Rural Concentrations of Physicians
Rural locations with concentrations of physicians are natural experiments worthy of observation. The impact of a rural super center or major center is significant. This impact of concentration on workforce and on surrounding locations is much more obvious in a rural location. In major urban environments the impact of physician concentrations is often hidden when medical center concentrations compete with one another, cluster together, and suppress nearby urban underserved or marginal urban physician levels.
Rural locations with top levels of physicians were considered as examples of concentrations for further study. The following are physician levels as captured in the 2005 Masterfile.
|
Demographics |
Physicians |
||||||||
|
County |
City |
ST |
Urban Inf 1993 |
Pop of County |
County Median Family Income |
Active Per 100,000 at zip code |
Total Active |
FM |
Office Primary Care |
|
Montour |
|
PA |
6 |
18,236 |
$45,224 |
1913.8 |
276 |
3.6% |
27.5% |
|
Grafton |
|
NH |
7 |
81,743 |
$50,424 |
715.66 |
586 |
8.4% |
26.5% |
|
Wood |
|
WI |
5 |
75,555 |
$50,798 |
322.94 |
435 |
7.1% |
36.1% |
|
Otsego |
|
NY |
5 |
61,676 |
$41,110 |
257.8 |
245 |
4.5% |
29.0% |
|
Oneida |
Rhinelander |
WI |
8 |
36,776 |
$44,293 |
176.75 |
144 |
7.6% |
35.4% |
|
Beaufort |
Beaufort |
SC |
7 |
120,937 |
$52,704 |
130.65 |
374 |
11.5% |
29.7% |
|
|
National |
|
|
% US Pop |
|
|
% US Docs |
|
|
|
All |
Super Center |
|
|
11.8% |
$54,631 |
804.1 |
38.5% |
6.2% |
28.6% |
|
Med Sch |
Super Center |
|
|
4.8% |
$50,767 |
837.5 |
16.4% |
5.0% |
26.6% |
|
Urban |
Super Center |
|
|
6.9% |
$57,346 |
778.9 |
21.9% |
7.1% |
30.2% |
|
Rural |
Super Center |
|
|
0.0% |
$48,310 |
1189.4 |
0.2% |
5.7% |
29.4% |
|
Rural |
Major Center |
|
|
1.8% |
$44,009 |
322.9 |
2.4% |
14.8% |
35.7% |
The example rural super center and major center locations are consistent with the national findings. The percentages of family practice and primary care are lower across all super center concentrations with rural and medical school super center locations having the lowest percentages of all. Despite lowest percentages, the three most concentrated rural centers listed above have sufficient primary care (physicians per 100,000 times office primary care percentage). The other three rural centers fail to reach the recommended level of 100 primary care physicians per 100,000.
The impact of graduate medical education is also important in rural super centers as in urban versions with 10 – 40% of physicians found in residency primary practice activities. The concentrations of physicians increase to higher levels when including residents. Dartmouth boosts physician and resident levels substantially in the Grafton County area of New Hampshire.
Counties adjacent to the above 6 rural center counties were marked and analyzed for workforce composition. Surrounding areas also have insufficient physicians with 40 – 75 physicians per 100,000 or less than 25% of the national physician average of 300. This is in the rural underserved range and indeed there were at least 4 of the 29 adjacent counties that were whole county primary care shortage areas. Surrounding areas also have top percentages of family physicians at 32% and primary care at 40% although the primary care physicians per 100,000 were in the 20 to 40 range or 20 to 40% of the minimum recommended primary care physicians per 100,000. This is also in the range of the locations with bottom primary care concentrations in the nation, the urban underserved locations.
Across the nation the super centers again have sufficient primary care, the major centers are right at the borderline of sufficient primary care, and the remaining 65% has insufficient primary care. Counties adjacent to concentrations have health care shaped at least in part by their powerful neighbor. Beaufort household and family income levels were $16,000 higher than neighboring counties and the adjacent counties had over 20% in poverty or double that of Beaufort. Montour County levels were $6000 higher than neighbors. The remaining adjacent counties shared similar income and poverty levels. Where poverty levels were slightly higher, the location was often designated as a whole county primary care shortage area.
The adjacency issues are not unique in rural health. Commuter counties face difficulties in economics and health care when positioned next to large economically powerful major metro areas. They are often whole county primary care shortage areas for some time until development, population growth, and medical centers move directly into the county and the adjacent county becomes a rapidly growing suburb. Rural counties that are adjacent to rural super center counties also feel the effects similar to commuting counties.
Not uncommonly the locations with concentrations of physicians also share concentrations of income and concentrations of poverty in the same location. This presents a challenge to cost and quality. The three most costly populations and those that are at risk for quality problems are represented. Concentrations of the wealthy who overutilize and have too much access, concentrations of those who work in health care who also overutilize and have too much access, and concentrations of poor who have combinations of too much and too little access and access health care inappropriately or not at all.
Lower middle income people appear to have the most difficult challenges of all at the current time as they make too much to qualify for help, their employers may not have the best health care coverages, and they make too little to be able to pay for medical care. Rural areas often have significant populations that are just below government guidelines to receive services, adding to the complexity of the health care problem.
Other Rural Location Types
Rural centers should be contrasted with marginal rural and rural underserved locations that have different populations, physicians, and workforce needs. Concentrations of poverty are consistent in rural underserved locations with 21% of the population at or below poverty. The marginal rural and rural underserved concentrations of physicians are 60 – 120 physicians per 100,000. This compares to 300 as the national average and much higher levels for rural super centers. Even with higher levels of primary care, marginal and underserved locations fail to have sufficient primary care.
Differences in Workforce Are Exposed with PDC Coding Rather than Geographic Coding
Comparisons with national averages can illustrate the magnitude of differences and some of the problems when using geographic coding rather than coding by physician concentration. The 1993 urban influence codes 3 – 8 are nonmetropolitan.
Responsibilities for Shaping Workforce Environments
The super center and major center coding schemes imply a central unit of organization, but in reality the PDC coding is based in the zip code geographic unit. It is important to remember that many of the zip codes, especially in the most urban areas, have multiple institutions or no institutions. The workforce decisions at rural super center locations are more easily traced to one institution.
Details Regarding Otsego County New York
More details are provided for Cooperstown NY at the zip code
13326. This is a RUCA 10.5 location that is designated isolated rural when
compiling RUCA codes into urban, large rural, small rural,
and isolated rural locations. The concentration of physicians at the zip code
is one of the highest in the nation with a Z-Score in physicians per 100,000 at
6.22 or six standard deviations above the norm. For the county location the
physician concentration was 1.95 standard deviations above for FIPS code 36077
or Otsego County.
About 50% of the physicians at Cooperstown were born in metropolitan locations and 50% were born in nonmetropolitan. Typically rural areas have 75% urban born. This is because 90% of United States physicians are urban born. The 10% rural born become about 25% of rural physicians. Cooperstown appears to do better than expected with rural origin physicians. This implies that Cooperstown is dependent upon rural born admissions. This is also confirmed in rural specialists, rural internal medicine physicians, and rural pediatricians.
Declining rural born admission levels with less than 8% of new entrants to the United States workforce represent a growing problem. The only other sources are J-1 Visa obligations (also declining) and the few remaining distributional medical schools in the nation. Major center locations such as Cooperstown may have a number of options to meet their needs. Rural marginal and underserved locations will have fewer options with fewer rural born physicians, fewer family physicians, fewer J-1 Visa obligations, and declining impacts from distributional medical schools, including some schools that have departed their distributional missions.
Family physicians are found at lower levels from a number of perspectives in Cooperstown. There seems to be little interest in hiring family physicians or perhaps family physicians are not interested in Cooperstown. Even during peak family practice production years and peak years of major medical center hiring of family physician only 1 family physician was recruited from the 1997 – 2003 FP residency graduates although the data can take time catching up for recent graduates. Again more direct studies are a better indication of local physicians. There was only 1 family physician listed in Cooperstown out of the entire 14 year cohort of 1987 – 2000 medical school graduates. Of course some could have been hired and terminated already using Masterfile 2005 data. Rural major medical centers have terminated family physicians, family medicine residency positions, and even family medicine training programs.
Rural Locations and Specialties
Most Concentrated, Remaining Rural Major Centers, Rural Served, Rural Underserved
|
FIPS, |
33009 Grafton NH |
36077 Oneonta NY |
42093 Montour PA |
45013 |
55085 |
55141 |
Other Rural MMC |
Marginal Rural |
Rural Under-served |
|
Allergy |
0.2% |
0.3% |
0.4% |
0.2% |
0.0% |
0.7% |
0.4% |
0.2% |
0.2% |
|
Anesthesia |
5.4% |
4.9% |
3.3% |
5.4% |
3.7% |
4.6% |
4.7% |
3.8% |
2.7% |
|
Cardiology |
3.5% |
2.6% |
3.9% |
2.4% |
0.5% |
2.7% |
2.4% |
1.4% |
1.3% |
|
Dermatology |
1.8% |
0.9% |
3.1% |
1.4% |
1.1% |
1.2% |
1.2% |
0.6% |
0.5% |
|
Emergency Med |
2.4% |
4.3% |
6.1% |
4.7% |
5.3% |
1.8% |
4.0% |
4.1% |
3.4% |
|
Family Medicine |
5.3% |
3.5% |
2.3% |
9.4% |
7.0% |
6.9% |
14.6% |
25.9% |
25.7% |
|
Gastroenterology |
1.5% |
2.0% |
2.9% |
1.7% |
0.0% |
1.9% |
1.3% |
0.6% |
0.7% |
|
General Practice |
1.2% |
0.3% |
1.2% |
3.3% |
3.7% |
0.5% |
5.0% |
7.0% |
9.8% |
|
General Surgery |
6.6% |
10.1% |
5.1% |
6.8% |
8.0% |
6.2% |
5.7% |
6.6% |
6.8% |
|
Internal Medicine |
20% |
27.2% |
21.1% |
11.9% |
20.3% |
25.3% |
15.3% |
12.8% |
14.5% |
|
Medicine Peds |
0.0% |
0.0% |
2.9% |
0.0% |
0.0% |
1.6% |
0.3% |
0.4% |
0.4% |
|
Neurology |
2.4% |
2.3% |
3.3% |
1.6% |
1.6% |
3.9% |
1.5% |
0.8% |
0.7% |
|
Neurosurgery |
1.4% |
1.7% |
0.6% |
0.5% |
0.0% |
0.9% |
0.6% |
0.3% |
0.1% |
|
Ob-Gyn |
4.0% |
4.3% |
5.3% |
9.1% |
7.0% |
3.5% |
5.6% |
5.2% |
5.3% |
|
Ophthalmology |
1.8% |
2.6% |
1.4% |
3.5% |
3.2% |
2.1% |
2.9% |
2.2% |
1.8% |
|
Orthopedics |
2.7% |
2.6% |
3.3% |
6.5% |
4.3% |
3.4% |
3.9% |
3.7% |
2.8% |
|
Otorhino (ENT) |
0.9% |
1.7% |
2.7% |
1.9% |
2.7% |
1.4% |
1.6% |
1.0% |
1.1% |
|
Psychiatry |
6.4% |
4.1% |
2.0% |
4.2% |
4.3% |
2.1% |
4.8% |
4.0% |
3.1% |
|
Pediatrics |
8.4% |
5.8% |
10.5% |
7.0% |
7.5% |
7.8% |
6.3% |
5.0% |
6.1% |
|
Physical Med |
0.2% |
0.3% |
0.2% |
0.5% |
2.7% |
1.8% |
0.8% |
0.5% |
0.3% |
|
Plastic Surgery |
1.2% |
0.9% |
0.6% |
0.3% |
0.5% |
0.7% |
0.5% |
0.3% |
0.2% |
|
Pathology |
4.2% |
2.6% |
2.9% |
2.8% |
2.7% |
4.2% |
2.5% |
2.0% |
1.6% |
|
Pulmonary |
0.7% |
1.4% |
1.4% |
0.5% |
0.0% |
0.7% |
0.8% |
0.3% |
0.5% |
|
Radiology |
5.1% |
3.2% |
5.7% |
5.8% |
7.0% |
5.1% |
4.6% |
4.0% |
3.3% |
|
Radiation Onco |
0.6% |
1.2% |
0.2% |
0.2% |
1.1% |
0.4% |
0.6% |
0.3% |
0.2% |
|
Thoracic Surgery |
0.6% |
1.2% |
0.4% |
0.2% |
0.5% |
0.9% |
0.5% |
0.2% |
0.2% |
|
Urology |
1.7% |
3.2% |
1.2% |
2.4% |
1.6% |
1.2% |
1.9% |
1.4% |
1.3% |
|
Others |
9.4% |
4.6% |
5.9% |
5.8% |
3.7% |
6.5% |
5.6% |
5.7% |
5.9% |
There are variations in specialty distributions when comparing the 4 types of rural locations. The most concentrated rural super centers and major centers have internal medicine-based models of care similar to super centers in urban and medical school areas. This may involve the initial model established and replicated ever since. It also may involve the tendency of major medical centers, regardless of geographic location, to hire the same personnel and to administrate health care in the same way.
Another possibility is that family physicians prefer to avoid major medical centers. This can involve inability to obtain the needed scope to do well, lower salaries, or effects of the environment. Of course with the decline of internal medicine, pediatric, nurse practitioner, and physician assistant primary care, family practice physicians are the remaining permanent form. Whether rural centers can adjust to be able to attract and retain family physicians is yet to be seen.
Specialists appear to decrease little visually across the table from left to right from super center to major center to marginal to underserved, but the decreases are consistently 20 – 40% across each transition. The specialty and primary care losses are replaced by family physicians. The scope of practice also increases for family physicians across the same gradient. This tends to address many specialty needs, but rural and even rural underserved areas still need specialists most prominently in areas such as cardiology, urology, orthopedics, psychiatry, and general surgery.
Family practice levels increase with decreasing concentrations of people, physicians, income, college education, professionals, social organization, and health facilities.
Although internal medicine levels are elevated in the rural super center locations, the internal medicine levels and pediatric levels are amazingly constant across a wide variety of geographic, socioeconomic, and other categories. The major shifts are away from specialists and toward family physicians. In physicians per 100,000, the family physician concentrations remain relatively constant at 20 – 40. One interpretation would be that family physicians distribute equitably to all locations unless their hiring and support is suppressed, as in areas of physician concentration (super center) or areas near physician concentrations where all physician concentrations are suppressed. These include marginal urban areas with reasonable income and some of the lowest poverty levels that should have more than 150 physicians per 100,000 and the urban underserved areas with only 80 physicians per hundred thousand, a level lower than even rural underserved locations. This again is an indicator of the potential impact of nearby concentrations to suppress nearby levels of physicians, especially in urban areas with close proximity.
Cooperative, Competitive, or Worse
The author also participated as an expert witness in a federal district court case. This involved detailed studies of the impact of a rural medical center upon surrounding counties and particularly the primary care and family physicians in these locations. The impact of top concentrations of physicians in rural centers can be identified in numbers and concentrations in nearby locations, but numbers do not approach the magnitude of impact out in the field. While some major centers can be cooperative and supportive of their smaller weaker neighbors, this may not be the case for all and workforce can be weakened along with the economics, services, and leadership associated with physicians. Health care quality is often involved. When physicians contact rural centers to indicate problems with the care provided, most would seem to be willing to work to improve health care. In some cases, it appeared that a simpler strategy was just to take over the weaker location.
Urban Competition
New developments can also mean additional problems for rural centers. Subspecialty physicians have developed their own hospitals focused on various surgical procedures. This can impact all rural hospitals indirectly with losses of services and rural centers more directly with losses of specialty physicians.