About GME - Insider Trading Is More than Just Wall Street

Insiders dominate the designs of health spending and the designs of health professional training. Not surprisingly these insiders shape workforce, services, and spending to just a few states and a few locations.

Resident training is even more stacked against care where needed. The determination of practice location is about origin influences, training influences, and specialty choice. Origins, training, and specialty influences are moving away from states in need, away from primary care, and away from care where needed locally.

Top Concentration States - Physician and GME - About 6 states receive 50% of the economic impact of US medical education which is 500 billion a year according to AAMC. Actually insider stacking is even more prevalent as only a few dozen counties receive this impact. Origin and training location facilitate concentrations of clinicians in a few states and in a few locations.

Top Concentration Zip Codes or Super Centers - About 55 - 60% of residents are trained in Super Center zip codes with 200 or more physicians or 1100 zip codes in 1% of the land area with only about 12% of pop, 45% of the physicians, and well over 50% of health spending - This may be the only practice location shaping experience of allopathic private graduates, graduates of exclusive/research/MCAT schools, and international graduates - which is why these cohorts have lowest distribution       Physician Distribution By Concentration

Major Centers are the sites of training for about 25% - 30% of residents. They are trained in zip codes with 75 - 199 physicians (Major Centers) in about 2.5% of the land area - this is a midrange between Super Centers and Outside

Together about 72% of physicians are found in about 3.5% of the land area in 3400 zip codes inside of super center and major center concentrations - leaving only about one-quarter of physicians remaining for care outside of concentrations. The highest concentrations of 82% of graduates inside of concentrations are seen in allo private, most exclusive US school grads, and international graduate cohorts. The best distribution at 50% inside and outside is seen in medical schools with 20 - 35% FM choice. This is also the result of family medicine choice as well as origins and training more normal with regard to state and location.

Experiential Place or Past Life Influences Help Explain Concentration and Distribution

Exclusive in origin and training and specialty results in concentration with poor distribution. More normal distributes.

Normal Origin and Training Facilitates More Normal in Distribution

Sadly less than 15% of residents are trained in 40,000 zip codes outside of concentrations of physicians. Outside zip codes have 68% of the population including higher proportions of the elderly as well as all who are increasing in population and in care demand. With declines in physician concentrations the health spending goes down, the complexity goes up, and the non-family practice workforce melts away.

The Family Medicine Multiplier

Family medicine is a three times multiplier of "outside" zip code practice location controlling for origin and training influences. FM multiplies needed result across medical schools and across types of locations outside of concentrations of physicians. All other specialties result in further concentration where physicians are already concentrated.

Generic expansions of graduates without FM predominating are only going to facilitate more concentration - especially with 11% annual increases in subsubspecialty fellowships and 4% annual increases in subspecialty fellowships (Jolly, Acad Med, 2001 - 2011) 

Expansions outside of FM allow more opportunities to escape FM or primary care. This is the opposite of the 1990s when massive declines in choice of hospital based residencies took FM over 3600 annual grads for a brief time. Specific is indicated - not generic.


Until there is an end to aberrant payment design and...
Until there is an end to all out assault upon core specialty result from training, there will not be care where most Americans need care. 

Insiders Dominate Inside with Highest Specialization, Academization, Centralization, and Concentration. 

More normal core specialties dominate care outside of concentrations - FM, primary care IM, primary care PD, general surgical specialties. All are stagnant or in decline by designs for training and payment. 

Designs for inside, shaped by insiders, fail for most Americans, fail for primary care where needed, and fail for most family physicians who are outside.

Nurse practitioners and physician assistants are also concentrated in the same zip codes and counties as physicians and physician specialists. Only the family practice result from NP or PA distributes above NP or PA averages - or reaches the 2 to 3 times multiplier of FM. This FP result continues to decline with each passing class year and year after graduation for NP and PA down to 25% and below.

Once you know how payment design fails for primary care and for distribution for all types of clinicians, you can understand how generic expansions continue to facilitate even more non-primary care and even greater concentrations of clinicians.

Insider trading and focus is found beyond Wall Street.

As Commonwealth recently speculated, the designs for health care may indeed shape America in ways not best for most Americans.

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

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