic choices regarding care for Americans most in need of care. The US can focus on the health care needed for nearly all people nearly all of the years of their lives in nearly all locations or the US can continue to spend its $7000 per person ($2.5 trillion) on the health care needs for only some of its people for a only a few years of their lives, with health care delivery services concentrated in only a limited number of locations (4% of the land area).

There is little point to research about rural workforce, health access, or primary care until the nation makes a decision to quit sending health care spending to locations with top concentrations for the care of Americans already with the most care."

Any economist – or wise investor or businessperson – can tell you about “opportunity cost”. This means “if you spend money on one thing, you can’t spend it on something else.” Therefore, the benefit of what you spend money on needs to be looked at not only for its intrinsic value (“will spending $12 billion a year on lung cancer screening with CT save lives?”) or against a very limited range of options (“Is it more cost effective than screening with chest x-rays?”) but weighed against reasonable alternative strategies to improving the health of people – all people.

Dr. Bowman gives strong arguments for the benefit of investing in primary care workforce development, and particularly in family medicine. Maybe there are other strategies for most improving the health of most of our people. But looking at new scientific advances in isolation is clearly a flawed approach.

[1] For a detailed description both of this measure – standard primary care (SPC) years – and the reasons that Family Medicine, as opposed to other physician and non-physician primary care training (internal medicine, pediatrics, physician’s assistants, nurse practitioners) is the most efficient producer of SPC years, see Ten Biggest Myths Regarding Primary Care in the Future, January 15, 2009.

Wednesday, November 17, 2010

Disparities in physician income are related to disparities in health

A major focus of public health, about which I have written several times, is addressing the disparities in health arising from modifiable conditions (such as inequality of opportunity, income, and racial and ethnic differences). While it is common for those with privilege – wealth, health, opportunity – to believe that they have these privileges because they are “deserving”, i.e., because of their hard work, education, etc., such an outlook minimizes the critically important fact that there are lots of people who work just as hard and have very little. The “illegal immigrant”, working 3 minimum (or sub-minimum) wage jobs to try to just keep his or her family fed and housed, is not only not lazy, but working a lot harder than many of us who are able to enjoy weekends off, play golf, watch the kids’ sporting events.

So it is clearly not hard work alone. It is very much influenced by where you start, and what your opportunities have been. These are the social determinants of health (e.g., Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010) and the capability that people have of acting in healthful ways (Capability: understanding why people may not adopt healthful behaviors, September 24, 2010). It is common for people who have a lot to minimize, rather than to emphasize, the degree to which their position at the start of the race has affected their current position. Attacks on those who would seek to redress some of the most egregious inequities are still couched in terms of “economic class warfare” by those who have already won the war. Those with privilege are very concerned about change that would leave them with less of a leg up; they may give lip service to Horatio Alger heroes, but are more likely to wish to follow the model of George W. Bush. “If you’ve spent your entire life with the wind at your back,” a wise sage once noted (and I do not know to whom to attribute it), “a calm day seems unfair”. In terms of health, the connections are very clear. It is good for your health to be born rich. The Horatio Alger hero, pulled up by their own bootstraps, has worse health outcomes than the child born to privilege.

Health disparities, then, are real and important. But why should we – should anyone – be concerned about the disparities in physician income? After all, even the more “poorly” paid specialists, in primary care, make far more than the average American. Yes, they have worked hard to get into and through medical school and residency training, but, just as noted above, so have a lot of other people who will never make nearly as much. The problem is that, if the presence of a larger number/percent of primary care physicians is associated with improvements in the health of the population, and if the presence of wide disparities in income significantly influence students to choose higher paid specialties instead, then these disparities in health status are likely to continue and the overall health of the American people is likely to suffer. There is good data on both counts. Many of the posts in this blog have addressed the first, the positive influence of primary care on the health of the population (e.g., Lower Costs in Grand Junction: More Primary Care, Less High Tech, October 18, 2010; Primary Care, IMGs, and the Health of the People, August 14, 2010; and many others) and on health disparities[1]. I have also addressed the other point, the decrease in the number of students choosing primary care careers (e.g., Primary care specialty choice: student characteristics, July 12, 2010; Primary Care’s Image: A Problem?, November 17, 2009, and others).

A study published in the Archives of Internal Medicine by Leigh, et. al, “Physician wages across specialties”[2], is the most recent effort to quantify the differences. They utilized the large Community Tracking Study (CTS) of physicians from 2004-2005 to gather information on physician income. They grouped the physician responses into 4 broad categories (surgical, internal medicine and pediatric subspecialties [IMPSS], primary care, and other) and again into 41 specific specialties. They went beyond previous studies to calculate gross personal income on an hourly basis (thus controlling for hours worked per week) and did further adjustments to control for other variables, principally sex and age. They used a statistical manipulation to estimate incomes above the maximum set for the CTS (for some reason set at $400,000, much lower than many subspecialists make).

The outcomes were not surprising in comparison to previously reported data. In the 4 broad-group comparisons, primary care physicians averaged about $60/hr compared to IMPSS at $85, other medical at $88, and surgical at $92. In the single specialty comparisons, General Surgery was taken as a reference being actually near the middle ($86/hr), with the top incomes in neurosurgery ($132), radiation oncology ($126), and medical oncology ($114). At the bottom were family practice, general practice, general internal medicine, geriatric medicine, internal medicine/pediatrics, and “other” pediatric subspecialties (whichever those may have been) with a range of $50-$58.

There are several reasons to think that differences are, in fact, greater than those reported. There was only a 53% response rate to the CTS, and so we do not know if non-respondents made more, less or the same as respondents. “Hospital-based” specialties, specifically anesthesiology and radiology, which are among the highest-paid, were excluded. Other high-end specialties, such as cardiovascular surgery or transplant surgery, do not appear as specific specialties, and may have their incomes hidden when grouped with “thoracic surgery” or “other surgical specialties”. There are many sources of income for many physicians, including a variety of expenses that can be paid by practices and which would presumably be greater for higher income practices. Many highly-paid specialties are paid by hospitals directly (such as anesthesiology and radiology) or through “physician service agreements”. The correction used by the authors of the study for incomes over $400,000 could have been inadequate; certainly anecdotal experience in many locations would suggest that considering $400,000 as a reasonable top end for the highest paid physicians would understate that by at least half.
Nonetheless, the income differences, even in 2004-05, were impressive. Given the debt load that medical students (particularly those, obviously, from the less wealthy families) graduate with, the significant attraction to higher pay is clear.

The Wall St Journal, in two recent articles (“Secrets of the system”) published October 26, 2010, looked at the Relative Value Update Committee (RUC), a group of 29 physicians convened by the AMA from different specialty organizations that make recommendations to Medicare on how to pay physicians for their, well, relative value. One, “Physician panel prescribes the fees paid by Medicare” by Anna Wilde Matthews and Tom McGinty, describes how this group meets to divide up a pie that Medicare seeks to keep constant. In the other, “Dividing the Medicare pie pits doctor against doctor”, Matthews discusses the contentiousness that happened when primary care physicians (greatly outnumbered) challenged their surgical colleagues to get a higher portion of the money (that is, to revalue activities done by primary care physicians relative to surgical specialists).

In the same issue of Archives of Internal Medicine that Leigh’s article appeared in, Federman and colleagues[3] surveyed physicians about whether they thought reimbursements were inequitable or not; 78.4% agreed that they are, with not that much difference between generalists and subspecialists. However, when the idea of shifting payments from subspecialists to generalists was raised, there was a marked difference; 66.5% of generalists supported this, while only 16.6% of surgeons did; overall 41.6% were supportive and 46.4% were opposed. That is, for most specialists, paying generalists more is ok, but paying themselves less is not.

The WSJ‘s Matthews quotes an email from Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services (CMS) saying that the Medicare agency is moving to “improve Medicare's physician systems to correct historical biases against primary-care professionals." That needs to happen. The changes need to be dramatic. And they need to happen soon.

[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380
[2] Leigh JP, Tancredi D, Jerant A, Kravitz RL, “Physican wages across specialties: informing the physician reimbursement debate, Arch Int Med 25Oct2010; 170(19):1728-34.
[3] Federman AD, Woodward M, Keyhani S, “Physicians’ opinions about reforming reimbursement: results of a national survey”, Arch Int Med, 25Oct2010;170(19):1735-42.

Thursday, November 11, 2010

Hospital Readmissions: Who pays, who decides, and for whom?

I recently attended a Forum on health reform put on by the Sunflower Foundation of Topeka, Kansas in Lawrence. The keynote speaker, John McDonough, PhD, gave an excellent rundown of the contents of the ACA health reform law. Prior to that a panel of experts from state government, that included Sandy Praeger (a Republican), Kansas Insurance Commissioner and former chair of the National Association of Insurance Commissioners (NAIC). She made it clear that the requirement that large insurers spend 85%, and small ones 80%, of their premiums on actually providing health care (infamously known as the “medical loss ratio” in insurance circles) will be taken seriously, and that insurance commissioners in NAIC, which is the group charged with making the recommendations on this issue to HHS, will not blithely allow insurers to load lots of costs not obviously related to patient care (like marketing and paying the folks that deny your claims) into this bucket. Other participants included Andy Allison, head of the Kansas Health Policy Authority, a governmental agency that, in addition to doing health policy runs the state Medicaid program, and several people from area foundations and consumer advocacy groups. One might have thought, listening to the discussion, questions from the audience (largely health advocates and professionals), and the responses to them, that Kansans are not only thoughtful but caring, worried about the health of their neighbors and fellow citizens, and hoping that health reform will really bring about positive change.

So, all the rest of you non-Kansans, keep this in mind when you see who we elect to statewide office, to our legislature, and to Congress. They don’t represent everyone in this state. Maybe their positions don’t even represent their own beliefs but rather crass political calculations. Or, perhaps, financial calculations; looking at where the big contributions are coming from, and serving the interests of those donors.

As panelists discussed what they saw as important parts of ACA, I was struck by the comment of one person, representing a consumer group, that a big way that ACA would save money would be in Medicare not paying for hospital re-admissions. (Actually, the term, in Section 3025 of the ACA, Public Law 111-148, p. 290, the term is “excessive” readmissions.) The assumption here is that the re-admission was a result of inadequate care on the previous admission, premature discharge (motivated, presumably, by the length of stay guidelines that are widely in use by organizations such as, say, Medicare!), etc. This is an attractive idea; after all, if you bring your car in to be fixed, and it breaks down shortly thereafter, should you pay for the second visit to the mechanic? (She didn’t say that; it is my metaphor.)

But, of course, only if it for the same problem, right? Not if the first hospitalization was for a broken leg, and the second for heart failure. After all, if your car had its brakes fixed and the transmission goes 2 weeks later, it is not the mechanic’s fault. Unless, maybe the second hospitalization was for a complication of the first, like say a blood clot in the lung. Especially if the patient was not given proper clot prophylaxis the first time. But what if they were given that prophylaxis and the clot happened anyway? It is not always so simple.

It is not always so simple even when the re-admission is for the same problem. People with advanced chronic diseases have advanced chronic diseases. They can be treated as outpatients, but will frequently decompensate, and require hospitalization. Remember Red, Blue, and Purple: The Math of Health Care Spending (October 20, 2009)? This is one of the main groups comprising the 5% of people who use 50% of the health care dollars; even when they are brought into the hospital and “tuned up” (yes, this automotive phrase is in fact used), even, or especially, when they have spent time in intensive care, they get sick and require hospitalization again. Their body is dying, but modern medical care can do remarkable things to forestall that death, to patch folks up, to send them back home, or to a nursing home -- for a while, until their body resumes its inevitable decline; the closer a person in this condition is to dying, the more frequent the readmissions. To continue the automotive metaphor, it is one thing to bring in a 3 year old car for new brakes and have them begin to fail 2 weeks later and bring it back; it is quite another when the car is 15 years old, has multi-system failure and won’t run, but the great mechanic can patch it up so you can drive it off – when it fails again in 2 weeks, is this the mechanic’s fault?

It is obviously unreasonable to say that you won’t pay the mechanic the second time, or for Medicare or other health insurance to not pay the hospital and doctors for the work they do on the re-admission. It might be reasonable to decide that the person, like the car, is not salvageable beyond the very short term and should not be readmitted, but this is a decision that can’t be made by the treating doctors and hospital, and it is unreasonable to not pay them when the patient returns because they did such a good job of keeping him/her alive the last time. When are these readmissions “excessive”?

So who should make the decision? Ideally, the patient, in consultation with family members or others s/he trusts, maybe even his/her doctor. This is, after all, the idea behind what we call “Advance Directives” such as Living Wills and Durable Powers of Attorney for Health Care. But not everyone has them, not everyone has even discussed their preferences with their family or their doctor, not to mention put their decisions down on paper so that those responsible for making decisions when s/he cannot have both something to guide them and, indeed, something that requires them to do it. Doctors are not paid to have these extensive discussions with people, although many of them do it anyway; the component of ACA that was going to reimburse for these discussions was struck after being maligned as (wrongly) being “death panels” that would “decide to kill your grandmother”.

But who should decide? If an elderly person is demented, cannot communicate, is in kidney failure and heart failure and has been admitted several times, including to intensive care, and kept alive by medical technology, who should decide if they will be readmitted from the nursing home when they get worse? Often the nursing home just sends them. If there is family, they are the ones who currently make these decisions, provided that they can agree. What if the patient cannot swallow without choking, but the family doesn’t want him/her to “starve” – should this person get a big central IV to give basic nutrition, or have a surgical procedure to feed directly into the stomach? The family does not pay, Medicare does. What would you decide? You would never do this to your parent or want it for yourself? Are you willing to be on the “death panel” that overrules the family? What about the similarly demented and sick person who has been admitted to the intensive care unit 3 times in the last year, amazingly “survived” to discharge, and finally, after several later readmissions, finally does die. And the daughter wants to sue because “somebody” must have done “something” wrong? Should we not pay the hospital? Should we tell the ambulance not to pick her up? Will you be the one to tell the daughter that the fact that she has obviously unresolved issues, and that she should have accepted during the first 6-week ICU stay that her mother was going to die soon?

I hope you will be. I hope you will be out there, helping support the healthcare professionals to make the right decisions, not because Medicare is paying but because they are right. And help us to figure out what the right decisions are. While all of us feel differently about those close to us than about strangers, "save money on them, spend it on me!" is not a reasonable, or moral, strategy.

Friday, November 5, 2010

Training rural family doctors

In a recent report from the University of Washington’s WWAMI Rural Research Center, “Family Medicine Residency Training in Rural Locations”,[1] Chen et. al. repeat their 2000 study of rural training in the US. They note that this is very important given the health needs of the American people, 20% of whom live in rural areas, most of which are underserved given the less than 9% of doctors who practice there (Primary Care and Rural Areas, April 28, 2010; Medicare Costs in Rural America: A case of reaping what we haven't sown?, March 26, 2009). Most rural training is of family doctors, but a majority of it comes from urban programs.

How is this so? This is because over 90% of the family medicine residency programs in the nation are located in urban areas, and only 7% in “large rural areas”; it is very hard to have a program entirely in a “small rural area” as the requirements for family medicine training include a great deal of time spent in the hospital and working with other specialists. Nonetheless, the authors surveys discovered that nearly half of the family medicine programs felt that training rural doctors was an important part of their mission.

From the Executive Summary: “Rural residency programs provided a higher proportion of rural training than urban programs, but because more programs were in urban settings, there was more rural training in urban than rural programs. Overall, 15% of respondents had a formal RTT [rural training track]; of these, 61% were in rural and 10% in urban programs. Rural residency programs conducted 83% of all rural residency training in RUCA[2]-defined rural areas. Comparing the 2000 and 2007 surveys, rural training increased from 372 to 408 FTEs, but rural training in urban programs declined from 186 to 79 FTEs, resulting in an overall decrease in the amount of rural-focused family medicine training.” See figure for example of a “RUCA map” in a state (Kansas) with a high percentage of “isolated rural” areas; Other states (say, New Jersey) look different!

The authors found that while virtually all (99.9%) of the training FTEs reported as rural in rural programs in fact occurred in rural (RUCA-defined) areas, only 21.7% of those reported by urban programs were in such areas. The net result was that only 7.3% of family medicine residency training FTEs are in rural areas, with 83% of these conducted by rural programs. Interestingly, to me, a higher percentage of urban programs listed rural training as “very important” (45.3%) than listed urban (underserved) training (40.4%).

The authors discuss the policy implications of this situation, including the possible impact of several components of the ACA health reform law that encourage training in rural areas. An important one has to do with Medicare funding of GME (residency) positions, the arcane but major source of funding for such training (Funding Graduate Medical Education, May 25, 2009; Public Law 111-148, Sect 5506, p 661). The change would make it easier for non-hospital sponsors of training (such as community health centers, an area the authors have also written about[3]) to receive this funding (Public Law 111-148, Sect 5508, p.668). The law – and policy – also favors redistribution of unfilled GME spots to rural hospitals. However, there are counterpressures: many big urban hospital training sites are “over their cap”, meaning they have more residency positions than are funded by Medicare. In these cases, the hospital, or another entity, funds the positions; these are virtually always in those specialties that make more money for the hospital, not in primary care, and certainly not in rural tracks (Primary Care and Residency Expansion, January 7, 2010 ). As they expand, in response to the demand for more physicians and medical school class increases, they will exert great political pressure to have new GME slots assigned to them to help cover their costs.

So here is the situation:
· There is a tremendous shortage of doctors in rural areas.

· Rural family medicine training programs, particularly those located in rural areas, are very effective in producing physicians who will practice in those rural underserved areas.

· Only 7.3% of family medicine (FM) residency positions are in such rural programs. This is way better than any other specialty, and may in fact be higher because while the authors did not count many of the trainees claimed as rural by urban FM residencies because they are not actually occurring in RUCA-defined rural areas, “Training locations may be defined as 'urban' using RUCA definitions but may still be sparsely populated and serve a predominantly rural patient populations.”

· Even if all FM positions claimed by their sponors as rural are in fact so, FM residents are only about 10% of all residency positions (2,630 of 25,500 in 2010), and virtually no other residents are trained for, not to mention likely to enter, rural practice…despite the need for other specialists, especially general surgeons, in these communities.

· ACA has a number of components that target an increase in the production of rural physicians (particularly family doctors and general surgeons, Public Law 111-148, Sect 5501, p. 534), but even if these are fully implemented, and taken advantage of by students, it will be many years before they have a significant impact.

· Despite these ACA changes, there will be counterpressures to use many of the new training slots for training non-primary care residents in urban sites, and particularly in academic health centers; these will come from both the academic health centers and their teaching hospitals themselves, the subspecialty physician medical societies, and the medical students themselves who overwhelmingly prefer to live in urban areas, as well as to earn the much higher incomes of subspecialists.

How might this be changed or modified? The provisions in the ACA law funding of GME slots to non-hospital settings such as community health centers, preferentially training primary care doctors (and general surgeons), and supporting the growth of community health centers and health extension services are a start, but they are not sufficient. The key is going to be greater incomes for doctors practicing primary care and general surgery in rural areas compared to those practicing subspecialties in urban areas. Supply and demand is insufficient; while there is demand for such doctors in rural areas, there is demand for more subspecialists by urban hospitals that see them as cash cows. Medicare sets reimbursement rates, as almost all payers model their rates as percents (usually higher) of Medicare’s. The reimbursement has to change so dramatically as to make primary care doctors in rural areas make, if not more, at least not nearly so much less as subspecialists in cities.

This financial change will begin to level the playing field. Medical students who have no interest in rural practice can still stay in urban areas, and even in subspecialties, but they should have to pay a financial price, making less than they would if they were to practice in what (to them) might be considered a less desirable area. As long as we make some careers pay a lot more, often for no more or even less work, as well as be located more popular (urban metropolitan) areas, we cannot expect any different outcome from the one we currently have.

[1] Chen FM, Andrilla CHA, Doescher MP, Morris C, “Family Medicine Residency Training in Rural Locations”, Final Report #126, WWWAMI Rural Health Research Center, University of Washington School of Medicine Department of Family Medicine, July 2010.
[2] RUCA = Rural-Urban Commuting Areas; a measure of population density that accounts for nearness to an urban area; obviously two counties may have similarly low population densities, but if one is surrounded by similar counties while the other is adjacent to a county with a large – or moderate – urban area, the first is “more” rural.
[3] Morris CG, Chen FM, Training Residents in Community Health Centers: Facilitators and Barriers, Annals of Family Medicine, Nov2009;7(6):488-94

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