Why are there so few doctors in poor neighborhoods? CSS recently completed a study on the availability of
primary care in nine of New York's low-income neighborhoods. It is disappointing, although perhaps not surprising, to discover that these communities suffer from a shortage of doctors. In communities that house 1.75 million New Yorkers, over 300 new primary care physicians are needed to provide a minimum standard of availability. And
since most doctors in these neighborhoods work less than full-time, in fact it would probably require 450 new doctors practicing in these communities to achieve a reasonable level of availability. It is worth noting that ten years ago, when CSS conducted an earlier study, the shortage was even greater - over 500 new physicians were needed. While the situation has improved in the last decade, the gap between the number of doctors needed to provide basic health care needs and the number available remains large.
This is astounding considering that the shortage is occurring within a nation-wide physician surplus. The number of physicians in the United States has been increasing since the mid-1960's. It is projected to increase through at least 2010. Many people argue that we are experiencing a glut of physicians, and we are training more doctors than we need. A common measure of the physician supply is the physician-to-population ratio, which takes into account the country's population growth in estimating the need for doctors. Between 1965 and 1992 the overall physician-to-population ratio went from 115 per 100,000 to 190 per 100,000, and it is projected to rise to 219
per 100,000 by 2010. Some estimate that this is10 percent more doctors than are needed.
Because New York City has 8 academic medical centers, more doctors are trained here than any other U.S. city. With less than 7 percent of the nation's population, New York State trains 15 percent of the nation's doctors, the vast majority in New York City. Many of those doctors - over half of those who complete a residency in New York - choose to remain here. While the physician to population ratio for the country as a whole is 190 per 100,000, in New York it is 232 per 100,000. So why is it that many New York City neighborhoods continue to face a shortage of doctors? And why is this so important?
Primary care capacity - having enough primary care physicians to meet people's needs for health care - is a critical link to health status. Research has indicated that geographic considerations have a powerful impact on access to primary and preventive care. People who have primary care conveniently located, in close proximity to their home, receive more care. And availability of primary care plays an important role in preventing more serious illness. For example, a recent review of the literature on the link between health coverage and poor health, prepared by the American College of Physicians, reinforces the finding that with adequate primary care for conditions such as asthma, diabetes and hypertension many hospitalizations are avoidable. Without adequate primary care, these avoidable hospitalizations impose large personal costs by causing unnecessary illnesses and disabilities. Avoidable hospitalizations also generate a large financial cost to the health care system - in part, through an increased dependence on the emergency departments to meet basic health care needs. In communities without after-hour physician care, for example, parents frequently rely on the local hospital to tend to their children's routine illnesses such as earaches and flu. This places a large, costly and unnecessary burden on the entire health care delivery system.
Inner city neighborhoods and rural areas have long been plagued with a paucity of doctors. The causes can be traced to a number of pressures influencing two distinct policy arenas - physician supply and the financing of medical care. Some of the issues that affect physician distribution include graduate medical education and health manpower policies, which directly relate to the supply side of the problem. On the demand side the concern is with reimbursement policies, especially within the Medicaid program, and the socioeconomic status of these communities, particularly the large numbers of individuals who are either on Medicaid or who lack any health insurance.
Physician Supply Issues
Since, as we have seen, both the country and the city are experiencing a surplus of physicians, it is apparent that adequacy of supply is no guarantee that we have the right kind of doctors, or that they are distributed where they are needed. To begin with, the total number of primary care doctors is severely limited by the disproportionate emphasis on specialty training within our academic medical centers. The number of specialists trained relative to generalists is skewed. While experts agree that the split between primary care and specialty care should be about fifty-fifty, in fact about 70 percent of medical residents choose to do training in a specialty area. Even as the total number of physicians rises, the number of primary care physicians is barely keeping up with the need for such care. This maldistribution has implications in terms of physician availability.
Changing the clinical mix of the physician supply requires changing the mind-set within academic medical centers, away from their historical emphasis on research, technology and ever more specialized training. The rewards of academic medicine, both in prestige and in financial compensation, continue to be directed toward specialty practice. With the advent of managed care and its emphasis on primary care, however, a consensus is beginning to emerge that academic medicine must do more to enhance and expand training in primary care.
New York State has recognized the need to encourage more training in primary care. New York State subsidizes graduate medical education through GME pools that receive funds through assessments on certain health services and on health insurance policies. The funds are then distributed to hospitals based on the size and specialty mix of their residency training programs. Primary care training programs receive a higher level of financing through the GME pools. This has encouraged New York's academic medical centers to expand those programs. Initiatives like the GME Reform Incentive Pool have been successful in shifting greater numbers of residents into primary care training. In fact, in New York the number of residents who specialized in primary care rose 41 percent between 1990 and 1995.
A second area where training can have a major effect on creating an appropriate physician supply is in community-based care. Most residency training occurs in a hospital setting; most primary health care is provided in the community. It is logistically more complicated to train residents outside of the hospital, as the resources and faculty are centralized at the hospital setting. Nonetheless, in recognition of the practical need for residents to have experience in the setting they are most likely to practice, training programs are increasingly entering into partnerships with community-based sites.
Moving residency training out of the hospital setting is a slow process. A federal program provides enhanced Medicare rates to academic medical centers that have agreements with ambulatory care centers to house residency training programs. The New York State Council on Graduate Medical Education has recently approved a recommendation that would build on that program, using enhancement to the Medicaid rates for academic medical centers that have written agreements with ambulatory care sites for resident training.
A final consideration in increasing the primary care physician pool in poor communities is the need to support underrepresented minorities. The profile of providers working in underserved neighborhoods reveals disproportionate numbers of minority physicians. African American and Latino physicians tend to practice in areas with fewer primary care physicians. They are more likely to have large numbers of minorities under their care, and are also more likely to treat patients who are uninsured. It therefore becomes incumbent on us to improve medical school recruitment. Recruiting students from poor neighborhoods is one way to increase the pool of physicians subsequently interested in serving in those neighborhoods.
In order to increase minority enrollment in medical schools, it is necessary to look at the preparedness of students at the high school and junior high school level. It is insufficient to simply look at college graduates who have the training and preparation that will assure their acceptance into (and success in) medical school. Most African-American and Latino New York City college graduates with degrees in science already apply to medical school. It is therefore necessary to increase the number of students graduating from high school who are prepared for the rigors of medical training. Medical schools need to think more expansively about their outreach strategies and about ways to provide academic support even before students reach college.
Financing Issues
An adequate supply of providers is obviously necessary, but that alone will not guarantee that doctors will locate their offices in poor neighborhoods. Having a flow of patients who can pay for their care, either directly or through their health insurance, is equally important. Many low-income New Yorkers have Medicaid coverage. New York's Medicaid program is relatively generous in terms of eligibility and coverage. The reimbursement rate that private physicians receive for an office visit, however, is shockingly inadequate. New York State recently raised the rate to $30 per visit (until this year it had been $11, an amount that had not been increased in 20 years). The rate remains the same regardless of what is wrong with the patient, regardless of how much time the physician spends with the patient, regardless of what it actually COSTS the physician to provide care. Nationwide, the average payment is just over $26. In Connecticut private physicians receive $35 for an office visit; in California the payment is $49. New York's Medicaid reimbursement rate for primary care, while no longer the lowest in the country, still falls well below the cost of providing care.
For providers whose patients are mostly privately insured, a practice can afford to take on a limited number of Medicaid patients. In this circumstance, the provider is actually cross-subsidizing within his or her own practice, using the income from better-insured patients to cover the cost of providing care to Medicaid patients. But in low-income areas, where large numbers of people have Medicaid coverage, the Medicaid rate has been so low that it cannot sustain a medical practice. Even with the increase in the rates, for practices with a large volume of Medicaid patients, it is difficult to stay afloat.
Medicaid managed care creates new challenges as we attempt to redress this problem. As managed care becomes the dominant mode for organizing health care delivery, it is harder to utilize government policy to create financial incentives that encourage physicians to work in underserved neighborhoods. The health plan acts as an intermediary between the state as payor and the physician as provider. The amount that individual providers are reimbursed is negotiated between the health plan and the physician; the state does not play a role in those negotiations.
Nonetheless, it is possible to develop financial incentives that would encourage differential reimbursement rates for primary care providers serving in neighborhoods with a primary care shortage. New York has direct experience that shows that if you pay physicians adequately, they are willing to provide care to the Medicaid population in even the most underserved communities. A related problem in poor communities is the large number of individuals who have no health insurance at all. Nearly 28 percent of city residents under the age of 65 were uninsured in 1997. New York State has just approved a number of new health coverage initiatives as part of the Health Care Reform Act 2000, the most significant one being the Family Health Plus program, a Medicaid expansion designed to reach low-income uninsured adults. Family Health Plus, when fully implemented, will extend Medicaid coverage to families with incomes up to 150 percent of the federal poverty level and to childless individuals with incomes up to the federal poverty level.
Stemming the growing numbers of uninsured is essential to maintaining the viability of the health care delivery system, especially the primary care system. While the insurance programs included in HCRA 2000 are significant, even the most optimistic projections expect that over 2 million New Yorkers will not be covered by the programs. FHP and the state's Child Health Plus program provide useful models for expanding coverage.
We have seen important progress during the past decade. More physicians are available in New York's poorest neighborhoods. Basic indicators of accessibility and quality, such as 24-hour coverage, hospital admitting privileges, and board certification, occur more frequently. The academic medical community, responding to incentives created by state policy on graduate medical education, increased its emphasis on primary care. Yet excessive shortages persist.
CSS Recommendations
Regarding physician supply:
(1). Offer financial incentives to teaching hospitals and community-based clinics to provide well-supervised residency positions in community-based primary care settings;
(2). give teaching facilities specific incentives to recruit residents who express a desire to practice in underserved areas of New York City by expanding the number and amount of grants going to New York medical schools to encourage underrepresented minorities; and
(3). begin large-scale programs to prepare primary and high school students for science studies, by providing assistance in studying, test-taking and problem-solving skills.
Regarding Financing:
(1). Raise Medicaid fees for all private physician office visits to a level comparable to Medicare rates;
(2). create financial incentives for health plans to reimburse primary care providers in neighborhoods with a primary care shortage at a higher rate than other primary care providers; and
(3). improve health coverage.
