Five Periods of Health Policy and Physician Career Choice

 Robert C. Bowman, M.D.   October 30, 2006

The nation has had two excellent natural experiments to test the impact of health policy upon medical student career choice. This work compares these two periods and the remaining three over the past 41 class years.

Background:

General practice levels have consistently declined throughout the past century in a close parallel with rural population levels and rural physician levels. The deteriorations in general practice left the nation without a suitable physician for rural and underserved areas. Only in recent decades has the pattern changed. National debates highlighted the particular problems of the poor and elderly and the need for a return of general practice. The nation made sweeping changes in a number of areas during the late 1960s and 1970s. This involved a time period of primary care emphasis, increased state and federal funding for medical schools, and the creations of Medicare, Medicaid, and family medicine. In many ways this was a perfect storm for family medicine and primary care choice. Medical student choice of family medicine soared. During the 1980s the nation had a different focus but maintained some level of support. It was a neutral period. In the 1990s the nation entered a new level of support for rural and underserved populations, primary care, and areas outside of major medical centers. The nation again changed health policy in the form of managed care and health reforms. Prominent factors were a "forced" choice of family medicine and primary care, increases in primary care reimbursement and decreases in subspecialty funding. In more recent years the nation has returned to a “market forces” plan for physician support with career choices much like 40 years ago. Losses in primary care include more than just new medical student decisions as seen in losses of nurse practitioners and physician assistants. Primary Care Retention

At current levels of deterioration, family medicine will increase share to 40 - 60% of total primary care, rural primary care, and underserved primary care. Changing Primary Care Contributions 1970 - 2015 Sadly this has to do more with losses of other forms than gains in medical student choice of family medicine.

Differences and Definitions provides more background on the types of students who distribute, the types of schools, the various differences in primary care types, definitions, and limitations of physician distribution.

Rural Coding - about the RUCA coding and distributions

Despite regular medical student career choice changes with health policy changes, few studies have explored this relationship. To understand health policy impacts it is important to explore in a number of dimensions.

The following themes are supported:

• Policy and practices that facilitate choice of family medicine, improve funding for primary care, and increase support outside of major medical centers will improve physician distribution.
• Policy and practices that impair choice of family medicine, decrease primary care support (decreased reimbursement or increased costs or impaired primary care delivery), and increase support to major medical centers will concentrate physicians in major medical centers.

In the following graphic the family medicine and general practice career choice is shown by class year of medical school graduation. A comparison is made with the rural born graduate percentage, a relative measure of the potential for distribution in medical students. This relationship is best seen in the neutral health policy impact period from 1979 to 1990 when FM choice % paralleled rural born medical student %.

When considering medical student choices there have been 5 health policy periods.

1. Little or no health policy support as in the time period before 1965.
2. Medicare and Medicaid Creation - Health policy support for lower income, older, inner city, and rural populations increasing from 1965 to 1978
3. Neutral health policy impacts from 1979 to 1990
4. Managed care and health reform impacts from 1991 – 1997
5. Rapid return to market forces from 1998 to the present and likely to 2010 or longer given the years it has taken to change health policy (selections 2 and 4)

Note that the rural born "line" is a proxy for distributional student admissions which include all who have origins outside of major medical centers: rural born, lower income, older, children not of professionals, middle income. This is a group of about 30% of admitted medical students but represents 70% of the population. Those with origins outside have the most potential for outside location, most fully expressed by choice of family medicine and during times when the nation maximizes health policy for distribution.

The First Period: Below the Line

The first period prior to significant intervention was characterized by severe problems for lower and middle income elderly, those in poverty, and particularly for young people in poverty and rural areas. Access to physicians and hospital care was limited to the most urban areas and those with higher income or health care insurance. It was difficult for physicians to locate in rural and underserved locations without the support of state and federal government or a booming local economy with health care coverage. Rural and underserved locations also did not enjoy the economics generated by federal and state health care. (Few understand how health care and education dollars from federal and state sources are important for economics and other parts of rural and underserved areas, how efficient education and health care can be in such areas, and how cuts in education and health devastate these areas.) Major national reports illustrated the problems stemming from declining primary care and general practice choices. State and federal support for medical education was poor.

In the graphic, the levels of family medicine and rural choice were “below the line” or lower than the percentage of rural born students admitted. The nation’s health policy did not support distribution.

Second Period: Massive New Investment

The second period was influenced by the nation’s War on Poverty and involved efforts in education, social programs, child development, and economics targeting low income and underserved areas. Despite the long term and determined opposition of organized medicine, the nation created Medicare and Medicaid. These programs grew rapidly relieving pent up demand for health care. The nation also created family medicine and funded new medical schools with state and federal funding. The nation also supported expansion of medical schools during this period of primary care emphasis.

The result was a doubling of medical students and a doubling of primary care percentage, with a quadrupling of total primary care and family medicine numbers in just ten years. The new allopathic and the only 6 osteopathic public schools that were created continue to lead the nation in primary care, family medicine, rural, and underserved distributions.

By the graduating class of 1975, the new family physician graduates were choosing rural practice at 30%. Family physicians have supplied 30% of the rural physicians for each subsequent graduating class as still found in practice in 2005 and despite major health policy changes. In the newer schools the contributions of family medicine were 50 – 80% of all found in rural locations.

The nation divided into medical schools with higher levels of distribution and those without much distribution. The distributional medical schools provided concentrations of graduates for rural and for underserved areas that made up much ground for the medical schools failing to distribute. Expansions in these non-distributional schools provided lower contributions to distribution and a dilution effect that captured the attention of workforce planners in the nation and resulted in a slowing of medical education growth.

The earlier period of time also involved a different United States. Education was emphasized 1960s and 1970s at local, state, and national levels. A much broader range of candidates was presented to medical school admissions committees. The lower income, middle income, and rural born physicians had much higher levels of admission in this time period. Sadly these humble origin types did not gain ground with the opportunity of medical school expansion. There was some increase in the numbers of rural born, Black, and Hispanic medical students admitted, but the percentages remained much the same or continued to decline as in rural born admissions.

Expansion did help the nation discover the value of older medical students (over 29 years at graduation) who increased from 5% to 15% of admissions and continued to increase to the present 22%. Older physicians are an important source of primary care, family medicine, psychiatry, rural, and underserved physicians. Divisions in Physician Career and Location Choice Related to Age at Graduation

Asian and foreign born medical students were not a major part of medical education during this time period. The top income quintile of predominantly white medical students continued to dominate admissions with 60% of graduates; however the differences between the highest and lowest income students and education differences were much lower. The nation has separated richest from middle and lower income groups in all ethnicities and races since this time with great impacts on the composition of the medical students. Changes in Admissions in Allopathic Medical Schools

In the graphic, the levels of family medicine and rural choice increased to a level above the percentage of rural born students admitted, indicating some measure of support for physician distribution. Reimbursement support such as Medicare is also a consideration.

Third Period: Neutral Health Policy or Admissions-Determined Distribution

The third period was a neutral period of health policy influence with a slow decline in choice of primary care and family medicine at about the same rate of decline as the rural born student admissions (again a reflection of all distributional type admissions not just rural born). This period involved limited growth of state and federal programs, energy problems, massive increases in foreign policy and military spending, and lower levels of support for rural and underserved areas. The nation did not ignore health policy, but it also did not improve health policy support. New wrinkles began to appear. The reimbursement formulas in health care were based on percentage increases. Each year left behind the lowest paid physicians and facilities especially in rural areas, primary care, and locations outside of major medical centers. Young physicians in the early parts of the period were treated to even lower levels of funding. Rural hospitals were closing from declines in funding and as major medical centers discarded their chains of rural hospitals that they had acquired during cost-plus reimbursement.

Family medicine became increasingly focused on academic settings as the first generation “from the field” leadership gave way to those connected to academics throughout life, education, training, and practice. Not surprisingly the focus has remained medical school departments, programs in every state, match rates, and Title VII funding.

The focus of medical schools also changed. A passing interest in the millions provided in medical education support regarding primary care was soon surpassed by graduate medical education funding that grew into the billions. Subspecialty, graduate medical education, and major medical center emphasis grew while primary care, teaching, rural, and underserved areas lagged.

Multiple steady changes were difficult to comprehend. Questions were raised about primary care and family medicine. Late in the period the steady declines in family medicine choice became the subject of conversations and publications. These may have had little impact other than becoming a major topic of conversation at medical schools and among medical students, potentially resulting in lower choices of family medicine. This was minor compared to the swings in opinion to come during managed care and the managed care rebound. National changes in health policy, education, and medical school admissions were not considered as factors in the steady declines.

The levels of family medicine choice remained “above the line” but were decreasing steadily along with rural born admissions.

Fourth Period: Managed Care and Health Reform, Redirecting Resources

The fourth period was the managed care era. This was also an era of health reform although managed care conflicts overshadowed many of the changes. This is also the period of the most abrupt changes in medical student career choice toward and then away from primary care and family medicine. Not since the creation of Medicare and Medicaid had health policy changes generated so much controversy. Within a short period of time all medical students and all residents were more than aware of coming problems that would impact all not choosing primary care. The abrupt increase and decrease provided a specific impact on a limited number of class years, providing a natural experiment regarding health policy impact. The impact was greatest upon family medicine choice for those in medical school at the time (medical school graduates of 1995 – 1997 at peak) and on internal medicine retention in primary care for those in internal medicine residency.

Managed care dominated the agenda along with workforce reports projecting massive decreased need for subspecialists and hospital beds. Almost lost in the controversy were the health reform components. The nation doubled Medicaid from 1990 – 1995. Reimbursement support such as Medicare is also a consideration. No longer did the nation allow new massive investments as in the 1960s. Increases in one area had to come from a different and related area. Reimbursement reforms shifted funding away from subspecialty care and major medical center care and into primary care and outpatient settings with a series of increases. The older reimbursement systems that guaranteed steady declines in primary care and rural payments relative to other areas were replaced by better payment systems, although still far from equitable. Organized medicine and medical education protested the managed care changes vigorously. Increasing costs of delivering care (liability, supplies, personnel), decreasing state and federal support for medical education, exodus of patients from training centers with the new health plans emphasizing patient choice, declining local support (closures of county hospitals) and retention of the most subspecialized faculty with losses of the more general subspecialty faculty that did more teaching were just a few of the changes facing medical schools. The changes moved significant funding out of major medical centers to primary care and to locations outside of major medical centers. The controversies and protests added to the impact on medical student choices.

New sources of primary care were supported and physician assistant and nurse practitioner programs grew. The initial programs often involved an emphasis on students with origins outside of major medical centers and training outside of major medical centers, but these patterns would change with health policy leading the way.

Residents in internal medicine during the time period turned back to office based primary care. After declining steadily to 40% for the 1992 residency graduates, retention in primary care increased back to 53.5% for the 1996 graduates and then decreased back to 40% for the 2001 residency graduates. The correlations between Masterfile office based choices and reported primary care levels of internal medicine graduates are within a few percentage points. Now first year internal medicine residents indicate that they plan to remain in primary care at less than 20% levels. (Garibaldi 2005)³

Internal medicine retention in generalist office base care had declined to 40% and increased back to 53%. These are comparisons in the 2005 Masterfile for the previous graduating classes. The family medicine choices are stable. The internal medicine residency graduates in office based primary care deteriorate steadily with time after graduation and this may influence observed patterns at a later date (see medicine pediatrics figures). Overall across this managed care period this was a fairly level period of time with similar career choices.

Family medicine choice went through the roof and somehow programs managed to expand from 2200 positions to 3400 by 1996 although the levels are half of this total now. (Pugno 2006)¹² Family medicine choice increased above 60% for the peak levels compared to the trough levels of 1988 – 1990 graduates. At maximum over 2200 US MD Grads chose family medicine in the match but actual peak levels of US MD Grads choosing family physicians were over 2600. Rural location in family medicine remained at 25% choice but numbers increased 68% from an average of 405 for the 1988 – 1990 classes to 638 for the 1995 – 1997 graduates as found in 2005 locations. Family physicians found in underserved areas also increased from 12% to 14% of family physicians but increasing from 200 to 360 or an 80% increase before declining again.

Current 2005 Careers and Locations, 3 year Averages at Trough and Peak Levels

Medicine pediatrics numbers did double during the time period, but the apparent increases above using Masterfile data are not accurate. They appear to be higher due to losses outside of medicine pediatrics, most likely to subspecialization. These substantial losses do not allow calculations of changes. The steady losses of past class years mean that more recent graduates and the hardy office based crew that remained in medicine pediatrics skew the observed contributions as in 17% serving in rural areas. Those remaining in medicine pediatrics are older and tended to graduate from schools with lower subspecialization rates and higher choice of family medicine. When the denominator becomes all who matched into medicine pediatrics and these are adjusted for rural location rates for subspecialists (7 – 8%), the medicine pediatrics contribution decreases to less than 10%.

Increases in internal medicine are also likely to be impacted by the same factors as subspecialization does occur over time. Pediatrics and obstetrics changes are smaller.

Graduates in primary care that subspecialized later would not be counted in the 1988 – 1990 graduates as primary care physicians.

The table above uses 2005 careers and locations. For stable specialties it is accurate. For specialties with changes over time, it is a reflection of current and recent contributions more than past contributions. Retrospective career and location indicators do not capture earlier primary care careers, obligations fulfilled, or brief first time rural and underserved careers. However the 2005 snapshot does capture a workforce in equilibrium conditions and those making long term contributions to primary care, rural, and underserved areas. For a specialty such as family medicine where 99% remain active, 98% remain in family medicine, and over 90% remain in office based primary care; there is a consistency in the contributions. Primary Care Retention⁴ In family medicine, first time practice choices and distributions within states, types of states, and geographic and socioeconomic classifications within the nation tend to remain the same over time. 

The greatest levels of change in family medicine choice involved instate born students and those born in the same county where they attended medical school. A switch to family medicine may well have preserved options to remain in the same location as birth, education, training, family, and other contacts. The career changes in this massive group of medical students greatly added to total primary care numbers and with family medicine choice, these primary care levels were preserved over time. Those at either end of the distributional spectrum were least impacted by health policy changes with 30 – 40% increased choice, the humble origin types and the elite students in elite schools. The elite choices involved up to 50% increase, but this impacted an actual change of 1 – 3 medical students a year more choosing family medicine. The most humble and most elite students may represent the students that have decided on medical careers earlier than more typical medical students. The typical students in the broad middle group were impacted at greater levels. Family medicine choice in the historically black schools and the medical schools with more Black and Hispanic students were also impacted at greater than average rates for the peak 1995 – 1997 graduates compared to choices before managed care or current choices. (Bowman 2006) 2  Primary Care Retention 4 

Also missed during the controversy was a glimpse of what sufficient numbers of medical students could do for family medicine curricula. Usually family medicine programs appear to be all things to all types of students in the hope of attracting enough candidates. For the first time the programs had more than enough students interested. Family medicine programs no longer faced the same pressure to be much like other programs. Some were able to pursue a form of subspecialization quite different than the past 50 years. This movement largely appeared to be guided by the influence of program directors and their contacts, interests, and past experiences. Family medicine programs subspecialized into people and population needs and into available clinic populations, not organs, body parts, or technologies. The programs diversified into inner city training, liaisons with Community Health Centers, smaller programs, programs in rural areas, rural training tracks, fellowships (in geriatrics, obstetrics, procedures, rural, or sports medicine), and combinations of family medicine training with psychiatry, emergency care, other forms of primary care, and medical schools (Accelerated Family Medicine Training Programs).

Distribution levels were at a peak, those trained were trained more specifically for rural and underserved areas, and health policy increased the capacity of rural and underserved areas to support the increased numbers of primary care physicians, physician assistants, and nurse practitioners.

Also missed during the controversy was a natural experiment regarding limitations of graduate medical education positions. There were no official policies that cut subspecialty positions or any other first year resident positions, but the nation’s workforce reports forced student career changes that greatly diminished the choice of anesthesia, radiology, and pathology. Mental health and subspecialty choices also suffered during the era as health policy dictated different career choices. The students were forced into family medicine in subtle way that escaped much notice. Of course a more direct approach would have added to the controversy, but would also be likely to generate much the same results.

Also unnoticed was the rapid rise of Asian and foreign born medical students during this period. Asians in Education and Medical Education These are medical students most closely connected to medical schools by proximity, professional parents, most urban origins, and highest income levels. (Bowman 2006) 2  The full impact of increasing admissions of those least likely to distribute outside of major medical centers would not be discovered for some time yet, certainly not at a time when the nation was experiencing peak distribution and proving that the nation could distribute physicians, with the proper health policy support.

The nation’s choices of family medicine during the managed care period greatly exceeded the rural born percentages which continued to decline steadily. The departure was abrupt and unprecedented and in some ways beyond the health policy changes, indicating some level of panic generated from the controversy. The rebound from this would be just as abrupt.

Fifth Period: The Return of the Major Medical Center

The fifth and current period appears to be a complete reversal of the gains in health policy in periods 2 and 4. Some new problems have been added as well. Diminishing support for Medicare and Medicaid, internal shifts of Medicaid away from primary care (to chronic care and hospital care), academic primary care investments gone sour when increasing government and insurance support vanished, increases in a number of regulations, constant changes in regulations making practice more complicated (especially for the smaller groups), increases in the costs of delivering health care, massive increases in the cost of living and working in most medical school areas, massive increases in medical student tuition and cost of living, state budget crunches, the return of energy costs, deteriorations in education and social programs complicating the work of all professionals in underserved areas, active movements of private and so-called not for profit health care resources away from underserved populations, reversals in affirmative action and other indications of the use of the legal system to improve education and health opportunities for those with the highest income levels (and highest standardized test scores), massive declines in federal support of programs for lower and middle income areas, diversions of funding to defense and foreign policy, massive deficits, tax cuts, and resulting poor economics in rural and underserved areas have all played a role.

Exposing Changes in Admissions  This massive changes in this period did not result entirely from health policy changes alone. This period exposed the long term cumulative losses of lower income and rural born students that occurred before the period. The period did include more massive losses of the lower and middle income medical students from admissions. The changes were greatest for the 1997 – 2001 matriculants that were under the direct assault of medical school interpretations of reversals of affirmative action and US News and World Report rankings and changes in education. For the 16,000 entering medical students each year about 1500 lowest income and 1500 middle income types were replaced by medical students from parents making over $100,000 that increased by 3000 (3765 to 6828) during the period from 1997 to 2004. (Minority Students in Medical Education: Facts and Figures XI and XIII) ^{13, 14} This was an increase from 23% to 42% of medical students with continued increases likely for some time. The highest income and most urban replaced those most different in socioeconomics and distant in miles. Those with the greatest probability of distribution were replaced by those most connected to major medical centers. Students of the most urban and highest income origins, Asian students, and foreign born students had the highest probability of admission with probabilities 2 to 10 times greater. These groups are found in family medicine, primary care, rural, and underserved areas at the lowest levels in 2005. They were all born and raised in the closest proximity to the nation’s medical schools and they were the least likely to depart these practice locations, especially with loss of family medicine choice. There is little chance that current medical students with even more connections to major medical centers will leave such locations for practice at any higher level. Subspecialty needs in rural areas are particularly dependent upon rural born admissions. (Bowman 2006) 2

With the loss of health policy support for primary care and distribution and with the loss of the lowest income and rural born students, family medicine choice is becoming the only way to enhance distribution for the remaining students most connected to major medical centers during their first 30 years. Family medicine doubles distributional choices for all types of medical students. Those least likely to distribute are the most numerous medical students and increase from below national averages for distribution to twice the nation’s level of rural (8% to 19%) and twice the level of underserved (6% to 13%) physician location in the urban and highest income types. Family Medicine Physician Distribution 11

Impacts upon the highest income urban origin types are critical as 90% of US MD Grads are urban origin and 70% of the nation’s rural physicians are urban origin. Without rural origins or choice of family medicine, rural workforce concentrations decline below the 11% rural average. Without lower income origin students or choice of family medicine, underserved workforce concentrations decline below 7%. More graduates only dilute the concentrations further. NP and PA contributions also appear to have declined below the line. This is also a likely impact of health policy that supports subspecialty and major medical center employment at higher levels.

In the current health policy, the distribution of health professionals is reduced to admissions of those most likely to choose family medicine. This involves humble origin types of students. This in turn means changes in education and child development, most prominently in rural areas and in the major urban areas with medical schools where 50% fail to finish high school. (Jay Greene High School Graduation Rates in the United States)¹⁵ Teachers, nurses, public servants, and family physicians are difficult to graduate without the support of local, state, and national efforts in child development and early education. What the nation fails to observe is the tens of thousands of school teachers, nurses, and other serving young professionals that are born and raised and educated in states that distribute income and education who are recruited by states that fail to invest enough in children to support their own needs. They take what they need from every other state and nation. This results in losses of education and health resources from other nations, many of them allies in need of the stabilizing influences of health, education, economics, and leadership that stem from their best and brightest.

Admissions of distributional types of students is no easy task. The nation’s top 146 colleges have 74% from the top income quartile (Carnevale in Kahlenburg http://www.tcf.org/Publications/Education/leftbehindrc.pdf) ¹⁶ and the major socioeconomic advantages involved can be tracked back to child development. (Hart, B., and Risley, T. 1995)¹⁷ Medical students are much the same with 60% from the top quintile and another 20% from the second quintile. (AAMC Debt) ¹⁸ Declines in the admissions of distributional types of students and in choice of family medicine in US MD Grads are a disaster for distribution. The nation’s physician assistants and nurse practitioners have also followed the subspecialty and major medical center location pattern laid out by the nation. The primary care contributions of internal medicine and medicine pediatrics have declined below 30%. Only family medicine at 90% and pediatrics at 66% remain solidly behind primary care and only family medicine distributes outside of major medical centers with 57% compared to 31% of pediatrics. About 69% of office based internal medicine and pediatrics remains within major medical centers where multiple revenue lines supplement primary care and multiple duties dilute actual primary care contributions. (Bowman 2006)²

Other than family medicine outside of major medical centers with higher patient care volume, longer hours, higher levels of call, and some measure of procedures and hospital care; the nation has reduced primary care to a loss leader necessary for referrals or teaching purposes or cost savings.

The declines of NP and PA contributions in primary care also indicate health policy changes. PAs working with family physicians have declined from 40% to 28.5% in the past ten years and this trend is likely to continue at about 1 percentage point a year for some time. PAs in rural areas have declined from 25% to 17% and also decrease at a similar rate. http://www.aapa.org/research/index.html ⁵ The reason is simple. PAs and NPs are changing in origins, training, and practice locations. PAs and NPs were “designed” to help in primary care, rural, and underserved areas. However the design also allows (and in some way facilitates) movements away from areas that receive less support from health policy. PAs and NPs can generate more revenue in emergency rooms, procedural care, and major medical centers where health policy rewards hospital and subspecialty care. PAs get the higher salaries in major medical centers and those switching from primary care can gain 10 – 12% income boosts.  http://www.aapa.org/research/index.html   Primary Care Retention ^{4, 5} Primary care physicians, particularly family physicians and pediatricians with incomes fixed by Medicaid and Medicare and serving lower and middle income populations outside of major medical centers cannot meet these salary increases. About 60% of PAs have no call and this allows them to do shifts in emergency rooms, urgent care centers, corporate clinics, or chain stores. The massive support of major medical centers fueling the growth of PA and NP programs is also not a surprise. PAs and NPs allow major medical centers to save on their number one budget item: personnel costs. One of their most expensive items is physicians. PAs and NPs are much the same as family physicians in limited productivity studies comparing the best of the PAs and NPs to the most limited forms of family medicine in managed care and major medical center settings. PAs and NPs replacing emergency physicians, residents in training, and various hospital physicians and their benefits and shared profit plans can save millions.

The nation also failed to observe that the rebound from managed care and health reform basically returned choice in family medicine below the line of rural born percentage, indicating that the nation has little support for distributional careers. Fortunately the nation has other sources of family physicians in osteopathic and Caribbean and distant international schools. Also missed is the fact that family medicine continues at levels of graduates not much different than peak levels. The distorted allopathic focus has missed this.

Missing and Disturbing Information in the Age of Information

The rapid increases in the higher income and most urban medical students are changes ignored or impacts yet to be identified. Changes in NPs and PAs are evident only with national data that is often not available. It is no longer accurate to note that NPs and PAs will be the source of primary care in the future. The best that can be expected without changes in policy is for PA program growth to be able to maintain current numbers in the face of declining percentages in primary care and rural areas. Further declines in primary care from physician sources outside of family medicine have been mentioned, but have been underestimated in total impact in a number of areas. Continued family medicine contributions have been minimized, again largely a part of the allopathic US school focus.

Family medicine retention in primary care is a critical piece of evidence regarding health policy impacts. With declines or with compromises in family medicine, the differences would become invisible and the nation’s medical leaders could state that distribution is impossible. No medical educator should ever state this again. The nation has more than proven the ability to distribute physicians, even in difficult health policy periods and despite changes in education and income distribution.

Also missing throughout all the major health policy changes and in the workforce literature is the continued dedication of family physicians to their initial purpose. Family medicine continues to serve half of Community Health Center physician positions and 61% in rural locations. (Rosenblatt 2006)  ⁷  The RN plus FP model remains the nation’s choice in efficient, low cost, effective health care. Family medicine rural choices remain at 24% or 2 times the national average of 11% and underserved distribution at 16% or over 2 times the national average of 7%. Graduating more family physicians distributes physicians away from major medical centers. Graduating any other type of physician means more for major medical centers and the most served locations. ¹¹

Also disturbing in recent decades has been increased use of federal programs designed for rural and underserved areas by major medical centers. In some cases the programs were abused by a few to the point of near termination as in Rural Health Clinics, the termination of other forms of cost-based funding, and major reforms and regulations. Abuses in billing in a few medical schools have forced increasing regulations which have made it most difficult for the training programs in primary care or those with smaller numbers. Areas outside of major medical centers often do not have the expertise to apply for the more and more complicated forms of funding. Major medical centers have more than enough expertise to adapt to all funding methods, including rapid adaptations to prospective payment and managed care. Major medical centers have mastered federal and state shortage designations, use of National Health Service Corps scholarship and loan repayment physicians, bonus programs designed for shortage areas, and J-1 Visa positions (to meet increasing faculty shortages in medical schools).

What is perhaps most disturbing is that the nation has made the same “trickle down” mistake twice, fails to support the primary care and distributional areas that have been successful, allows health poli