Focus on Finances Not International Graduates

A commenting family physician indicates the need for some restraint for FM leaders jumping to the defense of international graduates via the immigration limitations. Restraint is indeed a good idea. AAFP should not play the shortage card lightly, since no other specialty has the 2 to 4 times multiplier of distribution where needed. 

Basic Health Access Passes 100,000 Mark - Thanks!

If access was indeed a top priority, where was AMA, AAMC, and AAFP when the Fifth Pathway was terminated - one of the major sources of Spanish speaking US physicians and a major source of access? As usual, organized medicine focuses on its own interests and finds a way to capture headlines - without really supporting the changes that would resolve access woes.
What Actually Fails Access to Care is Not Insurance or Training

1. The financial design of primary care (revenue minus cost of delivery) is what fails overall US primary care in the nation and what fails having enough team members distributed according to the population.
2. International graduates are most likely not to be in the US and have low retention in active primary care. Their low choice of family medicine limits retention in primary care and distribution over a career. 
3. Training cannot overcome financial failure as workforce follows positions and dollars.

The literature, as usual, fails in the long term studies 
which results in too rosy a picture for various 
drug interventions, digital interventions, and training interventions.

Medical School Grads 1987 to 1998 as found in the AMA Masterfile 2013 in practice zip codes with over 75 physicians (Super Centers and Major Centers)

77.3% Allopathic Private Most exclusive origins, training, specialties, locations
77.0% Other Distant International
75.4% MS in India
71.7% National Average
70.3% Allopathic Public
68.2% Central American
61.4% Caribbean
57.9% Osteopathic Private
54.1% Osteopathic Public Least exclusive origins, highest choice of FM, and best distribution
50.1% Canadian Over 30% found in Canada

Most concentrated results in the least distribution and is a result of exclusive origins, scores, selections, training choices, careers, and top concentrations of health care dollars.

Standard Primary Care Years (Active in US, Office Primary Care, Career Years)
13.49 Osteopathic Lower MCAT Higher proportions active in US, FM dominant
12.48 Osteopathic Higher MCAT
12.04 Caribbean US and international origin medical school graduates
11.80 Historically Black
11.53 Allo MCAT 8.5 - 9.25 Lower MCAT results in higher primary care contributions
11.50 West Distribution U of Washington and U of California Schools were doing better at the time
11.38 The Philippines
10.61 Nigeria
10.39 Allo MCAT 9.25 - 9.5
9.97 Early Admission Schools
9.88 Allo MCAT 9.5 - 10
9.60 Allo MCAT 10 - 10.5
9.54 Central America Lower due to loss of 5th pathway, major source of Spanish speaking docs
8.88 Pakistan
8.73 National Average 1987 - 1998 Grads All Sources
8.05 Allo MCAT 10.5 - 12 Exclusive origins, scores, schools result in most exclusive careers/locations
7.36 Puerto Rico
7.22 India Origins most concentrated, US training in most concentrated settings, few in FM
5.68 Other Distant
5.37 Canadian
4.04 China Lowest proportion active in US and in office primary care

A greater range of tracking of graduates reveals limited contributions of international graduates due to losses out of the US after training, exclusive origins among concentrations, exclusive locations for US training, low choice of family medicine, and poor retention in primary care for those taking primary care training due to predominant IM choice.

Full tracking over an entire career would likely reveal even lower contributions.

Studies that capture only the few years of graduation often capture international graduates at temporary locations and in temporary careers before departures from the US, from primary care, and from places where most needed.

AAFP should not emphasize any training intervention as a solution, even Teaching CHCs. This is because the reason why people fail to have access to care in the United States is about the financial design - a design that has absolutely prevented enough team members in enough places across primary care, mental health, and basic services. Even Teaching CHCs with 100% FM output just help rearrange the deck chairs as one source displaces others (also Teaching CHCs are not specific to FM, to training location where physicians are needed, or to states where physicians are most needed). More absolute dollars specific to more team members in more places is the only shortage solution.

The failure of access by financial design has long been demonstrated. An increase to six sources of primary care with massive expansions of NP and PA since 1980 has only resulted in steadily lower proportions found in primary care - especially in family practice positions. Soon NP plus PA graduates will exceed physician graduates and this will still not resolve primary care, access, or distribution woes. The massive NP and PA expansions have only replaced collapsing internal medicine primary care contributions - the dominant choice claiming half of international graduate choices.

About 160 billion in annual health spending or 6% of health spending for 55% of encounters is too little to address primary care. The primary care payments are concentrated where workforce is already concentrated - preventing distribution. The payments are lowest for the generalist and general specialty services that are 90% of the services where workforce is needed. The payments for the same services are less where lower concentrations of physicians are found. The innovative payment designs have not increased payments and have increased costs of delivery, and pay less where care is most needed by Pay for Performance scheme.

AAFP must constantly demand the major revisions that will absolutely result in more team members supported in more places with low to no access. It should not allow a distraction from this top priority important to most Americans and most family physicians - and to the health access value for the nation most important for past, present, and future FM graduates.
The immigration order is a poor choice by national leaders, but claiming any MD DO NP PA training as a solution is a distraction from a real solution. 

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