The GME Lie Distracts from Payment Reform
Once again the designers are promising a solution for shortages of physicians that cannot work. The expansion of graduate medical education will not send more physicians to counties short of physicians. Expansions of MD DO NP and PA have all resulted in steadily higher concentrations in fewer counties that already have higher concentrations. The evidence is already in the databases. Until the financial design is fixed with more dollars for basic services, there will be no solution for care where needed.
MD DO NP and PA are finding more ways not to go into primary care and this pathway is all about dollar distributions, or lack thereof.
Under the current financial design there is no way that any GME, MD, DO, NP, or PA expansion can actually address shortages. GME is 94% in the wrong counties with only 6% found in counties lowest in physicians, health spending, economics, and health outcomes. Residents are 154 per 100,000 in 79 top physician concentration counties. The 2621 lowest physician concentration only have 115 active physicians per 100,000 and this may be shrinking further. Residents are concentrated at a ratio of 24 to 1 or 154 per 100,000 in top concentration counties to 6.4 in lowest physician concentration counties.
Residents tend to locate in the same state and same county or nearby county after graduation - another factor in poor distribution. The US has 6 - 7 top concentration states and 30 left behind. The same is seen in counties with 79 top physician concentration counties and 2621 lowest physician concentration counties - essentially the Red Counties and about 50 rural counties with majority African American, Hispanic, or Native American populations.
Workforce goes where the dollars go and the dollars dictate higher and lower concentrations of physicians. Family practice positions filled by MD DO NP and PA are the only population based distribution with about 36% found in lowest concentration counties with 40% of the population. All other specialties concentrate as physician concentrations increase as seen below. The Ratio is a measure of concentration. It takes multiple times more graduates to result in a lowest concentration physician. The higher the ratio, the more it takes.
More correctly, the limitations in dollars going to these counties limit the workforce as seen in the 2010 data on NP and PA and the 2013 AMA Masterfile.
Other specialties have worse distribution
Nurse practitioners and physician assistants are also not the solutions as claimed. If anything, they are more flexible with substantial movement following the payment dollars to more support, less complexity, and higher salaries. More specialties are added with more added to each new specialty - leaving primary care and family practice positions behind. Turnover is higher in NP and PA, previously twice as high as for physician primary care. Moving from lower support to higher support is a move away from morale issues, burnout, higher turnover, and more to do with less to do it - such is the power of the financial design. More to do in areas such as primary care includes the rapid changes of innovation, regulation, and certification. It is hard to design as many obstacles to care as team members in primary care where needed have faced - with more to come.
Note how geriatrics is not a solution. Too few enter and too few distribute. This is also the result of a crippled financial design with payment too little and complexity too high. In kind donations are needed to support geriatrics usually by academic institutions, largest systems, or nursing homes. The result is a 7.46 ratio for extremely poor distribution.
The elderly and their cardiac, lung, cancer, and diabetic conditions are concentrated with 45% found in lowest concentration counties. High ratios are seen in these specialties. Endocrinologists are 10 to 1 against lowest concentration counties where 50% of diabetics are found and only 12% of endocrinologists. Smokers, obese Americans, and those with mental illness are concentrated in lowest concentration settings along with preventable deaths.
The Newer Graduates Have Worse Distribution
The oldest physicians are seen in lowest concentration settings. This is an indicator of lack of replacement by newer physicians. It is also a predictor of worse to come. Hospitalists and emergency physicians have registered increases in lowest concentration counties - but have greater growth in higher concentration settings. Even worse, these tend to be family physicians who were often previously in primary care. Indeed, the family medicine contribution has decrease from 90% office family practice to less than 70%. The levels are even lower in newer graduates. Soon, entire graduating classes at FM residency programs will be avoiding office family medicine as has been the case for internal medicine and pediatrics for some time.
No Expansion of MD DO NP and PA Can Work for Distribution
No expansion of primary care or surgical residency positions can result in more serving in primary care or general surgical specialties as too many move on to additional fellowships or other careers. Internal medicine is over 85% not primary care. Pediatrics is one-third primary care. New FM graduates may be 60% primary care and could break the 50% level without payment change. PA is down to less than 20% and NP will soon be there too. There simply is not enough payment to provide the care and the team members and the support for such complexity. General surgery, general ob-gyn, general orthopedics and other general surgical careers are not chosen by graduates who have must better support, less complexity, more team members, and locations similar to their exclusive origins by taking one or more fellowships.
Even targeted MD DO NP and PA interventions for rural or underserved or Teaching Community Health Centers cannot work. These graduates may fill needed positions at higher levels. Good for them and for their program. But this only displaces other graduates from such positions. Such is the dominating power of the financial design. Only so many dollars go to these positions in places of need. Lowest concentration counties do not need a rearrangement of the deck chairs and more games playing by academics - they need real solutions.
But designers are not looking to add dollars in any place or service. It has been cost cutting as the dominant policy since the 1980s. Even worse, the basic services and the practices least organized and most distant and smallest have been ignored.
It's the Economy Stupid - The Economics Fail to Measure Up
It is the financial design that is broken with too few dollars designed to go to the places shortest in MD DO NP PA and RN. It takes more dollars going to 2621 lowest concentration counties to actually begin to redistribute workforce, services, and dollars. These are counties with services that are 90% lowest paid generalist and general specialty services. Only increases in office, cognitive, mental health, basic, primary care services can redistribute funding.
Real Solutions
Hospitals are important for the support of physicians. Without a hospital the emergency room and hospitalist positions go away - the only growth seen in recent years. The general surgical specialties also tend to go away. This leaves primary care behind and tends to erode the internal medicine leaving family medicine behind. The financial design has most eroded family practice MD DO NP and PA - most important for counties without a hospital.
In the next decade, more counties will be added to the lowest concentration counties. At closures of 15 hospitals per year in these counties, the number could easily reach 2800. They are already paid less. About 40% of rural hospitals have negative margin. Readmissions penalties hit them harder - 2 to 3 times harder. But there is worse to come.
CMS just announced that it will be taking away the disproportionate share funding beginning as early as October. They have already announced cuts in support for high cost medications. The combination of ACA and the current administration plus potential cuts by Congress will worsen matters.
Health access practice is about the population. What happens to the population shapes access and also health outcomes. Losses of SNAP, housing, utility support, and disability funding will hit lowest concentration counties hardest. This will add to the costs and complexities of delivering care where needed.
Payments Are Broken and Are Being Made Worse
A return to evidence basis is indicated, as in the end of pay for performance schemes that are known by major reviews of the evidence basis not to result in improvements in health outcomes. From P4P to Readmissions Penalties to Value Based, these have been costly and discriminatory - especially for the providers that take on the challenge of serving where most needed where patients inherently have lesser outcomes before and after care, regardless of care.
And even worse, the payment designs all lead to fewer dollars going to these counties - resulting in worse outcomes. Health information technology promotions are rampant these days, but these are cash transfers from lowest to highest concentrations - the formula for greater disparities and worse outcomes in lowest concentrations.
The GME Recommendations Are Self-serving
GME expansions cannot solve the physician shortage. It cannot get physicians to places where physician positions are not supported by the financial design.
GME expansion promotions also have a distorted literature base - as seen in international medical graduates promoted as a solution. This was exposed in the recent rural location and retention study from the Graham Center. Not surprisingly there was no headline or promotion of this fact. My studies using the cross section Masterfile have long indicated poor contributions from IMGs. The international graduates overall have some of the worst distribution - right there with Harvard, Yale, and other most exclusive US MD school graduates. Only a few states benefit. Only graduates from a few nations contribute above average. About 20 - 30% leave the nation after training. This is but one major flaw in these studies. Only studies of the first few years demonstrate distribution - which is actually limited as well.
Cherry picking results is promotion, not the truth.
The Logic Is Undeniable
If GME leaders truly think that expansions are the solution, then we must graduate 3 to 7 times more to solve shortages. Obviously graduating many more is destructive to those who find themselves deep in debt and at the mercy of employers during a time of a glut of MD DO NP and PA. This time may not be too far away.
MD DO NP and PA are finding more ways not to go into primary care and this pathway is all about dollar distributions, or lack thereof.
Under the current financial design there is no way that any GME, MD, DO, NP, or PA expansion can actually address shortages. GME is 94% in the wrong counties with only 6% found in counties lowest in physicians, health spending, economics, and health outcomes. Residents are 154 per 100,000 in 79 top physician concentration counties. The 2621 lowest physician concentration only have 115 active physicians per 100,000 and this may be shrinking further. Residents are concentrated at a ratio of 24 to 1 or 154 per 100,000 in top concentration counties to 6.4 in lowest physician concentration counties.
Residents tend to locate in the same state and same county or nearby county after graduation - another factor in poor distribution. The US has 6 - 7 top concentration states and 30 left behind. The same is seen in counties with 79 top physician concentration counties and 2621 lowest physician concentration counties - essentially the Red Counties and about 50 rural counties with majority African American, Hispanic, or Native American populations.
Workforce goes where the dollars go and the dollars dictate higher and lower concentrations of physicians. Family practice positions filled by MD DO NP and PA are the only population based distribution with about 36% found in lowest concentration counties with 40% of the population. All other specialties concentrate as physician concentrations increase as seen below. The Ratio is a measure of concentration. It takes multiple times more graduates to result in a lowest concentration physician. The higher the ratio, the more it takes.
More correctly, the limitations in dollars going to these counties limit the workforce as seen in the 2010 data on NP and PA and the 2013 AMA Masterfile.
| Active Physicians Per 100,000 in 2013 | Counties By Physician Concentrations | ||||
| Top Concentration to Lowest | Ratio Top to Lowest | Top | Higher | Middle | Lowest |
| % of US Population | 10% | 20% | 30% | 40% | |
| Counties in Category | 79 | 152 | 286 | 2621 | |
| Primary Care Best to Worst Distribution | Ratio of Top to Lowest | 32 million people | 64 million people | 96 million people | 128 million people |
| Family Medicine | 1.18 | 30.77 | 33.08 | 29.19 | 26.03 |
| NP/PA Fam Practice Position | 1.18 | Estimated | |||
| FM then Geriatrics | 2.57 | 0.36 | 0.31 | 0.23 | 0.14 |
| General Ob-Gyn | 3.42 | 20.48 | 15.21 | 10.99 | 5.99 |
| Medicine Pediatrics | 3.44 | 2.58 | 1.75 | 1.01 | 0.75 |
| General Pediatrics | 4.13 | 32.55 | 22.16 | 15.79 | 7.88 |
| All Active Physicians | 4.14 | 468.12 | 304.77 | 222.06 | 113.05 |
| Internal Medicine | 4.31 | 64.79 | 42.72 | 30.85 | 15.03 |
| Internal Med Geriatrics | 7.46 | 2.81 | 1.63 | 0.98 | 0.38 |
| Physician Assist NPI 2010 | 2.71 | 43.73 | 28.94 | 25.05 | 16.13 |
| Advanced RN NPI 2010 | 3.21 | 104.06 | 66.55 | 45.98 | 32.41 |
| Other Specialties | |||||
| General Surgery | 2.75 | 11.69 | 7.82 | 6.12 | 4.25 |
| Gen Orthopedics | 2.86 | 9.08 | 7.19 | 5.57 | 3.17 |
| Physician Assist Not FP | 3.70 | Estimated | |||
| General Urology | 4.08 | 5.41 | 3.63 | 2.67 | 1.33 |
| Otorhinolaryngology | 4.20 | 5.42 | 3.42 | 2.57 | 1.29 |
| Intervent Cardiology | 4.45 | 1.39 | 0.99 | 0.70 | 0.31 |
| Ortho Sports Med | 4.58 | 1.10 | 0.71 | 0.55 | 0.24 |
| Advanced RN not FP | 4.60 | Estimated | |||
| Ophthalmology | 4.93 | 11.20 | 6.98 | 5.03 | 2.27 |
| Anesthesiology | 4.94 | 24.03 | 16.54 | 12.57 | 4.87 |
| General Radiology | 5.26 | 16.64 | 10.65 | 7.29 | 3.16 |
| Gastroenterology | 5.40 | 8.71 | 5.31 | 3.88 | 1.61 |
| Gen Cardiology | 5.53 | 14.12 | 8.65 | 6.02 | 2.55 |
| Radiation Oncology | 5.58 | 3.01 | 1.80 | 1.29 | 0.54 |
| General Pathology | 5.69 | 7.07 | 4.04 | 2.93 | 1.24 |
| Physical Medicine | 5.89 | 5.44 | 3.74 | 2.61 | 0.92 |
| Nephrology | 5.90 | 5.97 | 3.58 | 2.57 | 1.01 |
Nurse practitioners and physician assistants are also not the solutions as claimed. If anything, they are more flexible with substantial movement following the payment dollars to more support, less complexity, and higher salaries. More specialties are added with more added to each new specialty - leaving primary care and family practice positions behind. Turnover is higher in NP and PA, previously twice as high as for physician primary care. Moving from lower support to higher support is a move away from morale issues, burnout, higher turnover, and more to do with less to do it - such is the power of the financial design. More to do in areas such as primary care includes the rapid changes of innovation, regulation, and certification. It is hard to design as many obstacles to care as team members in primary care where needed have faced - with more to come.
Note how geriatrics is not a solution. Too few enter and too few distribute. This is also the result of a crippled financial design with payment too little and complexity too high. In kind donations are needed to support geriatrics usually by academic institutions, largest systems, or nursing homes. The result is a 7.46 ratio for extremely poor distribution.
The elderly and their cardiac, lung, cancer, and diabetic conditions are concentrated with 45% found in lowest concentration counties. High ratios are seen in these specialties. Endocrinologists are 10 to 1 against lowest concentration counties where 50% of diabetics are found and only 12% of endocrinologists. Smokers, obese Americans, and those with mental illness are concentrated in lowest concentration settings along with preventable deaths.
The Newer Graduates Have Worse Distribution
The oldest physicians are seen in lowest concentration settings. This is an indicator of lack of replacement by newer physicians. It is also a predictor of worse to come. Hospitalists and emergency physicians have registered increases in lowest concentration counties - but have greater growth in higher concentration settings. Even worse, these tend to be family physicians who were often previously in primary care. Indeed, the family medicine contribution has decrease from 90% office family practice to less than 70%. The levels are even lower in newer graduates. Soon, entire graduating classes at FM residency programs will be avoiding office family medicine as has been the case for internal medicine and pediatrics for some time.
No Expansion of MD DO NP and PA Can Work for Distribution
No expansion of primary care or surgical residency positions can result in more serving in primary care or general surgical specialties as too many move on to additional fellowships or other careers. Internal medicine is over 85% not primary care. Pediatrics is one-third primary care. New FM graduates may be 60% primary care and could break the 50% level without payment change. PA is down to less than 20% and NP will soon be there too. There simply is not enough payment to provide the care and the team members and the support for such complexity. General surgery, general ob-gyn, general orthopedics and other general surgical careers are not chosen by graduates who have must better support, less complexity, more team members, and locations similar to their exclusive origins by taking one or more fellowships.
Even targeted MD DO NP and PA interventions for rural or underserved or Teaching Community Health Centers cannot work. These graduates may fill needed positions at higher levels. Good for them and for their program. But this only displaces other graduates from such positions. Such is the dominating power of the financial design. Only so many dollars go to these positions in places of need. Lowest concentration counties do not need a rearrangement of the deck chairs and more games playing by academics - they need real solutions.
Too few dollars equals too few positions.
But designers are not looking to add dollars in any place or service. It has been cost cutting as the dominant policy since the 1980s. Even worse, the basic services and the practices least organized and most distant and smallest have been ignored.
It's the Economy Stupid - The Economics Fail to Measure Up
It is the financial design that is broken with too few dollars designed to go to the places shortest in MD DO NP PA and RN. It takes more dollars going to 2621 lowest concentration counties to actually begin to redistribute workforce, services, and dollars. These are counties with services that are 90% lowest paid generalist and general specialty services. Only increases in office, cognitive, mental health, basic, primary care services can redistribute funding.
Real Solutions
- A 15 - 20% boost to the same payments as higher concentration settings. These are practices paid 20% less for the same service delivered. Primary care should be separately and equitably paid - not more marginalized where care is already most marginalized.
- After equity, a 20% boost in payments for basic services represents a 40% boost for care where most needed - this would need to be maintained from 2018 to 2040 with adjustments due to any additional cost of delivery increases (regulation, innovation, certification) to hope to provide care for 45% of the population in these counties in 2040. We are already 10 years behind in a process that takes 20 years.
- Primary care is only about 6% of spending for 55% of services - a small boost in dollars represents a large gain in terms of primary care team function. Michigan did not get a boost from Primary Care Medical Home. Blue Cross invested in primary care with more dollars to get the boost. It takes more dollars for more and better team functions including higher primary care functions.
- Reduction in cost of delivery - HITECH to ACA to MACRA has added more than $100,000 cost of delivery per physician. This is at least a 16% cut in revenue for another 20% lost considering productivity and other consequences.
- Turnover is up to $300,000 per lost primary care physician and may be higher in these lowest concentration counties with more consequences and higher turnover. This is at least $100,000 a year that has to be paid by the practice, a local facility if it exists, or the community. None of these has the dollars to spare where dollars are least concentrated.
Hospitals are important for the support of physicians. Without a hospital the emergency room and hospitalist positions go away - the only growth seen in recent years. The general surgical specialties also tend to go away. This leaves primary care behind and tends to erode the internal medicine leaving family medicine behind. The financial design has most eroded family practice MD DO NP and PA - most important for counties without a hospital.
In the next decade, more counties will be added to the lowest concentration counties. At closures of 15 hospitals per year in these counties, the number could easily reach 2800. They are already paid less. About 40% of rural hospitals have negative margin. Readmissions penalties hit them harder - 2 to 3 times harder. But there is worse to come.
CMS just announced that it will be taking away the disproportionate share funding beginning as early as October. They have already announced cuts in support for high cost medications. The combination of ACA and the current administration plus potential cuts by Congress will worsen matters.
Health access practice is about the population. What happens to the population shapes access and also health outcomes. Losses of SNAP, housing, utility support, and disability funding will hit lowest concentration counties hardest. This will add to the costs and complexities of delivering care where needed.
- Lily Tomlin — 'Lady, I do not make up things. That is lies. Lies are not true. But the truth could be made up if yo know how. And that's the truth.'
Payments Are Broken and Are Being Made Worse
A return to evidence basis is indicated, as in the end of pay for performance schemes that are known by major reviews of the evidence basis not to result in improvements in health outcomes. From P4P to Readmissions Penalties to Value Based, these have been costly and discriminatory - especially for the providers that take on the challenge of serving where most needed where patients inherently have lesser outcomes before and after care, regardless of care.
And even worse, the payment designs all lead to fewer dollars going to these counties - resulting in worse outcomes. Health information technology promotions are rampant these days, but these are cash transfers from lowest to highest concentrations - the formula for greater disparities and worse outcomes in lowest concentrations.
The GME Recommendations Are Self-serving
GME expansions cannot solve the physician shortage. It cannot get physicians to places where physician positions are not supported by the financial design.
GME expansion promotions also have a distorted literature base - as seen in international medical graduates promoted as a solution. This was exposed in the recent rural location and retention study from the Graham Center. Not surprisingly there was no headline or promotion of this fact. My studies using the cross section Masterfile have long indicated poor contributions from IMGs. The international graduates overall have some of the worst distribution - right there with Harvard, Yale, and other most exclusive US MD school graduates. Only a few states benefit. Only graduates from a few nations contribute above average. About 20 - 30% leave the nation after training. This is but one major flaw in these studies. Only studies of the first few years demonstrate distribution - which is actually limited as well.
Cherry picking results is promotion, not the truth.
The Logic Is Undeniable
If GME leaders truly think that expansions are the solution, then we must graduate 3 to 7 times more to solve shortages. Obviously graduating many more is destructive to those who find themselves deep in debt and at the mercy of employers during a time of a glut of MD DO NP and PA. This time may not be too far away.
No MD DO NP or PA Expansions can fix shortages that are actually about the financial design. Too few dollars to too few places supporting too few positions is the real problem. Reversing the financial design is the only true solution.
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