Where Doctors Locate

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. 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 — 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 — 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 — 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.

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24 replies »

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  3. @John Smith makes a good point, that these estimates will be off, but I think the dispersion of the other providers he mentions will follow the same overall trends. I don’t think the wives of DOs or PAs are any more eager to move out to the boondocks for the long term (great comment, @Peter!).

  4. The data posted here are BS. It uses data compiled from the Texas medical board. Only problem is that the TMB only counts MDs, not DOs. DOs make up 35% of all doctors in Texas and furthermore are much more likley to pratice primary care than MDs, and probably more likely to practice in rural areas. So right off the bat this data is bunk because it ignores 35% of the working population of doctors.
    Secondly, this data set pretends that ONLY doctors delivery medical care. As any tour of Texas will tell you, there are thousands of “urgent care” clinics staffed by NPs and PAs in these rural areas; there is no doctor on site and they usually have an MD/DO available by phone for complicated patients or other supervisory needs.

  5. I think steve nailed it. This guy is a partisan hack, signing as a PhD and then posing as anti elite populist. Laughable.

  6. “It seems it would be cheaper to transport the people to where the doctors are, say by Careflite.”
    That’s what Alaska does, at least for it’s native population, which gets oil revenue and free federal healthcare.

  7. Loving County TX, the blank space near the SE corner of New Mexico on Goodman’s map, has 71 people and no doctors. It seems it would be cheaper to transport the people to where the doctors are, say by Careflite.

  8. The main medical need in rural areas is primary care and ER type care. Anyone in need of sophisticated surgery like a CABG or hip replacement should expect to get it at a regional medical center. If there is an immediate need for such care, the patient will probably need to be transported by helicopter.
    Since I and others have already commented that lifestyle issues account for why it is so difficult to attract an adequate number of physicians to rural areas, perhaps a reasonable alternative is to have docs based in cities or large towns rotate in and out for a week or two at a time to supplement the efforts of the docs who live there year round. They could staff clinics or offices that would include living quarters. Decent electronic records could facilitate handoffs. While it may not be an ideal solution, I think it

  9. So let’s say that there is no Medicare or Medicaid. Folks in rural areas would most certainly be unable to pay out of pocket for medical services, which would translate into even less potential revenue for physicians and increased need for charity care. Would that be a better incentive for physicians (or their wives) to relocate to rural areas?
    If anything, the fact that there is a shortage of health professionals in rural areas, is pointing out to a need for more government involvement in the form of higher reimbursement rates in those areas. Or perhaps free tuition in Medical Schools in exchange for a certain number of years of service in shortage areas.

  10. This really saddens me. As someone who has a sick father and spending thousands for the hospital bills and medical means, it is very frustrating. It feels like being sick and affording to have a great doctor is a privilege only for those with money.

  11. 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.

  12. 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.

  13. 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

  14. 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

  15. “So what makes health care different? To begin with, one-third of the U.S. population is in Medicare or Medicaid

  16. 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.

  17. 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.