Chapters Rely on Physician Withdrawal Maps to Show Importance of FPs

Vincent Keenan, C.A.E., EVP of the Illinois AFP, adheres to the old adage that a picture is worth a thousand words; in the past few years, he has put that maxim to good use by relying on a series of physician withdrawal maps to show state legislators the dramatic impact of family medicine on health care access and outcomes. The maps are produced by the AAFP's Robert Graham Center in Washington, D.C.

"We can talk all we want about continuity of care and other things that are helpful," Keenan said in a recent interview. "But when you show those maps, you get instantaneous recognition of the situation."

The Graham Center has produced the physician withdrawal maps for the past seven years, updating them on a regular basis and making them available through the center's Web site. The center released its most recent set of physician withdrawal maps in late February. The maps, which are based on data from the Health Resources and Services Administration, the AMA and the U.S. Census Bureau, show the distribution of physicians throughout the United States, pinpointing areas of the country where physician shortages exist.

The federal government defines a physician shortage area -- called a "primary care heath professional shortage area" -- as a county (or a parish or borough) having only one physician for every 3,500 people.

The maps also demonstrate the impact of withdrawing family physicians and subspecialty physicians from the nation's health care infrastructure on a county-by-county basis, providing evidence about the importance of family medicine to the nation's health care system.

"The health care system depends on family physicians unlike any other specialty," said Robert Phillips Jr., M.D., M.S.P.H., director of the Graham Center. "People depend on family physicians for their health care unlike any other specialty."

In Illinois and other states, the maps are a component of physician advocacy efforts and are used by chapters to push for greater funding increases and to thwart attempts to cut physician reimbursement rates and other physician-related initiatives. The Illinois AFP, for example, distributed the maps to Cook County officials last year when they were considering a 17 percent reduction in the county's budget, a reduction that would have adversely affected family medicine. Cook County encompasses Chicago.

"With the maps, we were able to show officials the effect of that and how difficult it would have been for the county health system to provide many types of health care services without family physicians," Keenan explained.

In addition, Illinois lawmakers voted to cut funding for the state's competitive residency grant program during each of the past two years, but the Illinois AFP was instrumental in restoring the funding that had been cut in both instances by using the maps to demonstrate the vital role of residencies in producing family physicians and offsetting physician shortages, Keenan said.

The maps are a visual representation, a way of visually describing the role of family medicine, an important advantage in today's advocacy environment.

"It is not enough anymore in legislative politics or public advocacy to just tell a story or to even have a fact sheet," said Tad Fisher, EVP of the Florida AFP. "We need a visual of the story we are trying to tell."

The Graham Center has produced a total of six maps, each one color-coded to delineate physician shortage areas, partial physician shortage areas and nonshortage areas on a county-by-county basis.

Nearly 65 percent of the nation's counties are complete or partial shortage areas, demonstrating a "misdistribution" of physicians, according to Phillips. Unlike physicians in other specialties, family physicians are able to establish thriving practices in every part of the country, and, as a result, the distribution of family physicians largely mirrors that of the general population, a fact underscored by the withdrawal maps. Twenty-three percent of family physicians, for example, practice in rural areas, compared with 9 percent of internal medicine physicians and about 6 percent of pediatricians.

"Family physicians are the specialty that distributes most like the population," explained Phillips. "They live where people live, and they are the most accessible specialty for that reason."

In addition, "the United States government is particularly dependent on family medicine in rural and underserved areas," said Phillips.

The withdrawal maps demonstrate the extent of that dependence, showing, for example, that the withdrawal of family physicians would create nearly 750 new physician shortage areas, a 23.8 percent increase over current shortage levels. By comparison, the withdrawal of internal medicine physicians would lead to a 2.9 percent increase in the number of shortage areas, and the absence of pediatricians would increase the shortage areas by 1.1 percent. The withdrawal of OB/Gyn physicians would have the least impact, increasing the shortage areas by a scant 0.6 percent.

"I would like to see states own these maps," Phillips said. "I would like them to know the messages that are behind (the maps) and to use them to effectively negotiate better Medicare rates and better support for their residency programs."

Within the next several weeks, the Graham Center will launch a web-based mapping tool that allows users to tailor the maps to their individual needs. One component of an "interactive Web atlas" known as HealthLandscape, the tool will enable a physician or state chapter executive to enter an address into the system and find out whether it lies within a physician shortage area.

Furthermore, by using HealthLandscape, residency programs will be able to enter the address of their program into the tool and then instructing it to withdraw that program's graduates. This exercise will allow them to determine and demonstrate the program's impact on the health care system and to forecast what could happen if that program disappeared.

During the past few months, the Graham Center gave chapter executives for Florida, Georgia and a few other states access to the HealthLandscape technology, and it has already become an important tool in persuading state legislators to increase funding for residency programs that train family physicians.

Earlier this year, for example, Fisher and Florida AFP members met with the state senator who chairs Florida's Higher Education Committee, expressing concerns about projections for the training of primary care physicians and underscoring the importance of state residency programs that train family physicians. Florida will need 11,000 new primary care physicians between 2007 and 2020, according to Fisher.

The state senator resides in the Daytona Beach area, where a family medicine residency program is located. By using the HealthLandscape maps, Fisher was able to depict the spread of physicians who graduate from the program, showing that most of them settle within a 90-mile radius.

"I made the point that a lot of these doctors become embedded in that community and go on to become good public citizens involved in the community," Fisher noted.

Meanwhile, the Georgia AFP is supporting a bill that would boost the state's contribution to family medicine residency programs by $612,000, increasing the yearly per patient capitation rate from $19,000 to $21,000, said Fay Fulton Brown, M.H.S., executive director of the Georgia AFP. If approved, the increase would make the state a more attractive option for prospective medical students, said Brown.

Not surprisingly, the HealthLandscape maps have been a major part of the effort to increase those capitation rates.

"Everyone is looking for data," Brown said. "People want to know that if you put $612,000 into budget, it will generate something positive for the state."

Brown said the new mapping technology "will take us to the next level, giving us the tools to back up what we have been saying."