Retention of Rural Family Physicians After 20–25 Years: Outcomes of a Comprehensive Medical School Rural Program

By Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W. Markham, MD and Abbie J. Santana, MSPH
Journal of the American Board of Family Medicine, January-February 2013 vol. 26 no. 124-27
“The shortage of primary care physicians in rural areas, especially family physicians, has been a serious problem for decades, with major implications in access to health care for a substantial proportion of the US population….Retention is a key component of the rural physician supply, in part because it has a multifold impact on the rural workforce; for example, one physician practicing in the same rural area during a 35-year career has a similar impact as 5 physicians who practice for an average duration of 7 years…”.
The authors describe the impact of the Physician Shortage Area Program (PSAP), a special program at the Jefferson Medical College of Pennsylvania that “…recruits and selects medical school applicants that have grown up or lived in a rural area or small town for a substantial portion of their life after college and who were committed to practicing family medicine in a similar area” and provides them with other experiences during medical school. “Of the 37 PSAP graduates [from 1978-86] who originally entered rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 (including 5 in adjacent counties). Comparable data for non-PSAP graduates showed that 24 of 52 (46.2%; P = .02) were in the same rural area (including 5 in adjacent counties).”
These are really good results, demonstrating that the PSAP at Jefferson is effective in training students who not only enter rural practice but remain in it over time. And, they indicate, “PSAP outcomes are similar to those of the 5 other RPs with published outcomes.”
http://www.jabfm.org/content/26/1/24.full
And…

The Redistribution Of Graduate Medical Education Positions In 2005 Failed To Boost Primary Care Or Rural Training

By Candice Chen, Imam Xierali, Katie Piwnica-Worms, and Robert Phillips
Health Affairs, January 2013, 32(1):102-110
ABSTRACT Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation’s hospitals, largely in an effort to train more residents in primary care and in rural areas. However, when we analyzed the outcomes of this recent effort, we found that out of 304 hospitals receiving additional positions, only 12 were rural, and they received fewer than 3 percent of all positions redistributed. Although primary care training had net positive growth after redistribution, the relative growth of nonprimary care training was twice as large and diverted would-be primary care physicians to subspecialty training. Thus, the two legislative and regulatory priorities for the redistribution were not met. Future legislation should reevaluate the formulas that determine GME payments and potentially delink them from the hospital prospective payment system. Furthermore, better health care workforce data and analysis are needed to link GME payments to health care workforce needs…
http://content.healthaffairs.org/content/32/1/102.abstract

Note:  Today’s message on the shortage of rural family physicians was prepared by Joshua Freeman, MD, Professor and Chair of the Department of Family Medicine at the University of Kansas Medical Center. He also writes a highly commendable weekly blog on Medicine and Social Justice, accessible at: http://www.medicinesocialjustice.blogspot.com/
What is wrong with this picture? Taken together, these studies show us that despite the fact that we know what strategies work to increase the number of rural family physicians, they are not being truly embraced by policymakers at either the medical student or resident level. The PSAP and similar programs are effective, but are far too small. Twenty percent of Americans live in rural areas, but over the 9 year period studied in which 37 PSAP graduates entered rural practice, Jefferson Medical College, which has an enrollment of over 250 students a year, thus graduated over 2200 students. This is at a school with one of the nation’s most successful programs; at many schools it is much worse. At the graduate training (residency) level, only 3% of redistributed positions went to rural training, despite that being a primary intent of the policy.
The problem is that there are powerful forces whose interests conflict with these goals. Medical schools and their faculties are often more interested in replicating themselves by recruiting students with high grades who will enter medical subspecialties or research than they are in recruiting students who will meet the most urgent healthcare needs of our nation. The same motivation affects graduate medical education, where most training positions are not in primary care, and the vast majority are in urban centers. In addition, hospitals, which are the main sponsors of residency training, tend to be more focused on their own interests than the community’s. They therefore prefer residents and fellows in specialties that can make them more money or lower their costs rather than those training to be rural primary care providers.
At the medical student level, programs like PSAP need to be dramatically increased, even if taking more students committed to rural practice decreases the number admitted who have more “traditional” strengths. At the residency level, loopholes must be closed so that new residency positions intended to create more rural primary care doctors are not instead used for other, more popular or more financially desirable, specialties. To the extent that medical schools and hospitals can “game” the system, they will, so policymakers must recognize these tendencies and explicitly block them.

Idaho governor: Eliminate personal property tax

By The Associated Press
The Examiner, January 7, 2013
(Idaho Gov. C.L. “Butch”) Otter is… not immediately endorsing the expansion of Idaho’s Medicaid coverage to include more than 100,000 additional low-income residents whose bills would largely be paid for with funding from Washington.
Instead, Otter now plans to spend the next year studying how Idaho’s federal-state funded health care system for the poor can be revamped to make it less focused on paying fees for services and more on requiring Medicaid beneficiaries to take more responsibility for their health.
http://washingtonexaminer.com/idaho-governor-eliminate-personal-property…

Wow! What a great idea! Instead of paying for essential health care services for Medicaid patients, let’s make those people “take more responsibility for their health.” We could expand the same concept to everyone, including Gov. Otter, and then our health care spending problem would be solved.
Please excuse the abject frivolity of this comment, but what I really want to know is, what has happened to compassion in America?

National Health Spending In 2011: Overall Growth Remains Low, But Some Payers And Services Show Signs Of Acceleration

By Micah Hartman, Anne B. Martin, Joseph Benson, Aaron Catlin, the National Health Expenditure Accounts Team
Health Affairs, January 2013
Abstract
In 2011 US health care spending grew 3.9 percent to reach $2.7 trillion, marking the third consecutive year of relatively slow growth. Growth in national health spending closely tracked growth in nominal gross domestic product (GDP) in 2010 and 2011, and health spending as a share of GDP remained stable from 2009 through 2011, at 17.9 percent. Even as growth in spending at the national level has remained stable, personal health care spending growth accelerated in 2011 (from 3.7 percent to 4.1 percent), in part because of faster growth in spending for prescription drugs and physician and clinical services. There were also divergent trends in spending growth in 2011 depending on the payment source: Medicaid spending growth slowed, while growth in Medicare, private health insurance, and out-of-pocket spending accelerated. Overall, there was relatively slow growth in incomes, jobs, and GDP in 2011, which raises questions about whether US health care spending will rebound over the next few years as it typically has after past economic downturns.
Out-Of-Pocket Spending
Faster growth in 2011 reflects higher cost sharing for group health insurance plans and increased enrollment in consumer-directed health plans that have higher deductibles, copayments, or both. Additionally, increases in the number of uninsured people over the past few years had resulted in more direct out-of-pocket spending than might otherwise have been the case.
Medicaid
Slower growth in Medicaid spending reflected states’ efforts to control expenditure growth as the enhanced federal matching rates expired and state revenues continued to increase at a slow rate. With fewer federal matching dollars and continued pressure on their budgets, some states implemented cost-control measures that included provider reimbursement reductions, eligibility restrictions, benefit reductions, and increased cost sharing.
Medicare
Medicare spending for physicians’ services also accelerated in 2011, increasing 7.6 percent compared to 3.2 percent growth in 2010, even as the increase in physicians’ fees was lower in 2011. Faster fee-for-service spending growth for physician services, therefore, is attributable to a rebound in the volume and intensity of services after unusually slow growth in 2009 and 2010.
Conclusion
In 2011 national health spending increased 3.9 percent—the same rate of growth experienced in 2009 and 2010. The recent recession had an immediate and noticeable effect on the health sector because of high unemployment, loss of private health insurance coverage, and a reduction in the resources available to pay for health care. All of these factors contributed to historically low growth in aggregate health spending during 2009–11.
In 2011, however, there were some signs of change, evident in faster growth in nonprice factors such as the use and intensity of health care goods and services. Additionally, insurance coverage expanded in 2011 for dependents under age twenty-six, and overall private health insurance coverage did not decline as had been experienced in the prior three years.
Nonetheless, economic, income, and job growth in 2011 was modest and less than might normally be expected during an economic recovery. This fact raises questions about whether the near future will hold the type of rebound in health care spending typically seen a few years after a downturn. Data for the years 2012 and 2013 will provide important indications of the state of the US health system as the major insurance expansions associated with the Affordable Care Act grow nearer on the horizon.
http://content.healthaffairs.org/content/32/1/87.abstract

National Health Expenditures (NHE), 2011
$2,700.7 – NHE, billions
17.9 – NHE as percent of GDP
$8,680 – NHE per capita
In 2011, health care costs grew at the same rate as the growth in the gross domestic product (GDP). Thus the recent severe recession and slow recovery, plus the initial phase of implementation of the Affordable Care Act, have not had a major impact on the growth of health care spending.
At a time when Medicare spending is under close scrutiny, especially for potential opportunities to reduce the federal deficit, the fact that the volume and intensity of services have increased disproportionately warrants scrutiny. Physician behavior may drive reforms that could have other consequences, favorable, or more likely unfavorable.
Shifts in Medicaid spending should raise red flags. More of the costs are being shifted to states at a time that they are facing budget crises. States are responding with measures such as provider reimbursement reductions, eligibility restrictions, benefit reductions, and increased cost sharing. These changes can result in greater impairment of access just at a time when massive enrollment increases are anticipated. This can have very serious consequences for a welfare program that is already critically underfunded.
Out-of-pocket spending is increasing, especially due to an increase in enrollment in consumer-directed health plans with high deductibles – a market strategy to reduce health care spending by erecting financial barriers to care.
Although reducing the increase in health expenditures down to the rate of increase in the GDP sounds like good news, the trends behind the numbers should have us all deeply concerned.
Need I say, a single payer…

The Complexities of Comparing Medicare Choices

By Uwe E. Reinhardt
The New York Times, January 4, 2013
The roughly 50 million Americans covered by the federal Medicare program have a choice of receiving their benefits under the traditional, free-choice, fee-for-service Medicare program or from a private, managed-care Medicare Advantage plan. The private plans have a steadily increasing number of enrollees — currently 13 million, or 27 percent of beneficiaries.
A fundamental question that has engaged health-policy researchers and commentators for some time is whether coverage of Medicare’s standard benefit package under Medicare Advantage plans is cheaper or more expensive than it is under traditional fee-for-service Medicare.
The answer is yes.
At the risk of going over ground already covered in Economix and in the scholarly literature on the subject, this answer may warrant some explanation.
(At this point, Professor Reinhardt provides an excellent explanation, with numerous helpful links, of the complexities in pricing of the Medicare Advantage plans. If you wish to understand this topic better, and understand why his answer is “yes,” the full article is well worth reading. DMc)

The only correct “yes” is that Medicare Advantage plans are more expensive. The extra cost is invisible to beneficiaries because it is borne by taxpayers. The plans can be considered less expensive only if you believe that it is fair for taxpayers to provide the private plans with extra funds for their ability to cheat through well documented favorable selection (HSR DOI: 10.1111/1475-6773.12006) and the gaming of risk adjustment (GAO 12-51, Jan 12, 2012 and NBER Working Paper No. 16977).
While we’re at it, we should also mention the profound administrative waste of not only the Medicare Advantage plans but also the private Medigap plans (the latter paid by excessive premiums), and the administrative burden that they place on the health care delivery system.
Congress should stop wasting our public funds in these efforts to push us into private plans. If they took the same public and private funds already being spent and used those to improve the benefits of the traditional Medicare program (especially reducing cost sharing and capping out-of-pocket spending), then we would have an even better Medicare program. In fact, it could become the basis of the Improved Medicare for All that many of us long for but has remained elusive to a large extent because of the elevated stature that the private insurance industry holds in the Halls of Congress.
http://economix.blogs.nytimes.com/2013/01/04/the-complexities-of-compari…

Sen. Kirk returns to Senate after year-long recovery from stroke

By Emily Goodin
The Hill, January 3, 2013
Sen. Mark Kirk (R-Ill.) returned to the Senate on Thursday after nearly a year’s absence.
Kirk, who had a stroke in January 2012, walked up the Capitol steps holding a cane and with the help of Vice President Biden and Sen. Joe Manchin (D-W.Va.).
Cheers rang out as Kirk began his climb. He walked into the Capitol shortly before noon, when the 113th Congress was gaveled into session.
http://thehill.com/capital-living/275411-sen-kirk-returns-to-cheers-appl…
And…

Sen. Mark Kirk’s message to stroke victims: ‘Don’t give up’

By Natahsa Korecki
Chicago Sun-Times, January 2, 2013
(Sen. Mark Kirk) spoke with the Sun-Times in a sit-down interview in the U.S. Capitol one day before he plans his dramatic climb up the Capitol steps. He offered a new perspective on the Illinois Medicaid program and what it offers to those with low incomes.
He does plan to take a closer look at funding of the Illinois Medicaid program for those with no income who suffer a stroke, he said. In general, a person on Medicaid in Illinois would be allowed 11 rehab visits, he said.
“Had I been limited to that, I would have had no chance to recover like I did,” Kirk said. “So unlike before suffering the stroke, I’m much more focused on Medicaid and what my fellow citizens face.”
Kirk has the same federal health-care coverage available to other federal employees. He has incurred major out-of-pocket expenses, which have affected his savings and retirement, sources familiar with Kirk’s situation said.
http://www.suntimes.com/news/metro/17348299-418/mark-kirk-says-he-would-…

It was quite moving watching the live C-SPAN broadcast of Sen. Mark Kirk today, climbing the Capitol steps to the resounding ovation given to him by his colleagues in the Senate. After his severely debilitating stroke, his message to other stroke victims is, “Don’t give up,” and he didn’t.
He has had a year to think about stroke victims on Medicaid in Illinois and what the limit of a total of eleven rehabilitation visits must mean to them. This is clearly an inhumane public policy that must be changed.
But what about all of the other patients with major medical problems who do not get the care that they need because they are uninsured, or Medicaid doesn’t provide adequate access, or private insurance…
What about private insurance? Sen. Kirk has coverage through the Federal Employees Health Benefits Program (FEHBP) – a menu of private health plans. That is about as good coverage as you can get today, yet with the major out-of-pocket expenses, it has not protected his savings and retirement.
We have a much bigger problem in health care other than simply trying to figure out how we can get Medicaid patients adequate rehabilitative services after a stroke.
If only Sen. Kirk’s colleagues in the Senate and House could learn from his travails. They might begin to consider that we really do need a comprehensive health care system that takes care of all of us – an Improved Medicare for All.
In the battle for reform, remember Sen. Kirk’s words, “Don’t give up.”

By Katherine M. Flegal, PhD; Brian K. Kit, MD; Heather Orpana, PhD; Barry I. Graubard, PhD
JAMA, January 2, 2013

In this study, we used the National Heart, Lung, and Blood Institute’s terminology with categories of underweight (BMI of <18.5), normal weight (BMI of 18.5-<25), overweight (BMI of 25-<30), and obesity (BMI of ≥30). Grade 1 obesity was defined as a BMI of 30 to less than 35; grade 2 obesity, a BMI of 35 to less than 40; and grade 3 obesity, a BMI of 40 or greater.

The most recent data from the United States show that almost 40% of adult men and almost 30% of adult women fall into the overweight category with a BMI of 25 to less than 30.

In the United States and Canada, more than half of those who are obese fall into the grade 1 category (BMI of 30-<35).

According to the results presented herein, overweight (defined as a BMI of 25-<30) is associated with significantly lower mortality overall relative to the normal weight category with an overall summary HR (hazard ratio) of 0.94.

The summary HRs were 0.94 (95% CI, 0.91-0.96) for overweight, 1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity.

http://jama.jamanetwork.com/article.aspx?articleid=1555137

And…

Obesity Update 2012

OECD

Obesity rates

16.9% – All OECD nations

33.8% – United States

http://www.oecd.org/health/49716427.pdf

And…

NIH Body Mass Index (BMI) calculator:

http://nhlbisupport.com/bmi/

Comment

By Don McCanne, MD

If you are amongst the 30 to 40 percent of Americans who are overweight, you likely are resolving at the beginning of this year to finally do something about your weight. The good news is that you don’t have to. Being overweight (BMI 25->30) is associated with a mortality rate that is 6 percent lower than that for normal weight. Happy New Year.

In fact, even you fall into the category of grade 1 obesity (BMI 30->35), you still have no increase in mortality due to your weight alone. (You can use the BMI calculator at the NIH link above to determine where you fall.)

This, of course, does not mean that you are free to abandon healthy habits. Good nutrition and regular exercise are still important. To increase compliance, just be sure that the exercise program that you select is enjoyable and that it is easily integrated into your daily regimen. Same for selecting nutritious food.

Nevertheless, grade 2 and 3 obesity (BMI 35 or greater) are associated with increased mortality, so prevention and intervention are important. But is that primarily a responsibility of providers in the health care delivery system? Telling people to exercise and eat well is great advice, but it is not very effective, especially since everyone already knows that.

Prevention of obesity is more a function of society at large. Health education, school nutrition programs, responsible food product design by the industry, planning of communities to promote physical activity such as walking, biking or hiking, and including breaks for physical activity for those in sedentary occupations are types of measures that would take place out in the community rather than within the health care delivery system.

However, Grade 2 and 3 obesity do place a burden on the health care delivery system because of their association with chronic diseases. The policy community correctly emphasizes that the delivery system must provide chronic disease services. But that isn’t new. That is what primary care professionals have been doing all along.

What is a problem is that there has been a misplaced emphasis on chronic disease management as if that were a new solution to health care cost and quality issues. This has led to ineffectual tinkering by promoting nebulous models such as accountable care organizations. The efforts would be better directed toward reinforcing the primary care infrastructure.

If we really do want to improve the management of health care spending while improving quality we need to implement fundamental structural reform of our health care financing system by enacting a single payer, improved Medicare for all. It’s a system that would work great for all of us, even for those of us who are overweight.

Correction: “Overweight”

In today’s qotd message, “Overweight,” I wrote, “Being overweight (BMI 25->30) is associated with a mortality rate that is 6 percent lower than that for normal weight.”

The study demonstrated that the summary hazard ratio (HR) for overweight compared to normal weight was 0.94. Thus, “The researchers found that the summary HRs indicated a 6 percent lower risk of death for overweight.” (The JAMA Network, January 1, 2013).

http://www.digitalnewsrelease.com/?q=jama_3867

Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories

By Katherine M. Flegal, PhD; Brian K. Kit, MD; Heather Orpana, PhD; Barry I. Graubard, PhD
JAMA, January 2, 2013
In this study, we used the National Heart, Lung, and Blood Institute’s terminology with categories of underweight (BMI of <18.5), normal weight (BMI of 18.5-<25), overweight (BMI of 25-<30), and obesity (BMI of ≥30). Grade 1 obesity was defined as a BMI of 30 to less than 35; grade 2 obesity, a BMI of 35 to less than 40; and grade 3 obesity, a BMI of 40 or greater.
The most recent data from the United States show that almost 40% of adult men and almost 30% of adult women fall into the overweight category with a BMI of 25 to less than 30.
In the United States and Canada, more than half of those who are obese fall into the grade 1 category (BMI of 30-<35).
According to the results presented herein, overweight (defined as a BMI of 25-<30) is associated with significantly lower mortality overall relative to the normal weight category with an overall summary HR (hazard ratio) of 0.94.
The summary HRs were 0.94 (95% CI, 0.91-0.96) for overweight, 1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity.

http://jama.jamanetwork.com/article.aspx?articleid=1555137
And…

Obesity Update 2012

OECD
Obesity rates
16.9% – All OECD nations
33.8% – United States
http://www.oecd.org/health/49716427.pdf
And…

NIH Body Mass Index (BMI) calculator:

http://nhlbisupport.com/bmi/

If you are amongst the 30 to 40 percent of Americans who are overweight, you likely are resolving at the beginning of this year to finally do something about your weight. The good news is that you don’t have to. Being overweight (BMI 25->30) is associated with a mortality rate that is 6 percent lower than that for normal weight. Happy New Year.
In fact, even you fall into the category of grade 1 obesity (BMI 30->35), you still have no increase in mortality due to your weight alone. (You can use the BMI calculator at the NIH link above to determine where you fall.)
This, of course, does not mean that you are free to abandon healthy habits. Good nutrition and regular exercise are still important. To increase compliance, just be sure that the exercise program that you select is enjoyable and that it is easily integrated into your daily regimen. Same for selecting nutritious food.
Nevertheless, grade 2 and 3 obesity (BMI 35 or greater) are associated with increased mortality, so prevention and intervention are important. But is that primarily a responsibility of providers in the health care delivery system? Telling people to exercise and eat well is great advice, but it is not very effective, especially since everyone already knows that.
Prevention of obesity is more a function of society at large. Health education, school nutrition programs, responsible food product design by the industry, planning of communities to promote physical activity such as walking, biking or hiking, and including breaks for physical activity for those in sedentary occupations are types of measures that would take place out in the community rather than within the health care delivery system.
However, Grade 2 and 3 obesity do place a burden on the health care delivery system because of their association with chronic diseases. The policy community correctly emphasizes that the delivery system must provide chronic disease services. But that isn’t new. That is what primary care professionals have been doing all along.
What is a problem is that there has been a misplaced emphasis on chronic disease management as if that were a new solution to health care cost and quality issues. This has led to ineffectual tinkering by promoting nebulous models such as accountable care organizations. The efforts would be better directed toward reinforcing the primary care infrastructure.
If we really do want to improve the management of health care spending while improving quality we need to implement fundamental structural reform of our health care financing system by enacting a single payer, improved Medicare for all. It’s a system that would work great for all of us, even for those of us who are overweight.
Correction: “Overweight”
In today’s qotd message, “Overweight,” I wrote, “Being overweight (BMI 25->30) is associated with a mortality rate that is 6 percent lower than that for normal weight.”
The study demonstrated that the summary hazard ratio (HR) for overweight compared to normal weight was 0.94. Thus, “The researchers found that the summary HRs indicated a 6 percent lower risk of death for overweight.” (The JAMA Network, January 1, 2013).
http://www.digitalnewsrelease.com/?q=jama_3867