Changes in Physician Manpower: 1984-90

To view this page ensure that Adobe Flash Player version 9.0.124 or greater is installed.

Please login or register to make a comment!

© Oklahoma Medical Research Foundation " Center for Health Policy Research " 600 South College Avenue, Tulsa, OK 74104 (918)-5 82-5607 Health Policy Brief: Changes in Physician Manpower: 1984-90 Third in a series ... I n t r o d u c t i o n A major emphasis of the 1986 study by Duffy, Lewis and Miller was to estimate the need for Oklahoma physicians based upon specialty and multi-county planning regions. 1 To determine the relative supply of physician need within a county, Duffy et al.

grouped physician specialties as either primary, secondary and tertiary care. Primary care specialties were family practice, general practice, internal medicine, pediatrics and obstetrics & gynecology. 2 The remaining specialties were grouped a secondary care if the physician-to-100,000 population (PTP) ratio was greater than 2.3, and tertiary care if the PTP ratio was less than 2.3.

This grouping utilized the Graduate Medical Education National Advisory Committee (GMENAC) suggested physician specialty-to- population ratios. Based upon these groupings, they calculated the surplus or deficit of physician resources within specific geographical areas in Oklahoma. Primary care physician ratios were calculated by county; secondary care ratios by 22 multi-county hospital planning areas; and tertiary care ratios by catchment areas ... more. less.

of Tulsa and Oklahoma City. Oklahoma City and Tulsa are the two major metro- politan cities of Oklahoma. They represent approximately one-third of the state population. The physician-to-population ratios, when compared to suggested GMENAC specialty ratios, yielded csur- pluses d or cneed d for physicians in each specialty for each of these regions. The 22 hospital trade areas were not originally developed as a model to reflect needed physician distribution and therefore may not be the most appropriate method from which to determine the geographic cneed d for secondary and tertiary care physicians in a planning area because Oklahoma does not have 22 centers of csecondary care. d For example, Cimarron and Texas counties in Northwestern Oklahoma comprised a planning region with a population of 22,000. It seems economically impossible to support 19 secondary care physicians in this area as suggested by the previous analysis. The GMENAC methodology was not intended as a tool for the computation of physician need within states or regions of states. Furthermore GMENAC does not deal with population density, or optimum travel distances within a geographic area. We enlarged the hospital trade areas to better describe an economic market size that compensates for low population density. The method in this paper examines seven contiguous geographic service areas, and also provides an overlay to 50 mile service sectors to visually exam- ine distances and travel times within and between regions. Although the dramatic changes in transportation, hospital bed utilization and the increase in hospital based physician specialties has changed the infrastructure of medical care in the United States, the The most recent Oklahoma physician manpower analysis was completed in 1984-86. Those studies provided projections for the year 1990 and beyond. The study, cOklahoma Physician Manpower" updates, analyzes and refines discussion and methodologies in previous analyses. It includes 145 pages of discussion, analysis, and reference material. This brief synthesizes the 3rd of five studies in the complete analysis, "Specialty & Geographic Variations." The sections of the complete study are: " Medical Education in Oklahoma " Physician Manpower Revisited " Specialty & Geographic Variations " Factors Influencing Change " Projections and Need All methodologies are documented, and all citations included in the complete study but some may be omitted here for brevity. Copies of the complete study are available from the Center. This analysis was co-authored by Michael Lapolla, MHA, F. Daniel Duffy, MD and C.S. Lewis, Jr. MD. Drs. Duffy and Lewis co-authored the most recent state manpower studies in 1984 and 1986. Mr. Lapolla is the Director of the OMRF Center for Health Policy Research; Dr. Duffy is Professor and Chairman, Department of Internal Medicine, University of Oklahoma College of Medicine-Tulsa; and Dr. Lewis is a practicing physician in Tulsa, OK and Past President of the American College of Physicians. October 1990 Health Policy Brief: Changes in Physician Manpower 1984-90 Oklahoma Medical Research Foundation " Center for Health Policy Research " 600 South College Avenue, Tulsa, OK 74104 2 people, and their legislative representatives, from lower population density areas may still view the desirable geographic distribution of physician services for 1948 as that desired in 1990. Such a view will perceive a concentration of physicians in densely populated areas to be an oversupply, and fewer physicians in sparsely populated regions to be a shortage. This presumed maldistribution may be more perception based upon desire than a reality based upon the viability of certain physician services in a given geographic area. We undertook this analysis of geographic distribution of physician specialties in Oklahoma to document the location of specific services and to determine the magnitude of any maldistribu- tion. Finally, since we had a good data base for 1984 and 1990, we want to determine the movement of physicians over this six year period. M e t h o d s We divided the state into seven geographic regions to analyze physician movement and distribution. They are shown in Figure 3-1. These seven regions resulted from an analysis conducted at the OMRF Center for Health Policy Research. 3 These regions were described from an examination of actual patient travel patterns as reflected by hospital admissions, volumes of admissions, and existing health care support services within multi-county areas. A similar method was used to derive the 22 multi-county regions used by the Oklahoma State Department of Health. The geographic distribution of hospitals and physician manpower today resulted from a major post-World War II government investment. This effort included major infusions of funds to expand medical schools, hospitals and other segments of our delivery system. Travel time and distances between sites of care was greater than today. A goal was to place services within reasonable distance for patients. The post World War II hospital bed planning was based upon inpatient utilization rates that were much higher than exist today. 4 Given that physicians will concentrate their professional activities within close proximity of hospitals, it follows that physicians will be more geographically concentrated in the 1990 9s, and patients may travel greater distances in much less time than before. In this analysis, we assumed that patients will travel up to 50 miles and/or up to one hour to seek specialist physician care. For the vast majority of Oklahomans, that distance will be much less. Figure 3-1 is a map of the seven regions with circum- scribed 50 mile radius sectors. This map was constructed by connecting the Oklahoma and Tulsa circles and creating an oval extending northeast to southwest. That oval was surrounded by contiguous 50 mile sectors. The major secondary care center cities are also shown, as are the major out-of-state medical care centers along the Okla- homa border. Almost every portion of Oklahoma lies within a sector, with the exception of the far northwest and some of the southwest. The cities and towns which provide medical care services in each region all fall within 50 mile sectors. The sectors contain all of the secondary care centers in Oklahoma described by Duffy et al. It is interesting to note the number of cities that are at or very near the borders of two sectors thus potentially serving two sectors. We choose to examine specialty physician distribution in the context of these seven geographic regions. R e s u l t s The PTP ratios of the seven regions naturally segregate into three levels. The Oklahoma City-Tulsa regions (Central and North East) have the highest ratios and they contain the state 9s most specialized care centers. The North Central region has the next highest ratio. It includes the Enid MSA and medical education programs in Enid, and has a ratio of hospital-based and surgical specialties approaching Oklahoma City and Tulsa. The remaining four planning regions form a third level with relatively small PTP ratios. These geographic areas contain rural counties with medium to small sized commercial and health care centers. Fort Smith CENTRAL Amarillo Sherman Denison Wichita Wichita Falls NORTH WEST SOUTH WEST 050100 miles Joplin SOUTH EAST NORTH CENTRAL NORTH EAST SOUTH CENTRAL Texarkana Figure 3-1 Regional Analysis Map Circumscribed 50 mile Sectors Health Policy Brief: Changes in Physician Manpower 1984-90 Oklahoma Medical Research Foundation " Center for Health Policy Research " 600 South College Avenue, Tulsa, OK 74104 3 Some of the most apparently underserved counties of Oklahoma in the Duffy et al. paper border a major secondary care center in a neighboring state. We consid- ered the manpower needs of counties and regions in Oklahoma in relation to these neighboring centers of medical care. Table 3-1 lists the principal neighboring centers of care with the 1986 physician census and estimated population. Similar size cities in Oklahoma are also listed. In every case, the concentration of physicians in these border regions is greater than the similar secondary care centers in Oklahoma. It is known that residents living along the Oklahoma borders seek secondary secondary services (community hospital) out-of-state. Several important changes occurring concurrently during 1984-90. The total number of physicians increased modestly and the 1984-90 physician manpower changes occurred in intra-state movement resulting from the replacement of physicians discontinuing practice. This churning of specialties and regions is described by the major findings: "A change in primary care specialty mix. "An increase in medical and hospital-based physicians. "Some movement from smaller, less populous regions toward regional centers. "Large net increases in Oklahoma and Tulsa counties. Changes in Physician Specialty Numbers As shown in Table 3-2, all specialty groups increased their absolute number of physicians except the Family/ General Practice group which had 32 fewer physicians in 1990 than in 1984. Since the Family/ General Practice group has the largest number of physicians in the state (1,316 in 1990) the loss of 32 repre- sented a 2% decline in this specialty group. The Medical Specialty group grew the most, adding 115 physicians for a 14% 1984-90 growth rate. Following close behind was the Hospital Based specialty group which added 90 physicians for a similar 14% increase. Oklahoma experienced a 6.2% increase in total physician manpower growing by 274 physicians from 1984 to 1990. When one looks at the specialty mix according to primary, secondary (community hospital) and tertiary (urban referral center) care, the greatest growth was in the secondary care specialties. They grew by 208 physicians for a 12% growth rate. The tertiary care group had a 6% growth by adding 22 physicians. The primary care specialties barely changed by gaining 7 physicians for a 0.4% growth rate. Table 3-2 Changes in Oklahoma Physician Manpower 1990 Compared to 1984 By Specialty Groups G r o u p 1984 1990 C h a n g e P e r c e n t Family/General1,3481,316-32-2% Medicine834949+11514% Surgical814843+294% Hospital Based659749+9014% Pediatrics292293+10% Ob/Gyn257273+166% Psychiatric207225+189% Other Specialties 39 76 + 3 7 9 5 % GRAND TOTAL4,4504,754+2746% Population3,297,9003,309,700+11,8000.4% Since each specialty group represents specialties which share common features, they may be grossly linked; however, to get an accurate picture of the specific types of physician services available, one must examine changes within the groups. Family/General Practice and Primary Care In Family/General Practice the 2% decline of 32 physi- cians was the result of the loss of 59 DO and 57 MD general practice physicians. This physician attrition of 116 was the expected rate considering that 1,348 of these physicians were in practice, and they represented some of Table 3-1 County Physician Data for Medical Service Centers Bordering Oklahoma Est. CountyMD & DOCounty City/State C o u n t y P o p u l a t i o n P h y s i c i a n s PTP Ratio Amarillo, TXPotter98,637395400.5 Ft. Smith, ARSebastian94,930261274.9 Texarkana, TXBowie75,301163216.5 Joplin, MOJasper86,958178204.7 Wichita Falls, TXWichita121,082245202.3 Sherman/Denison TXGrayson89,796174193.8 Enid, OKGarfield61,400110179.2 Muskogee, OKMuskogee70,162115149.2 Lawton, OKComanche122,706142115.7 Health Policy Brief: Changes in Physician Manpower 1984-90 Oklahoma Medical Research Foundation " Center for Health Policy Research " 600 South College Avenue, Tulsa, OK 74104 4 the oldest practitioners in the state. The attrition was nearly offset by the 83 additional family practice physi- cians entering practice during this period. The sizeable number of new physicians did not, however, compensate for the large attrition. The losses to primary care produced by the Family/ General Practice group were completely offset by the gains in the other primary care fields of general Internal Medicine, Pediatrics and Obstetrics & Gynecology. Internal Medicine added 20 new physicians, Pediatrics added 4 and Obstetrics & Gynecology added another 16. These 40 additional primary care physicians combined with the 83 new Family Practice physicians produced a net gain of 7 primary care physicians for the state. Medical Specialties Cardiology grew by 56 physicians. This is the largest percentage increase (95%) within any specialty group. The absolute growth was 56 physicians which was second only to Family Practice. Within the Medical specialty group the next highest growth rate was in general internal medicine with 20 physicians for a 4% increase. Neurol- ogy with 12 (28%), Hematology/Oncology with 11 (31%), Gasteroenterology with 10 (22%) and Pulmonary with 8 (29%) increased their individual specialty numbers by more than 20%. With the exception of Hematology/Oncology, all of the major gains were accomplished in the procedure oriented specialties. These specialties require hospital resources. They tend to be well compensated for their technological services. The gains in Hematology/Oncology can be attributed to the increasing number of cancer patients and the need for in-state specialized services for their care. The losses all occurred in the more purely ccognitive d specialties, those specialties that rely upon physical examination and laboratory interpretation for their skill. These specialties have been less well paid than procedure oriented specialties. The federal government is attempt- ing to remedy the perceived payment imbalances of ccognitive d and cinvasive d specialties by adopting reformed method of physician payments through the Medicare program. The proposed Resource Based Relative Value Study (RBRVS) will attempt to recognize all specialties for skill, time and resources required to render care in relation to each other. The RBRVS is to be used by Medicare program as a basis for physician payment. 5 Table 3-3 Changes in Medicine Specialty Group 19841990ActualPercent S p e c i a l t i e s M a n p o w e r M a n p o w e r C h a n g e C h a n g e Anesthesiology1772062916% General Medicine487507204% Allergy2317-6-26% Cardiology591155695% Dermatology495124% Endocrinology1614-2-13% Gastroenterology46561022% Hem/Oncology36471131% Infectious Diseases98-1-11% Nephrology1719212% Neurology43551228% Pulmonary2836829% R h e u m a t o l o g y 21 24 3 1 4 % Totals83494911514% Hospital Based Specialty Physicians The Hospital based specialty group was the second largest growing group. It increased by 90 physicians for a 14% increase. This group accounted for almost one-third of the total 1984-90 increase in Oklahoma. Anesthesiology had the largest gains by adding 29 physicians for a 16% increase. Emergency Medicine grew by 22 physicians for a 15% gain. Adding only a few physicians (3) to a small base number provided a 75% increase in Nuclear Medicine; likewise the 5 additional Physical Medicine physicians produced a 56% gain. Radiology increased by 18 for an 8% increase and Pathology grew by 13 for a 12% gain. Over the six year period of this study, the Hospital Based specialties have increased the volume and mix of services available, especially in Radiology. The reimbursement patterns for the specialties in this group tend to be at the higher end of the scale. The increase in self-reported Emergency Medicine physicians may represent a change in practice location. Few of the Emergency medicine physicians practicing in Oklahoma are board certified Emergency Medicine physicians as the graduates from these GME programs are few. The large increase may represent some physicians leaving general GME programs, or leaving independent general practice and joining emergency medicine groups. The increase in Emergency Medicine physicians may account for some of the decrease in General Practice physicians. Health Policy Brief: Changes in Physician Manpower 1984-90 Oklahoma Medical Research Foundation " Center for Health Policy Research " 600 South College Avenue, Tulsa, OK 74104 5 Table 3-4 Changes in Hospital Based Specialty Group 19841990ActualPercent S p e c i a l t i e s M a n p o w e r M a n p o w e r C h a n g e C h a n g e Anesthesiology1772062916% Emergency Med.1421642215% Nuclear Medicine47375% Pathology1121251312% Physical Medicine914556% Radiology215233188% Totals6597499014% Psychiatric Specialties These specialists increased slightly with a gain of 11 (6%) adult psychiatrists and 7 (70%) child psychiatrists. Changes have occurred in demand, roles of professionals, and clinical compared to counselling services. There is a growing number of non-physician providers. Table 3-8 demonstrates the growing number of mental health workers nationally. Psychiatrists increased 30% while other mental health professional increased by 96%. Comparable data is not readily available for Oklahoma. Table 3-5 Changes in Psychiatric Specialty Group 19841990ActualPercent S p e c i a l t i e s M a n p o w e r M a n p o w e r C h a n g e C h a n g e Child Psychiatry1017770% Adult Psychiatry 197 208 11 6 % Totals207225189% Obstetrics and Gynecology Only one physician specialty is included in this group. These physicians increased by 16 for a 6% overall increase. Of ongoing public concern is the numbers of these physicians, as well as Family/General physicians choosing to discontinue the obstetrical portion of their practice while continuing to provide gynecological services. The Obstetrics and Gynecology physicians will continue providing obstetrical care to a much greater degree than Family/General physicians. 6 Surgical Specialties There was little overall growth within these specialties. The group increased by 29 for a 4% increase. Within the group, General Surgery lost 13 physicians for a -5% change. Thoracic Surgery also lost 14 physicians fore a 40% decline. There was an increase in each of the other specialties. Orthopedic Surgery grew the most by adding 16 physicians for a 10% increase. Otolaryngology grew by 25% by adding 15 specialists to the field. Urology grew by 13 physicians representing a 16% increase and Ophthalmology added 7 physicians for a 5% growth. Neurosurgery grew 12% by adding 4 physicians and Plastic surgery added 1 physician for a 3% increase. The decline in General Surgery physician, and the increase in other surgical specialties reflects national trends. The increase on Otorhinolaryngologists may have offset the decrease in Allergists; more allergy care is being rendered by ORL physicians, and surgical proce- dures in the field become less frequent. Increases in Urology and Orthopedic Surgery, specialties needed by older patients, are growing consistent with the aging population. P e d i a t r i c s These specialties grew the least by adding only 1 physi- cian to Oklahoma practice. General Pediatrics added 4 physicians for a slight 2% gain and Neonatology added 3 for a 25% increase. Every other sub-specialty field lost physicians. The population base required to support the services of a pediatric sub-specialist may be greater than Oklahoma can provide. Since there are very few physi- cians in these fields in Oklahoma, slight changes in numbers cause large percentage changes. Movement to Regional Centers Table 3-3 demonstrates the change in physician man- power for each specialty group in the urban referral centers (Oklahoma City and Tulsa) compared to the other 75 counties in the state. The aggregated 75 counties, other than Oklahoma and Tulsa, lost Family/General, Pediatrics and Obstetrics & Gynecology physicians. Nearly one-third of the added Medical special- ists and Hospital Based specialists located in counties other than Oklahoma and Tulsa. Half of Oklahoma 9s counties Table 3-6 United States Mental Health Professionals for 1975-85-90 P r o f e s s i o n a l 1975 1985 1990 1975-90 Psychiatrists26,00033,00036,00030% Clinical Psychologists15,00033,00042,00082% Clinical Social Workers25,00060,00080,00092% Marriage/Family Counselors 6,000 28,000 40,000 1 2 1 % Totals72,000154,000198,000 Health Policy Brief: Changes in Physician Manpower 1984-90 Oklahoma Medical Research Foundation " Center for Health Policy Research " 600 South College Avenue, Tulsa, OK 74104 6 experienced a net loss of physicians, while 9 had no change. The 30 counties experiencing increases had greater population densities than those that lost physi- cians. There are 40 rural counties in Oklahoma with populations less than 25,000. Of these 40 counties, 23 (58%) experienced net losses of physician manpower. Of those counties gaining physicians, almost all contain a regional commercial and health care center, and almost all are located along Interstate Routes 44 and 35 and turnpike arterials. Tulsa and Oklahoma Counties These counties received almost 90% of the net increase in physician manpower. Oklahoma county acquired 189 additional physicians and Tulsa county gained 55. These two counties gained 244 of the 274 net physician increase in the state. The other changes occurring within Okla- homa were in the context of inter-county movement and replacement of retiring physicians. The appendices provide additional detail by individual specialty. Table 3-7 Physician Changes in Oklahoma County, Tulsa County and Other 75 Counties of Oklahoma for 1984-90 Specialty Group T u l s a O k l a h o m a O t h e r S t a t e Family/General-2233-43-32 Obstetrics & Gynecology117-216 Medicine314638115 Pediatrics74-101 Hospital Based16452990 Surgical913729 Psychiatric93618 Other Specialties 4 28 5 37 Totals5518930274 Distances From Oklahoma City and Tulsa Each county gaining or losing physicians was analyzed considering its distance from either Oklahoma City or Tulsa. There was no correlation between distance of a county from these medical care centers and whether that county gained or lost physicians. The analysis indicated an almost perfect non-correlation of distance. Change and Population Density The counties gaining physicians had higher median population densities (measured as people per square mile) than those losing physicians. The table shows the number of counties, physicians measured as lost/gained, and the median population densities. There were nine urban counties gaining a total of 311 physicians between 1984 and 1990. These counties had a median population density of 89.5 people per square mile. There were 4 urban counties that lost a total of 23 physicians between 1984 and 1990. These counties had a median population density of 50.7 people per square mile. There was one urban county that had no change. Change and Per Capita Income There was no relation between county income and net physician census changes. Physicians did not leave poorer counties for wealthier ones. Considering the per capita income of all 77 counties in the state 7 , the median per capita income for counties gaining physicians was lower ($11,128) than those losing physicians ($11,613). In the 43 rural counties, the same was true. Those counties with no net change in physicians had the lowest median incomes of all; $9,801 for the state and $9,757 for rural counties. Minimum Numbers of Physicians Emerging models for provision of health care services in rural areas suggest a critical mass of at least three primary care physicians. 8 There are only six (6) counties in Oklahoma that have fewer than three primary care physicians. Two of these counties (Roger Mills and Dewey) had a net increase of physicians during 1984-90. Four of the six counties had two physicians. The counties listed below represent 1.1% of the state population. The counties with less than three primary care physicians are: Table 3-8 Oklahoma Counties With Fewer Than Three Primary Care Physicians in 1990 Primary Care1990 Est. C o u n t y P h y s i c i a n s P o p u l a t i o n Beaver27,205 Cimarron23,870 Dewey26,076 Cotton16,867 Love27,839 Roger Mills 1 5,481 Total1037,338 HMO Enrollments Certain methodologies computing physician need factor in HMO enrollments assuming that HMOs utilize fewer physicians per population. It is assumed that greater HMO enrollment in a market area will reduce the need for physicians. Previous studies for Oklahoma assumed a 15% HMO penetration in certain market areas and adjusted computed need accordingly. 9 Only one county, (Tulsa County at Health Policy Brief: Changes in Physician Manpower 1984-90 Oklahoma Medical Research Foundation " Center for Health Policy Research " 600 South College Avenue, Tulsa, OK 74104 7 13.2%), has a penetration above 10%. The state penetra- tion is 4.9%. 10 Change by Profession The total number of osteopathic (DO) physicians practic- ing in Oklahoma decreased by 1 during 1984-90, while the total allopathic (MD) physicians increased by 275. There were 158 newly trained osteopathic physicians that chose to practice in the state. This number did offset attrition of other osteopathic physicians leaving practice. Of the 158 new DO physicians, 32 were graduates of Oklahoma-based residency training programs and 126 were graduates of Oklahoma-based internships. There are 4,724 physicians practicing in Oklahoma as of February 1990. This cohort is comprised of 697 (14.8%) DO physicians and 4,027 (85.2%) MD physicians. This cohort does not include licensed physicians in graduate medical education programs. The maps on the following page show the 1990 distribution of these physicians as well as the Oklahoma population density in 1990. Osteopathic physicians are aggregated in Tulsa county, the site of a major osteopathic teaching hospital. S u m m a r y The period of 1984 to 1990 had two distinct sub-periods. Overall there was an increase of 274 practicing physicians in Oklahoma during 1984-90. However, all of the growth occurred during 1984-86. From 1986 to 1990 the state saw a decline in the overall physician manpower. Therefore, changes in physician manpower were of two kinds. The first involved the total numbers, and the second was the replacement changes as the overall numbers remained constant. The preceding studies examined the changing numbers, and the analysis following this one examines supply and distribution. This study examines the changes as they occurred. Some of the more significant findings of this study are as follows. " Half of Oklahoma 9s counties lost practicing physicians during 1984-90. These counties had a combined popula- Table 3-9 Net Physician Changes by County for 1984-90 by County Type, Physician Number and Median Population Density of the County (MedPopDen) Counties Gaining PhysiciansCounties Losing PhysiciansNo Change C o u n t i e s P h y s M e d P o p D e n C o u n t i e s P h y s M e d P o p D e n C o u n t i e s Urban Counties9+31189.54-2350.71 Rural Counties 21 + 9 3 24.4 34 - 1 0 7 18.1 8 Total30+40434.138-13018.79 U r b a n Metro Counties3+280894.01-1459.70 Suburban Counties 6 + 3 1 80.33 - 9 41.61 All Urban Counties9+31189.54-2350.71 R u r a l Large Rural (Over 50,000)3+2185.7002 Medium Rural (25-50,0007+4230.711-4246.10 Small Rural (Under 25,000) 11 + 3 0 14.923 - 6 5 12.06 All Rural Counties21+9324.434-10718.18 Counties Gaining PhysiciansCounties Losing PhysiciansNo Change C o u n t i e s P h y s M e d P o p D e n C o u n t i e s P h y s M e d P o p D e n C o u n t i e s Central8+21556.48-2541.21 North East9+10671.76-2519.55 North Central2+535.65-268.20 North West2+1111.54-74.30 South East3+2228.43-1221.52 South Central1+217.14-931.71 South West 5 + 4 3 13.18 - 2 6 12.80 State of Oklahoma30+40434.138-13018.79 Health Policy Brief: Changes in Physician Manpower 1984-90 Oklahoma Medical Research Foundation " Center for Health Policy Research " 600 South College Avenue, Tulsa, OK 74104 8 tion of 686,100 representing 27% of the 1990 Oklahoma population. " The state of Oklahoma has seven regions that each contain several regionally oriented community hospitals. These seven regions form three levels of physician concentrations. Two regions, Central and North East, have the greatest concentrations of physicians; a second single region is the North Central; and the remaining four regions, with relatively equal distributions of specialists, form a third group. " The Central Region accounted for 69% (190 of 274) of the 1984-90 increase of physicians; and Oklahoma County itself accounted for all of the regional change by adding 189 physicians. Tulsa and Oklahoma counties alone accounted for 89% (244 of 274) of additional physicians during 1984-90. " There has been an important change of mix in the primary care specialties. The number of one-year trained physicians are decreasing rapidly and are being replaced on a one-for-one basis by multi-year trained primary care physicians. There is no evidence that this is occurring at the overall expense of rural counties. Family practice physicians increased by 83, with 52 (63%) locating in counties other than Oklahoma and Tulsa. General internists increased by 20 physicians with all of the net new internists locating in counties other than Oklahoma and Tulsa. " There has been a significant increase in hospital-based and medicine specialty groups, relative to other groups. These two groups provided 205 of the 274 physician increase. Both groups increased by 14% between 1984- 1990. Almost half of the increase in the medicine specialty group was attributed to the single specialty of Cardiology. One third of the hospital-based group (32%) and medical specialty group (33%) located away from Tulsa and Oklahoma counties. " There has been a significant increase in specialty trained physicians. Secondary care physicians, as defined by Duffy et al, accounted for 208 (76%) of the 274 physician increase during 1984-90. Most of these physicians (82% of secondary care physicians) located in Oklahoma and Tulsa counties, but there is some movement toward other regional centers. " There is a trend of movement from less populous counties toward rural and small urban county regional centers. This movement is not likely to be individual physicians re-locating, but rather retiring physicians in one county being replaced in the region by new physi- cians in more populous counties. Small (less than 25,000) rural counties lost a net of 35 physicians; medium rural counties had no net change with 7 gaining 42 physicians and 18 losing 42 physicians. Large rural counties gained 21 physicians. " Two regions lost physicians. They were the North Central (-21) and South Central (-7). There was no observed correlation in a county gaining/losing of physicians due to county per capita income, or the distance of the county from Tulsa or Oklahoma City. References 1 Duffy, F. Daniel, MD, Lewis, C.S., MD, and Miller, MS, Deborah A., Policy Options for Oklahoma Physician Training Programs to Meet Manpower Needs Beyond 2000, Journal of the Oklahoma Medical Association, Vol. 80, pages 437-447, July 1987. 2 Primary care specialties include Family and General Practice, General Pediatrics and Internal Medicine as well as Obstetrics & Gynecology as defined by the Oklahoma Physician Manpower Training Commission. 3 Lapolla, MHA, Michael, Physicians for Oklahoma, OMRF Center for Health Policy Research, 1988. 4 Bauer, Jeffrey C., and Weis, Ellen M., Rural America and the Revolution in Health Care, Rural Development Perspectives, pages 2- 6, June 1989. 5 Becker, Edmund R., Dunn, Daniel, Braun, Peter and Hsiao, William, Refinement and Expansion of the Harvard Resource-Based Relative Value Scale: The Second Phase, American Journal of Public Health, Vol. 80, No. 7, pages 799-809, July 1990. 6 Lapolla, Michael, MHA, and Mahan, Carolanne, Obstetrics in Non- Metropolitan Oklahoma, Journal of the Oklahoma State Medical Association, Vol. 82, pages 613-621, December 1989. 7 U.S. Bureau of Economic Analysis provided by the Oklahoma Department of Commerce. 8 Bauer, Jeffrey C., and Weis, Ellen M., Rural America and the Revolution in Health Care, Rural Development Perspectives, pages 2- 6, June 1989. 9 Duffy, F. Daniel, MD, Lewis, C.S., MD, and Miller, MS, Deborah A., Policy Options for Oklahoma Physician Training Programs to Meet Manpower Needs Beyond 2000, Journal of the Oklahoma Medical Association, Vol. 80, pages 437-447, July 1987. 10 Personal Correspondence, Oklahoma State Department of Health, May 25, 1990

less