Petterson1

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Petterson1

  1. 1. The Rural Health Professional Workforce Stephen Petterson, PhD Robert Graham Center
  2. 2. Overview <ul><li>I. Introduction </li></ul><ul><li>II. The Health Professional Workforce </li></ul><ul><li>-Definitions of Rural, PCSA, Primary Care </li></ul><ul><li>-Data </li></ul><ul><li>-Findings </li></ul><ul><li>III. Health Professional Shortages </li></ul><ul><li>-In US as a Whole </li></ul><ul><li>-Across Levels of Rurality </li></ul><ul><li>IV. Primary Care and Scope of Practice </li></ul>
  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
  4. 6. Definitions <ul><li>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. </li></ul>
  5. 7. Definitions <ul><li>“ 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) </li></ul><ul><li> “ 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) </li></ul>
  6. 8. Data <ul><li>2009 AMA Masterfile </li></ul><ul><li>2008 National Provider Identification (NPI) Data </li></ul><ul><li>Dartmouth PCSA-Level Measures </li></ul><ul><li>2008 ABFM Diplomate Data </li></ul>
  7. 9. <ul><li>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. </li></ul><ul><li>The Flexner Report, 1910; cited by Howard Rabinowitz </li></ul>
  8. 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
  9. 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
  10. 17. Primary Care NPs and PAs 0 2 4 6 8 10 0 .2 .4 .6 .8 1 PCP to Specialist Ratio Density
  11. 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
  12. 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
  13. 22. PC Physician Shortage by Level of Rurality: Nationwide
  14. 23. PC Physician Shortage by Level of Rurality: Virginia
  15. 24. Policy and Shortages <ul><li>Physician distribution is a long term a problem (GAO 2005, HRSA 2007, IOM 2004) </li></ul><ul><li>Payment reductions are a recurring threat due to the Medicare Sustainable Growth Rate (SGR) formulae 21% in 2010 </li></ul><ul><li>Three other Medicare payment changes were not part of the policy conversation </li></ul><ul><ul><li>Physician Scarcity Area, Geographic Practice Cost Index, Health Professional Shortage Area </li></ul></ul><ul><li>No one agency monitored the four policies </li></ul>
  16. 26. 2008 Potential Medicare Payment Reductions
  17. 27. Scope of Practice
  18. 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
  19. 30. Conclusion <ul><li>A mix of current options: </li></ul><ul><li>Expansion of CHCs and RHCs </li></ul><ul><li>Expansion of NHSC </li></ul><ul><li>Larger rural/shortage area bonus </li></ul><ul><li>Teaching health centers </li></ul><ul><li>Creative use of NPs/PAs </li></ul>

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