From trickle down to paying up: making money talk.

It is always useful to read thoughtful writing that criticizes failed policy, proposes creative solutions for seemingly intractable problems, and underscores that change will be resisted and success will be uncertain. In fact, such a robust formula could be and has been applied to a multitude of problems in the health services realm. Tom Weil's view on the issue of physician maldistribution draws ably on this genre to try to challenge, provoke, and persuade us that he has a better idea. As an observer interested in both the maldistribution issue and the Medicaid managed care context, I was challenged and provoked by his argument, but it failed as a conversion experience. What the Proposal Has to Offer Weil's article provides us with an apt and candid characterization of the failure and futility of past policies to address maldistribution of medical resources. For a variety of reasons, no matter how many physicians get pumped into the reservoir we never seem to reach the supersaturation point at which they settle out to underserved areas on a meaningful scale. The ghastly, inefficient process of growing numbers of schools, programs, and students has, ironically, exacerbated oversupply in desirable locations, further amplifying disparities. The oft-romanticized NHSC has provided only a modest, if not trivial, exercise in attacking the shortage problem with more political payoff than long-term, capacity-building value. This was brought home recently to me while visiting a city-sponsored health clinic in a major metropolitan area. During an interview with the clinic administrator, I was informed that one of their physicians was a NHSC physician because they were in a designated underserved area. I felt obligated to ask how the clinic earned an underserved area status considering that outside of his office window I could see the tower of a renowned children's hospital on the campus of a celebrated medical school only 5 blocks away. His response was, "It all depends on how you draw the boundaries." Likewise, our ambivalent and ambiguous policy toward IMGs is appropriately challenged by Weil. However, my characterization is that the United States is far less a "drain" on the medical manpower of these other nations, as Weil suggests, than a place of economic asylum for physicians of the world. The role of community health centers may have merited more discussion, because they are in many respects a manifestation of what Weil is proposing-pay a premium rate to those providing care in underserved markets. In fact, that is part of the justification for cost-based reimbursement to clinics that meet federal qualification, and there is some indication that such subsidies have made a difference, although their actual cost-to-benefit ratios are unclear. Notably, there has also been a concern about this model's susceptibility to gaming and distortion, as suggested by the conclusion of the General Accounting Office (GAO) that the rural health clinic program has at times been exploited (GAO 1996. A fuller lesson can probably be drawn from more careful assessment of such targeted subsidy models than suggested here. What Weil does most effectively is to advance the argument for using both economic incentives and purposeful contracting strategies with organized, accountable systems of care to persuade physicians to boldly go where they may not have gone before. His clear-eyed endorsement of the "money talks" precept is an important start because it gets beyond the illusions of the past, where "clinicians of conscience" were expected to opt for undesirable practice sites-something they have hardly done any more nobly than mail carriers of conscience or professors of conscience. The suggestion, attributed to Uwe Reinhardt, to stop equating the suburban radiologist to Albert Schweitzer comes to mind here. But the key issue raised in the proposal is whether we can convince organized delivery systems to put together comprehensive care configurations where buyers want them and to make the necessary resource allocation and deployment decisions to be accountable to purchaser specifications. …