1. The Rural Health Professional Workforce Stephen Petterson, PhD Robert Graham Center
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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
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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
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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
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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
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
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Editor's Notes
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
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