February 08, 2011 Where Doctors Locate

By JOHN GOODMAN, PhD 

Pop quiz. How many doctors are at the top of Mt. Everest? None, actually. Yet, think about how many people get sick up there. Think about how many die.

Do you think extra bonus payments could coax a few doctors to relocate up there? What if we waived their student loan debt?

If you find these questions interesting, there's clearly something wrong with you. But cheer up. Today's Health Alert is written especially for your benefit.

As the map below shows, there is a lot of variation in the number of people per doctors across Texas counties. [Thanks to Jason Roberson and his colleagues at The Dallas Morning News for making the data available.] At one extreme, Bandera County in the Texas Hill Country has 21,266 people and only one doctor. At the other extreme, Baylor County, near the Oklahoma border, has 666 patients per doctor.

 

Should we care about any of this? If so, why?

Before getting into specifics, let me address a cultural issue that I believe greatly prejudices all discussions of doctor location.

Bandera County bills itself as "The Cowboy Capital of the World." It clearly promotes tourism. But the online reviews of its eight area restaurants don't make me want to visit any time soon. Ditto for the online reviews of its 10 hotels, motels and dude ranches. Still, a lot of people visit there and it has a growing population.

Now (here's the glitch) if you're a health policy wonk living, say, in Princeton or New Haven you cannot in your wildest dreams imagine why anyone would ever voluntarily choose to live in Bandera County. Think how far away it is from the Met, from Broadway, from Avery Fisher Hall. Think how far away it is from decent Chinese or Italian cuisine. Think how far away it is from… from… well, from civilization.

So to a great many of my colleagues, underdoctored areas are natural and inevitable. What graduate of Harvard Medical School is going to want to move to Bandera? It's hard to even imagine being able to bribe them enough with hard currency. It may require handcuffs and cattle prods, whips and chains â€" or whatever our 21st century courts rule is constitutionally permissible.

The problem with this kind of thinking is that it should apply to the other professions as well, if it were correct. After all, there's nothing particularly special about medical students. So I did a quick check and found seven area listings under "lawyer," seven under "accountant," and seven under "engineer." If Bandera attracted doctors at the same rate that it attracted other professionals, it would have a respectable 3,000 patient/doctor ratio!

So what makes health care different? To begin with, one-third of the U.S. population is in Medicare or Medicaid â€" government health insurance programs that impose price controls at a much different level than would occur in a free marketplace. A private health insurance system dominated by only a few large sellers, such as we have, then piggybacks on top of the reimbursement formulas used by those programs. Bottom line: in health care, when government dictates prices, the supply of health care cannot be properly allocated.

Another problem is that these discussions almost always ignore transportation. Surely the access issue is: how long does it take a patient to get to a doctor; not how many patients or doctors reside in any geographical area. Although this may come as a surprise to some, in most rural areas people no longer rely on horse and buggy. They almost all have… you guessed it… fossil fuel-burning vehicles. [I know. They pollute and cause global warming. A rational society would have rural free light rail. But what can you do?]

The Bandera County Chamber of Commerce, for example, lists seven Hill Country hospitals nearby, not counting San Antonio (about 70 miles from Bandera) and Austin (about 115 miles).  There are a dozen or so clinics as well.

Nationwide, most people in most "underdoctored" areas are not really that far from a doctor. A somewhat dated study in The New England Journal of Medicine found that 80 percent of rural residents lived within 10 miles' driving distance of some physician and 98 per cent lived within 25 miles.

Then, of course, there is the whole issue of medical practice laws that keep Physicians Assistants who treated our soldiers in the field in Iraq and Afghanistan from performing the same services for people who live stateside.

I'll sign off with a possibility not considered. Instead of patients traveling to see the doctor, why not reverse the travel pattern and let the doctor to come to you. Consider this:

Family practitioner Ken Jackson is known around Kingman, Ariz., as the "Cowboy Baby Doctor," though he says the nickname is a bit misleading â€" he doesn't always ride a horse or wear his cowboy hat, and he prefers alternative rock to country music.

But for the past three years, Jackson has traveled by horseback once a month deep into the Grand Canyon to provide prenatal care for Supai, a remote Native American village of about 400 that is inaccessible by automobile. It is the last place in the USA to which the U.S. Postal Service makes deliveries by mule.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

February 8, 2011 | Permalink

Comments

Besides some largely random points and pot-shots, was exactly was the point of this post again? There are shortages of a number of professionals (not just physicians) in a number of rural areas around this country. Part of the larger overall trend that has been ongoing where you are seeing massive depopulation in many parts of rural America for several reasons especially in the upper Midwest.

Posted by: MG | Feb 8, 2011 8:37:54 PM

http://anticanceragents.blogspot.com see this site to know about ANTI CANCER AGENTS in our foods and SAVE your life from CANCER

Posted by: Fayyaz | Feb 9, 2011 2:49:19 AM

Doctors locate where their wives want to locate.

Posted by: Peter | Feb 9, 2011 3:53:24 AM

This has been a problem for a long time in heathcare, and it predates Medicare and Medicaid. In fact, when Ronald Reagan recorded his record warning doctors' wives that Medicare was a socialist plot they should fiercely oppose, one of the dangers he cited was that Medicare would create a socialist government that would force doctors to practice where the government told them to, not where they chose. (Like all the other hysterical right-wing warnings, this did not come to pass).

In the 1960's, doctors' wives were well aware there wasn't anybody practicing in Appalachia or the Hill Country (where, incidentally, LBJ grew up), and most of them did not want to move from their very nice homes in Westchester or Beverly Hills to live there, so it was a VERY good scare tactic to get them to oppose Medicare.

Still, nice try to blame a market problem on the government. You get twenty conservative bonus points: 10 for slamming the government, and 10 for standing up against reality-based policy positions in favor of ideological bias.

Posted by: anon | Feb 9, 2011 5:10:53 AM

"So what makes health care different? To begin with, one-third of the U.S. population is in Medicare or Medicaid â€" government health insurance programs that impose price controls at a much different level than would occur in a free marketplace."

Then we shouldnt want to practice in NYC or Boston. You get the same patients and the cost of living is higher. Also, I was not aware that Harvard is the only medical school in the country. My wife went to med school at UTMB at Galveston, just so you know that other states have medical schools. (I know, this just an opportunity t take a shot at elites.)

As anon points out, this is a longstanding problem that precedes Medicare. Being old, and having grown up in the rural Midwest, I have firsthand experience with lack of access to medical care. When you have close family die because fairly routine emergency care was too far away, you tend to remember how things really were.

Lastly, after noting that Bandera has no docs, you claim that the surrounding area is full of them. That people do have access to care. Other than getting to take a shot at elites and AGW, what then was the point of this post? I think we can award you another 20 conservative points, 10 each for the elites and the AGW, to give you a grand total of 40.

Steve

Posted by: steve | Feb 9, 2011 5:47:56 AM

Even if Medicare and Medicaid paid the same rates as commercial insurers, doctors were paid twice what they could make in NYC, Boston or SF, and housing were free, most doctors would not want to live in rural areas. It’s a quality of life issue pure and simple. Even if they were willing to give it a shot, their spouses would probably object. With the possible exception of people who grew up in the area and like it enough to want to return and make it their home, it’s just not an attractive environment for doctors and many others as well, especially highly educated professional types. As MG notes, rural areas are likely to continue to depopulate. As farming and ranching continue to consolidate into fewer but larger entities, there will be fewer job opportunities that pay enough to support a family.

Posted by: Barry Carol | Feb 9, 2011 6:26:57 AM

Bandera County, being in the beautiful Texas Hill Country (and within driving distance of Austin and San Antonio) is arguably in a far better position that most rural counties. Doctors probably don't mind settling (or semi-retiring) in the area. Physicians are readily available in the larger towns. But, as other comments have said, rural communities are depopulating all across the country.

Physicians (and everybody else) increasingly do not want to live in small towns, remote areas or communities that lack the amenities commonly found in large cities. The rural county where I grew up subsidizes medical personnel who practice in the county. The county provides lavish income guarantees not just because of inadequate revenue (from too few residents), but presumably to encourage doctors to live (or commute) to the town, when physicians would otherwise would prefer to practice in larger towns.

I have fond memories growing up in a small, rural community but I sure don’t want to repeat the experience anytime soon. I like living in Big D â€" and the associated ability to try new restaurants, buy imported wines, shop at gourmet grocers (and visit friends) without having to drive 35 to 85 miles for mediocre products.

Posted by: Devon Herrick, National Center for Policy Analysis | Feb 9, 2011 8:41:52 AM

I would imagine the first question a physician considering locating to a rural area asks himself or herself is, "who is going to share my night and weekend coverage?"

As someone who was, for a number of years, the sole practitioner of a particular, emergency prone subspecialty in a rural county, I am familiar with the demands of this situation.

Lawyers and accountants don't have to consider this issue, and it profoundly affects one's quality of life.

Posted by: lurker | Feb 9, 2011 9:46:49 AM

Barry - You nailed the issues largely. Rural depopulation issues are almost exclusively tied to agricultural policies/trends in this country. They go hand-in-hand. Average farm has continued to get larger and larger for several reasons and independent ranchers have largely been run of the game due to the trends in the meat processing industry in the US.

Part of it is that younger people don't necessarily want the economic uncertainty/hardship of running the family farm but it is more simple economics. Just not enough job and higher-paying wages to support it. Not to mention the days of $1-$2/gallon gas are never coming back either.

Posted by: MG | Feb 9, 2011 10:08:07 AM

Post a comment