Part 1 why has the U.S. experienced such difficulty? - medical staffing in underserved areas persists

Physician Executive, Nov-Dec, 1998 by Thomas P. Weil

With health networks searching for additional market share and with a projected 30.2 million to be enrolled in Medicaid HMOs by 2000, more health executives will be weighing various strategies of how to attract qualified physicians to practice in poor inner-city and rural areas. Most frequently cited as solutions are: supplying more physicians, encouraging more medical school graduates to pursue primary care residencies, and modifying the number of international medical graduates entering U.S. residency programs. Part 1 of this article reviews the efficacy of these approaches, while the second part, which will appear in the January/February 1999 issue, explores a more pragmatic option: to simply improve the working conditions and just pay substantially more to physicians who practice in "less desirable" locations.

Key Concepts: Distribution of Physicians/ Medicaid HMOs/Underserved Communities

HEALTH NETWORKS ANXIOUS TO ENHANCE THEIR market penetration and particularly those providers now consummating agreements to deliver care to Medicaid HMO subscribers (projected to total over 30.2 million by the end of 2000), (1) are evaluating various strategies to attract qualified physicians to underserved areas. While the United States experiences an increasing number of physicians relative to population, a geographic maldistribution in its supply continues to plague America in a similar manner to nations that enacted universal comprehensive health insurance several decades ago. (2-3)

The inability worldwide, irrespective of the universality of health insurance coverage, to achieve an equitable distribution of physician services causes severe difficulties for many poor in inner-cities and in rural communities (one in six persons in the United States) to obtain reasonable access to quality medical care. Affluent city and suburban locations everywhere support an excess supply of highly qualified specialists, while those persons living in less prosperous areas not only experience a far greater incidence of acute and chronic illnesses, but frequently have more difficulty in obtaining appropriate physician and other health services. (4-5)

Although over the last half-century, various solutions have been proposed and then employed to achieve greater equity in the delivery of health care to the underserved, most experts in the United States agree that too few positive changes have been achieved. (6)

In attempts to remedy these shortcomings, 11 reports generated from 1988 through 1998 by the Council on Craduate Medical Education (COGME) analyzed graduate medical education trends and their potential impact on practicing physicians. The following were the group's major recommendations: (1) limiting first-year residency positions to 110 percent of the number of 1993 graduates of U.S. medical schools; (2) ensuring that at least half of the graduating medical students each year pursue primary care residencies; (3) doubling the number of medical students from under-represented minority groups; (4) eliminating the shortages of primary care practitioners that now exist in some communities; and, (5) improving physician practice conditions in rural and inner-city areas in order to encourage additional U.S. medical school graduates to locate there. (7)

Others argue that the "market" will eventually correct the current imbalances in the overall physician supply and in its specialty and geographic distributions; and, that health manpower policy-makers and planners should meanwhile leave well enough alone. (8-9) The inability in recent years of the residency programs in anesthesiology to attract a sufficient number of qualified candidates is frequently cited as an example of allowing market forces to correct inequalities. (10)

As a result of these divergent views, this article's major objective is to evaluate various strategies that are or could be used to attract a "reasonable" or an "adequate" number of qualified physicians to practice in Americas underserved communities (defined quantitatively in Table 1, Model C). Although, in the last decade, the United States may have witnessed a slightly improved distribution of qualified physicians in larger rural communities adjacent to metropolitan areas, (11) this article argues that neither by increasing the supply of primary care physicians nor by the other approaches commonly being proposed will the end result be achieving an adequate supply of qualified physicians available to provide high quality care to the nations underserved (many of whom will be eligible and later become Ineligible for Medicaid HMO benefits).

A more likely untested solution lies in significantly increasing the level of reimbursement paid to physicians who practice in poor rural and inner-city areas (for example, enhancing the current 10 percent bonus to the usual Medicare physicians' fee schedule now provided in a number of underserved environments) (7,12) This option calls for substantially bettering the working conditions and paying a sizeable premium to those doctors willing to practice in America's "less desirable" locations. It focuses on applying an argument cited several years ago in the New England Journal of Medicine.