There's no such thing as an "ideal ratio" of physicians per state, and many factors have to be taken into consideration to get an accurate assessment of physician access, says a Merritt Hawkins executive familiar with the data.
Northeastern states, led by Massachusetts, score highest in the nation on a new assessment of physician access.
The Physician Access Index, released Wednesday by Irving, TX-based physician recruiters Merritt Hawkins looks at 33 variables that could affect access to physicians, including, physicians per capita in each state, percentages of the state populations with health insurance, household income, access to urgent and convenient care, and Medicare/Medicaid acceptance rates.
Kurt Mosley, vice president of strategic alliances for Merritt Hawkins, says there's no such thing as an "ideal ratio" of physicians per state, and that other factors have to be taken into consideration to get an accurate assessment of access.
"It's one of those things depending on the state," he says. "In Massachusetts they have the highest physician to population ratio, but in our wait time survey they were the highest because 97% of the state is insured. There are always those factors. That is why we wanted to get our point across."
The Better the Metric, the Lower the Score
Massachusetts, which has 324 physicians per 100,000 population, finished first in the scoring with 442 points, while Oklahoma, with 182 physicians per 100,000 population, came in 50th with 1,096 points.
Using close to three dozen variables from sources as varied as the U.S. Census and the Association of American Medical Colleges provides interesting nuances to physician distribution and access to care. New York, for example, trains one-in-four physicians in the United States, yet is ranked 11th in physician access. New Mexico finished third from the bottom in the overall rankings, but ranks sixth in patient encounters per capita in Federal Qualified Health Centers.
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Atul Grover, MD, chief public policy officer for the AAMC, says the high physician per capita ratio in Massachusetts and New York are accurate, but doesn't tell the whole story. He credits Merritt Hawkins with attempting to provide a more detailed picture.
"They may appear to have a lot more physicians in the workforce, but that workforce may not be as available," he says. "Or if you look at the per capita numbers, the demographics of the people that are in that per capita population maybe very different, [and] may have higher healthcare needs."
"Think about some of the inner cities in Massachusetts and New York. Those needs may be very different in terms of high chronic disease, low health literacy, high minority populations, more people on Medicaid, than you have in say Dubuque, Iowa. This study tries to capture some of that by looking at rates of Medicaid and poverty. Those are all steps in the right direction.
In addition, Grover says, more than 50% of physicians in Massachusetts are on the faculty of some medical school or institution. "They may be able to offer only 20% to 30% of their time clinically and the rest of their time is spent teaching or in research, both of which are important, but aren't going to factor into access in the same way that a non-faculty community physician is providing care in a rural setting."
Emphasize State Strengths
Mosley says it's important that states understand their strengths and weaknesses as they try to recruit more physicians.
"Oklahoma has to look at this and say, 'we have to be more aggressive,'" he says. "The four factors that doctors always relocate for are quality of life, quality of practice, geographic location, and financial compensation. What can that hospital in Oklahoma do? Can they affect quality of practice? Absolutely. The issue of lifestyle and geographic location they can't do anything about. They're where they are. You focus and work aggressively on the opportunities you can control."
Mosley cited Texas as a state that has become "smart about recruiting doctors."
"Five years ago they did tort reform. Pain and suffering was limited to $250,000 and doctors started coming back into the state," he says. "They just refunded their state loan repayment program and it's better compensation than national health services corp. And the state is starting to fund their own residency programs."
"Our big issue has been to raise the cap on residency slots, nationally, but it's not getting done. Bills have been on the floor in Congress since 2007 and nothing has happened," Mosley says. "States are starting to see it's not going to come from Medicare funding, so they have to grow their own. The idea is to grow your own and keep them. And states like Texas are responding by trying to increase autonomy for nurse practitioners and physician assistants, and expand telehealth."
With a dallying dysfunctional Congress, Grover agrees that it may be time for states with acute physician shortages to start funding their own residency slots.
"States are going to have to at least take part of the burden," he says. "We have seen some action on that front in Florida, Texas, and Georgia state legislatures if not fund the positions then at least fund the hospitals that are willing to start training programs until they can build up to a Medicare cap and get some sort of a reimbursement from the feds as well."
One thing Congress definitely should not do, Grover says, is take away residency slots from states such as New York and Massachusetts and give them to other states with lower physician-patient ratios.
"When you talk about a lack of residency slots in Texas or Florida, it is not a zero-sum game where you can afford to take away resident training positions from New York, Minnesota, or Pennsylvania," he says. "Those states are now supplying a lot of physicians to states like Idaho and Wyoming and Montana. The challenge is there are not enough training slots, so places like Florida and Texas need to think about how they grow their training, whether through the creation of new teaching programs at prior nonteaching hospitals, which Florida and Georgia are doing, or working on legislation on the state and federal level to expand funding for residencies."
"There is more training going on in the Northeast because they've established those programs and made those commitments for a long time," Grover says. "If 50% of the hospitals New York are teaching hospitals and only 17% of the hospitals in Arizona are teaching hospitals, then there are a whole lot of hospitals there that could choose to start training residents."
The full report may be viewed here.
John Commins is the news editor for HealthLeaders.