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  • The RUCA classification is a collaborative product of Health Resources and Service Administration's Office of Rural Health Policy (ORHP), the Department of Agriculture's Economic Research Service (ERS), and the Rural Health Research Center (RHRC) at the University of Washington. RUCA is a relatively new Census tract-based classification scheme that utilizes the standard Bureau of Census Urbanized Area and Urban Cluster definitions in combination with work commuting information to characterize all of the nation's Census tracts regarding their rural and urban status and relationships. The Census Bureau defines an urbanized areas (UA) as densely settled territories that contain 50 thousand or more people and an urban cluster as .
  • For analytical purposes, primary care is based on specialty: Family Physicians, General Internists, Pediatricians, General Practitioners However, evidence that many physicians in these specialties are doing something else: Workforce studies often assume that primary care practice correlates with physician specialty. Recent evidence indicates that this is increasingly less tenable. A 2008 study in the New England Journal of Medicine reports that in 2006 19.0% of physicians who identified themselves as general internists practiced as hospitalists, up from 5.9% in 1996.23 A study of MEDPAC’s proposed Medicare claims-based definition of primary care shows that only 60% of family physicians and 40% of general internists meet the 60% threshold based on a narrow range of “primary care” codes.24 It can also be difficult to identify physicians who are retired or have otherwise left the workforce. For example, among the 580,000 physicians listed as being in direct patient care in the AMA Masterfile, about 38,000 are above the age of 70, with 18,000 of these above the age of 75. A recent comparison of the AMA Masterfile with U.S. Census Bureau Current Population Survey (CPS) data suggests the Masterfile may overstate the actual number of active physicians by 10%, due almost entirely to an overcount of physicians above the age of 55.25 Why focus on primary care in analysis of rural workforce? - Few specialists in rural areas…
  • ------------------------------------------------------------------------------------- -> rural_pcsa = 1 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 2659 28819.32 0 28819.32 28819.32 r_short~1500 | 2659 -25347.98 0 -25347.98 -25347.98 -------------------------------------------------------------------------------------- -> rural_pcsa = 2 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1115 1382.791 0 1382.791 1382.791 r_short~1500 | 1115 -6307.558 0 -6307.558 -6307.558 -------------------------------------------------------------------------------------- -> rural_pcsa = 3 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1343 655.7963 0 655.7963 655.7963 r_short~1500 | 1343 -4468.389 0 -4468.389 -4468.389 -------------------------------------------------------------------------------------- -> rural_pcsa = 4 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1202 334.6782 0 334.6782 334.6782 r_short~1500 | 1202 -2248.703 0 -2248.703 -2248.703 -------------------------------------------------------------------------------------- -> rural_pcsa = 5 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 218 54.63 0 54.63 54.63 r_short~1500 | 218 -296.3222 0 -296.3222 -296.3222 ------------------------------------------------------------------------------------- -> rural_pcsa = 1 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 2659 28819.32 0 28819.32 28819.32 r_short~1500 | 2659 -25347.98 0 -25347.98 -25347.98 -------------------------------------------------------------------------------------- -> rural_pcsa = 2 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1115 1382.791 0 1382.791 1382.791 r_short~1500 | 1115 -6307.558 0 -6307.558 -6307.558 -------------------------------------------------------------------------------------- -> rural_pcsa = 3 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1343 655.7963 0 655.7963 655.7963 r_short~1500 | 1343 -4468.389 0 -4468.389 -4468.389 -------------------------------------------------------------------------------------- -> rural_pcsa = 4 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1202 334.6782 0 334.6782 334.6782 r_short~1500 | 1202 -2248.703 0 -2248.703 -2248.703 -------------------------------------------------------------------------------------- -> rural_pcsa = 5 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 218 54.63 0 54.63 54.63 r_short~1500 | 218 -296.3222 0 -296.3222 -296.3222
  • ------------------------------------------------------------------------------------- -> rural_pcsa = 1 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 2659 28819.32 0 28819.32 28819.32 r_short~1500 | 2659 -25347.98 0 -25347.98 -25347.98 -------------------------------------------------------------------------------------- -> rural_pcsa = 2 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1115 1382.791 0 1382.791 1382.791 r_short~1500 | 1115 -6307.558 0 -6307.558 -6307.558 -------------------------------------------------------------------------------------- -> rural_pcsa = 3 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1343 655.7963 0 655.7963 655.7963 r_short~1500 | 1343 -4468.389 0 -4468.389 -4468.389 -------------------------------------------------------------------------------------- -> rural_pcsa = 4 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1202 334.6782 0 334.6782 334.6782 r_short~1500 | 1202 -2248.703 0 -2248.703 -2248.703 -------------------------------------------------------------------------------------- -> rural_pcsa = 5 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 218 54.63 0 54.63 54.63 r_short~1500 | 218 -296.3222 0 -296.3222 -296.3222 ------------------------------------------------------------------------------------- -> rural_pcsa = 1 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 2659 28819.32 0 28819.32 28819.32 r_short~1500 | 2659 -25347.98 0 -25347.98 -25347.98 -------------------------------------------------------------------------------------- -> rural_pcsa = 2 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1115 1382.791 0 1382.791 1382.791 r_short~1500 | 1115 -6307.558 0 -6307.558 -6307.558 -------------------------------------------------------------------------------------- -> rural_pcsa = 3 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1343 655.7963 0 655.7963 655.7963 r_short~1500 | 1343 -4468.389 0 -4468.389 -4468.389 -------------------------------------------------------------------------------------- -> rural_pcsa = 4 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 1202 334.6782 0 334.6782 334.6782 r_short~1500 | 1202 -2248.703 0 -2248.703 -2248.703 -------------------------------------------------------------------------------------- -> rural_pcsa = 5 Variable | Obs Mean Std. Dev. Min Max -------------+-------------------------------------------------------- r_surpl~1500 | 218 54.63 0 54.63 54.63 r_short~1500 | 218 -296.3222 0 -296.3222 -296.3222

Transcript

  • 1. The Rural Health Professional Workforce Stephen Petterson, PhD Robert Graham Center
  • 2. Overview
    • I. Introduction
    • II. The Health Professional Workforce
    • -Definitions of Rural, PCSA, Primary Care
    • -Data
    • -Findings
    • III. Health Professional Shortages
    • -In US as a Whole
    • -Across Levels of Rurality
    • IV. Primary Care and Scope of Practice
  • 3.  
  • 4. Definitions 10.0, 10.2, 10.3, 10.4, 10.5, 10.6 and >= 60 minutes travel distance to the nearest Urbanized Areas. Frontier 10.0, 10.2, 10.3, 10.4, 10.5, 10.6 and <= 60 minutes travel distance to the nearest Urbanized Areas Isolated Small Rural 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, and 9.2 Small Rural 4.0, 4.2, 5.0, 5.2, 6.0, and 6.1 Large Rural 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1; Urban RUCA Codes Rural Urban Spectrum
  • 5.  
  • 6. Definitions
    • The Primary Care Service Area (PCSA) Project offers the first national database of primary care resources and utilization for small areas. At the heart of the data are 6,542 areas defined by aggregating ZIP areas to reflect Medicare patient travel to primary care providers. The database includes information about pertinent health care resources, population descriptors, health care need measures, and Medicare utilization statistics.
  • 7. Definitions
    • “ Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” (Institute of Medicine, 1996)
    •  “ There is no question that part of improving health in poorer countries, as in richer, is the provision of comprehensive primary care.” (Sir Michael Marmot, Chair of the WHO Commission on Social Determinants of Health , 2006)
  • 8. Data
    • 2009 AMA Masterfile
    • 2008 National Provider Identification (NPI) Data
    • Dartmouth PCSA-Level Measures
    • 2008 ABFM Diplomate Data
  • 9.
    • The question is, then, not merely to define the ideal training of the physician; it is just as much [to]...distribute [them] as widely as possible.
    • The Flexner Report, 1910; cited by Howard Rabinowitz
  • 10. Physician Distribution across Rural-Urban Spectrum 424,773 45,388 72,180 10,525 80,239 301,621,157 Total FP: Family Physician, IM: General Internal Medicine, PD: Pediatrician. Data Source: American Medical Association Master File, July 2009; Census Population Estimate, 2007. 0.1% 0.1% 0.2% 0.8% 0.6% 1.6% Rural frontier 0.5% 0.5% 0.8% 3.4% 3.1% 2.5% Isolated small rural 1.8% 1.8% 2.4% 6.8% 7.4% 5.3% Small rural 6.4% 6.1% 6.6% 8.3% 11.1% 9.6% Large rural 88.1% 88.2% 87.4% 65.9% 75.5% 80.5% Urban Other PD IM GP FP Population RUCA
  • 11.  
  • 12.  
  • 13.  
  • 14.  
  • 15.  
  • 16. Counting NPs and PAs ARF = Area Resource File; GAO = Government Accountability Office; NPI = National Provider Identifier Count Study/Data Year Count Study/Data Year 62,771 NPI (RGC Analysis) 2008 92,000 NPI (RGC Analysis) 2008 73,075 ARF (2008) 2008 67,469 ARF (2008) 2007 47,575 ARF (2008) 2003 82,000 GAO Report 2005 Physician Assistants Nurse Practitioners
  • 17. Primary Care NPs and PAs 0 2 4 6 8 10 0 .2 .4 .6 .8 1 PCP to Specialist Ratio Density
  • 18.  
  • 19.  
  • 20. Data Source: National Provider Identifier (NPI), November 2008 4,669 61,250 90,031 301,621,157 Total 0.43% 1.32% 1.17% 1.56% Rural frontier 1.20% 1.47% 1.44% 2.54% Isolated small rural 3.34% 3.99% 4.13% 5.26% Small rural 8.31% 8.89% 8.77% 9.60% Large rural 86.72% 84.33% 84.50% 80.54% Urban CNM NP PA Population RUCA Table 3: Distribution of Physician Assistants, Nurse Practitioners and Certified Nurse Midwives Across Rural Urban Spectrum
  • 21. PCSA and State Level Capacity of Primary Care Workforce State analysis includes DC and PR. 1,674 438 10,101 6,125 #Excess Physicians/Providers 7 3 29 25 # States with “surpluses” -76,811 -69,627 -20,527 -13,915 #Physicians/Providers Needed 45 49 23 27 # States with “shortages” State Analysis 20,789 14,495 38,220 30,529 #Excess Physicians/Providers 919 708 1750 1,487 # PCSAs with “surpluses” -94,237 -82,681 -48,355 -38,642 #Physicians/Providers Needed 5,587 5,798 4,756 5,019 #PCSA with shortages PCSA Analysis 938:1 1154:1 1169:1 1500:1 Benchmark Providers Physicians Providers Physicians “ Optimal” Ratio National Average
  • 22. PC Physician Shortage by Level of Rurality: Nationwide
  • 23. PC Physician Shortage by Level of Rurality: Virginia
  • 24. Policy and Shortages
    • Physician distribution is a long term a problem (GAO 2005, HRSA 2007, IOM 2004)
    • Payment reductions are a recurring threat due to the Medicare Sustainable Growth Rate (SGR) formulae 21% in 2010
    • Three other Medicare payment changes were not part of the policy conversation
      • Physician Scarcity Area, Geographic Practice Cost Index, Health Professional Shortage Area
    • No one agency monitored the four policies
  • 25.  
  • 26. 2008 Potential Medicare Payment Reductions
  • 27. Scope of Practice
  • 28. Rural Scope of Practice Rural comprehensiveness reduces eligibility for proposed Medicare bonuses (MedPAC and reform bills) 76.7 54.3 Isolated/Frontier 72.8 49.1 Small Rural 69.5 46.6 Large Rural 78.7 62.9 Urban Post-adjustment Meet 50% Threshold Family Medicine meeting 50% “Primary Care” Threshold
  • 29.  
  • 30. Conclusion
    • A mix of current options:
    • Expansion of CHCs and RHCs
    • Expansion of NHSC
    • Larger rural/shortage area bonus
    • Teaching health centers
    • Creative use of NPs/PAs