The Arizona Physician Workforce Study

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Part I: The Numbers of Practicing Physicians 1992-2004 2005 The Arizona Physician Workforce Study ** * Health and Disability Research Group School of Health Management and Policy W. P. Carey School of Business Arizona State University and University of Arizona Health Sciences Center William G.

Johnson, PhD* Professor of Economics Mary E. Rimsza, MD, FAAP* Research Professor Tony Garcy, PhD* Project Director Michael Grossman, MD, MACP** Associate Dean for Graduate Medical Education Executive Director, Arizona Medical Education Consortium Sponsored by: The Flinn Foundation, St. Luke 9s Health Initiatives, and BHHS Legacy Foundation Acknowledgements The authors gratefully acknowledge the cooperation of Mr.

Tim Miller and Dr. Barry Cassidy the current and former Directors of the Arizona Board of Medical Examiners and Mr. Jack Confer and Dr.

Elaine LeTarte, the current and former Executive Directors of the Arizona Board of Osteopathic Examiners. This study could not have been accomplished without their assistance and the cooperation of their staffs. We would also like to thank the members of the Health and Disability Research Group (HDRG): Rebecca White, Senior Management Research Analyst/Project Director; Wade Bannister, Data Analytics Manager; Miwa Edge, Senior Application Systems Analyst; and Tameka Jackson, Administrative Specialist for their support, as well as Mark Speicher ... more. less.

who served as a consultant to the HDRG; and the authors would like to acknowledge Michelle Malonzo, Editorial Director and Matthew Thibault, Art Director of the HDRG for their editorial assistance and preparation of data for this report. Helpful comments were provided by Bill Read of the Flinn Foundation. 2 Executive Summary The health of Arizona 9s citizens depends on an adequate supply of physician services to meet their health care needs. The supply of physician services is determined by the number of practicing physicians, the mix of physician specialties, and by the productivity of physicians. This is the first of two reports on the supply of physician services in Arizona. This report describes the results of a comprehensive review of the current physician workforce in Arizona and of the trends in the number, specialty composition, and geographic distribution of the physicians. A subsequent report (Part II) combines the numbers of physicians with measures of productivity to estimate the supply of physician services. The Arizona physician workforce increased by 50% from 8,026 physicians in active practice in 1994 to 12,024 in December 2004 (Table 1). The increase in the physician workforce outpaced the increase in the Arizona population during the same decade resulting in an increase in the physician to population ratio from 190/100,000 to 207/100,000. However, the physician to population ratio in Arizona is still far below the national average of 283/100,000 (Figure 6). From 1992 to 2004, the physician workforce increased in every Arizona county. The rise in population exceeded population increases in 13 of the 15 counties. The rate of growth in physician to population ratios in some rural counties exceeded growth in urban counties but large geographic disparities in the distribution of physicians remain (Figure 7, 8). In 2004, approximately 86% of Arizona physicians practice in either Maricopa or Pima County, and the physician to population ratios range from a high of 276/100,000 in Pima County to a low of 48/100,000 in Apache County (Figure 7, 8). Approximately 75% of Arizona physicians are in private practice and 41% are in primary care specialties (Table 3, 4). This percentage is higher than the national average of 38%. Since 1992 the number of primary care physicians, hospital-based physicians, and surgeons has increased. However, the number of physicians practicing in allergy, cardiovascular diseases, endocrinology, gastroenterology, hematology, and infectious disease has decreased. Approximately 90% of Arizona 9s allopathic physicians graduated from medical schools outside the state (Figure 12). The addition of the Midwestern University Arizona College of Osteopathic Medicine (AZCOM) in 1995 and the planned expansion of the University of Arizona (UA) 3 College of Medicine will increase the numbers of physicians who are trained in-state. 1 If historical patterns continue, approximately 50% of these students can be expected to enter practice in Arizona. Even if retention rates increased, in-state graduates will remain a relatively small part of the workforce. The effect of enrollment increases in medical schools on the supply of practicing physicians is also subject to a considerable time lag. In 2006 enrollment growth, for example, will not increase the supply of practicing physicians until these students complete their residency training five to 13 years later in 2011-2019 (Figure 12). The lag between medical school matriculation and completion of medical training is an especially important consideration for Arizona because of the state 9s rapid rate of population growth. Unless population growth slows, increases in medical school graduates from Arizona will always lag population increases. The site of residency training is also a major influence on physicians 9 choice of a location for their practice. The duration of residency training ranges from three to eight years. During this time, residents have the opportunity to establish ties to the community and develop professional relationships, both of which are factors cited by newly licensed physicians as reasons why they chose to practice in Arizona. Approximately 39% of the physicians who entered practice in Arizona in 2004 completed residency training in the state and approximately 30% of all physicians currently practicing in Arizona completed residency training in Arizona. The number of physicians in residency training in Arizona has only modestly increased from 1,010 in 1992 to 1,076 in 2004 (Table 6). Some of the programs that have closed include osteopathic and allopathic family medicine training programs, the Maricopa Anesthesia Program, and other small fellowship programs. However, these closures have been offset by the development of new programs, especially at Mayo Clinic Scottsdale, which has increased its residency training from two programs with eight residents in 1996 to 30 residency programs with 110 residents in 2004. Residency training programs are expensive to maintain and some hospitals have been forced to close their residency training programs because of financial costs and/or failure to maintain 1 It was recently reported (June 3) that the A.T. Still University, a private osteopathic school based in Missouri, will open a four-year medical school in Mesa, AZ beginning fall 2007 (Snyder, 2005). 4 accreditation. Closure of these programs can have an adverse effect on the supply of physicians in the state. The relatively small enrollments in the two medical schools in Arizona combined with the lack of growth in the number of residency slots in Arizona limits the number of practicing physicians that can be obtained from these two sources. In consequence, Arizona will continue its historical dependency on attracting practicing physicians and recent graduates of residency programs from other states and other countries. The current projections of nationwide shortages in physicians will, presumably, increase competition among the states for the pool of physicians. Arizona faces a more difficult problem than other states because its population is increasing more rapidly than nearly any other state in the U.S. This report puts the question of the Arizona physician workforce in perspective by describing historical trends and discussing the influences that either attract or discourage physicians from practicing in Arizona. 6 Introduction Arizona citizens depend on an adequate supply of physician services to meet their health care needs. This report describes the current physician workforce and the trends in the number, specialty composition, and geographic distribution of physicians in Arizona. A subsequent report (Part II) combines the numbers of physicians with measures of productivity to estimate the supply of physician services. The supply of physician services is the product of the number of physicians in practice, the number of hours each spends in patient care, and their productivity. The productivity of a physician is determined by individual skills, technology, and the level of support from non- physician clinicians, such as nurse practitioners and physician assistants, as well as administrative staff. The number of physicians in practice is only the first of several influences on the supply of physician services (Figure 1). Figure 1. Influences on Supply of Physician Services Number of Physicians In Practice Number of Hours Each Spends in Patient Care Physician Productivity Factors of Physician Productivity Individual Skills Support by Non-Physician Clinicians Administrative Staff Please Sign In :// 122 Patient Files Technology Supply of Physician Services Ideally, the adequacy of the physician workforce should be measured by the quantity and type of physician services that are available to meet the health care needs of a population and by the effect of physician care on the health of the community. The difficulty of assessing the health 7 care needs, outcomes of physician care, and health status of communities have lead studies of the physician workforce to measure adequacy by comparing the ratio of number of physicians per 100,000 people in a locale to national averages (Feillet et al. , 1993; Schwartz et al ., 1980; Seifer et al. , 1995; A. M. Singer, 1989; Whitcomb, 1995). National mean physician to population ratios do not account for differences among states in the mix of physician specialties, the quality and productivity of their physicians, or population characteristics, such as age and ethnicity that affect the population 9s health care needs. In Arizona, for example, racial/ethnic minorities represent a higher percentage of the population than the total U.S. population (e.g., 37.3% of the Arizona population versus only 30.9% of the U.S. population in 2002). In addition, a higher proportion of the minority populations in Arizona are Hispanic or Native American and a lower proportion are African-American than in the U.S. Physician to population ratios are, however, useful as measures of changes in the supply of physicians relative to changes in the size of a population. The relationship between changes in supply and changes in population is especially important in Arizona because of its unusually high rate of population growth. Physician to population ratios are also useful to compare previous reports on physician supply in Arizona. This report, recognizing the limitations of physician to population ratios, describes the number of physicians practicing medicine and the physician to population ratios in Arizona in 2004. These ratios are compared with previous studies on physician workforce conducted from 1992-1997. The descriptive results on physician supply are supplemented by data on the (1) mix of primary care and specialty practices; (2) information on the process by which physicians enter practice in Arizona; (3) changes over time in practice patterns; (4) some data on compensation and medical liability premiums; and (5) results of a survey of physicians entering practice in Arizona. Our results on physician workforce are based on current and past licensing data from the Arizona Medical Board (AMB) and the Arizona Osteopathic Board (AOB) and survey questions that we include as part of the licensing applications submitted by physicians. Historical trends are obtained from past studies which also were based on the AMB and the AOB licensing data and surveys conducted under the auspices of the Flinn Foundation by the predecessor of the Health and Disability Research Group (HDRG) from 1992-1997 (W. G. Johnson, 1997; W. G. Johnson et al., 1992). Data on physician compensation are obtained from the Medical Group Management Association (MGMA), a nationally known organization whose members comprise 8 of large medical group practices as well as most medium and small practices; and, the Mutual Insurance Company of Arizona (MICA), a medical malpractice carrier for Arizona, Colorado, and Utah, provided data on medical liability (malpractice) insurance premiums in Arizona. Information on medical liability insurance premiums in other states was obtained from a variety of sources. The current surveys, described in detail later in this report, are the Practicing Physicians Survey (PPS), which monitors the number of physicians renewing their licenses; the New Physicians Survey (NPS) which tracks the number of physicians applying for an Arizona license for the first time; and the Graduating Residency Survey (GRS) which surveys the resident physicians who complete their residency training in 2005. The survey questions for renewal licenses (PPS) collect information that is needed to measure physician productivity (e.g., clinical work hours, patient panel) and practice patterns (e.g., time spent in non-clinical care). The NPS provides information on motivations for practicing in Arizona; and, the GRS provides information on factors influencing graduating residents 9 choice of practice location. The Physician Workforce in the United States: Surplus or Shortage? In 1980, the Graduate Medical Education National Advisory Committee (GMENAC) estimated that the U.S. would have a surplus of 145,000 physicians by the year 2000. The GMENAC report recommended limiting U.S. medical school enrollments and the immigration of international medical school graduates (Graduate Medical Education National Advisory Committee, 1980). The U.S. Congress responded to the GMENAC report by discontinuing federal subsidies for students in U.S medical schools. The 1983 Medicare hospital- reimbursement reform inadvertently provided a strong incentive for teaching hospitals to increase the numbers of foreign medical school graduates in the U.S. by increasing funding for teaching hospitals. Because the number of U.S. medical school graduates was limited due to decreased funding, teaching hospitals that wished to take advantage of this increased Medicare funding recruited graduates of foreign medical schools to fill their expanded number of residency positions. While the U.S. population increased by 24%, the number of graduates from U.S. medical schools increased by only 11% from 1980 to 2000. There were 16,172 graduates in 1980 9 compared to 17,953 in 2000. Thus, the number of U.S. medical school graduates per 100,000 people decreased from 7.1 in 1980 to 6.4 in 2000. An increasing proportion of the physician workforce in the U.S. is composed of foreign medical school graduates. The number of foreign medical school graduates practicing in the U.S. increased from 94,995 in 1980 to 178,048 in 2000. Most of the foreign medical graduates trained in U.S. teaching hospitals (Blumenthal, 2004). In 1986, the U.S. Congress created the Council on Graduate Medical Education (COGME) to advise the federal government on workforce issues. The COGME is mandated with the responsibility of assessing trends, medical training, and financing policies as well as advising and making policy recommendations to federal agencies and the private sector about physician workforce developments and needs. The COGME predicted a surplus of 80,000 physicians by the year 2000. The COGME also predicted that this surplus would be in specialty physicians whereas the number of primary care physicians would be adequate to meet the needs of the U.S. population (Blumenthal, 2004). In 1994, Weiner predicted a surplus of 165,000 physicians by 2000 based on a belief that increased use of managed care would decrease the need for physicians (Weiner, 1994). These projections were, however, based on the assumption that physician staffing patterns used by managed care groups at the time of Weiner 9s study would become the norm for all U.S. health care. The assumption proved to be incorrect. From 1991 to 2001, the physician workforce in the U.S. grew by 26% (from 541,000 to about 681,000 physicians) or approximately twice the rate of total population growth. The physician to population ratio in the U.S. increased to 283/100,000 by 2004 with physician to population ratios higher in metropolitan areas (Health Resources and Services Administration, 2005). In 1991, there were 242 physicians per 100,000 people in metropolitan areas compared to 99/100,000 in non-metropolitan areas. By 2001, the physician to population ratio in the U.S. had increased to 267 in metropolitan areas and 122 in non-metropolitan areas (US General Accounting Office, 2003). Despite the growth in the physician workforce, the projected surpluses have not materialized, and the majority of experts predict that there will be a shortage of physicians over the next 15 years. Cooper, for example, predicts a 200,000 shortfall in the number of physicians by 2020 10 because of economic expansion. He argues that economic expansion (e.g., increase in per capita income and gross domestic product) leads to increases in health care spending which then lead to increases in the health care labor force, including the supply of physicians. Cooper 9s estimate has been criticized because it does not provide a criterion for the number of doctors needed to optimize the health and well-being of the U.S. population. Cooper suggests that increases in health care expenditures are an outcome of income increases that are associated with economic expansion. The model adopts the principle of economic models of consumption in which increases in income, all else equal, increase the demand for most goods and services. His predictions assume that the U.S. economy will grow at an average annual real (inflation adjusted) rate of two percent, which is the historical average rate of growth in the U.S. (Cooper, 2004). The 16 th Health Resources and Services Administration (HRSA)/COGME report on the state of the nation 9s physician workforce was released in January 2005. The COGME now predicts that the nation will face a shortage if the population uses medical services in the future as it has in the past, and if physicians practice in the future as they have in the past (Health Resources and Services Administration, 2005). In their 2005 report, COGME predicts that the physician per 100,000 people ratio will increase from 283 in 2000 to 301 in 2015, but this increase will not be sufficient to meet the demand for services. They predict that the demand for physician services will increase due to population growth, aging of the population, and changes in the cage- specific d per capita physician utilization rates with those over 45 years using more services and the population under 45 years using fewer services. The report predicts a shortage of physicians in the U.S. by the year 2020. Two estimates were given concerning the size of the 2020 physician shortfall: (1) a demand based estimate suggested a physician shortage of about 85,000 full-time equivalent (FTE) physicians, and (2) a medical needs based estimate predicted that supply will be short by about 96,000 FTE physicians. In summary, there has been continued debate about the physician workforce over the past 25 years. Predictions of a surplus of physicians by the year 2000 were incorrect and experts now predict that there is a shortage of physicians in the U.S. Our analysis focuses on Arizona, but the analysis requires the same types of models and methods that one would use to make national projections. The next section describes the conceptual model that serves as the foundation for our empirical analysis. 11 A Model of the Supply of Physicians In addition to the absolute numbers of physicians, assessing the supply of physician services also requires an assessment of physician productivity. Physician productivity, all else equal, is increased by the number of other professionals with whom a physician works, such as non- practicing clinicians. Physician productivity in terms of services to patients is also reduced by the amount of time a physician spends performing administrative work. The analysis of the characteristics that affect physician productivity is reserved for a subsequent report. The analysis that is presented here begins with a simple model of the dynamics of the numbers of physicians practicing in a state in a year. The analysis is extended to consider the characteristics that influence physicians 9 decisions to practice in Arizona or alternatively to practice in other states. In summary, the number of physicians practicing in a state is determined by the number of new entrants (residency program graduates) and those established physicians who chose to relocate from other states. Changes in medical school enrollment, number of medical schools, number of residency positions, and national immigration policy affect the national supply of physicians. These same factors will affect the supply of physicians in Arizona, but the Arizona supply will also be influenced by the number of Arizona residents who enter medical school, medical school enrollment in the state, residency positions in the state, and attractiveness of the state to established physicians who are considering relocation. Entrants The number of physicians in practice at any point in time is the outcome of a process that begins with medical school matriculation. However, because of the long duration of medical training, there is a five to 13 year lag time between the start of medical school training and entering practice (Figure 2). Someone who begins medical school in 2005 and chooses to become an obstetrician will, for example, begin clinical practice in 2013. 12 Figure 2. A Timeline of the Supply of Physicians 4 year Medical School 4 year Medical School 4 year Medical School 1 year Internship 1 year Internship 1 year Internship 3 year Primary Residency 5 year Primary Residency General Practice Specialty Practice I to 3 year Sub-Specialty Residency Sub-Specialty Practice 0123456789101112131415 5 313 year time-frame to enter practice Years Approximately 93% of medical students will receive a medical degree four years after matriculation. However, there are only 123 allopathic and osteopathic medical schools in the U.S. These do not provide enough medical school positions for U.S. citizens who wish to become doctors. Approximately 1,400 U.S. citizens graduated from medical school outside of the U.S. and entered residency training in the U.S. in 2003. After completion of medical school, graduates begin residency training in a medical specialty at a teaching hospital. The size of most residency training programs is limited by the Accreditation Council on Graduate Medical Education (ACGME) residency review committee for each specialty. Other factors that influence the number and types of residency programs include the state and federal funding available to support the programs, access to faculty, and the availability of patients which are the necessary cteaching material d for residents. There are many factors influencing medical school graduates choice of specialty including the number, length, and rigor of the training programs work load (e.g., nights on call), as well as the educational quality of the available programs. Choice of specialty is also influenced by the future income potential and life style of practicing physicians (e.g., irregular work hours, night call) in each specialty. For example, the annual net income of practicing physicians in pediatrics, family medicine, and psychiatry is far less than the income of physicians practicing orthopedics, cardiology, or emergency medicine. Physicians who choose to practice pediatrics, obstetrics, surgery, and internal medicine also can expect to have irregular work schedules and night call responsibilities whereas physicians who choose to practice dermatology, emergency medicine, and pathology are more likely to work less hours per week and have limited night call. These factors will influence the graduating medical students 9 choice of residency and thus the availability of specialists in different medical fields. 13 Currently, some residency programs in specialties with low potential income and heavy workloads, such as family medicine, have difficulty filling all available residency positions. In contrast, some specialties have many more applicants than they can accommodate because of the popularity of the specialty and/or the limited numbers of residency positions. For example, in 2005, there were only 39 neurosurgery and 28 dermatology positions available in the U.S. 2 The ability to fill residency positions with U.S. medical graduates is a good indicator of the popularity of the specialty. For example, only 40% of the family practice positions were filled with U.S. graduates in 2005. This is the eighth consecutive year in which the number of U.S. seniors from allopathic medical schools entering family practice residencies has declined. In contrast, 74% of pediatric positions and 67% of obstetric positions were filled with U.S. graduates. The specialties in which over 80% of positions were filled with U.S. allopathic medical school graduates included emergency medicine, general surgery, and orthopedic surgery. In addition to U.S. citizens who receive their medical training outside the U.S., other graduates of foreign medical schools who are not U.S. citizens also may come to the U.S. for residency training if they are able to obtain a visa. However, the number of foreign-born medical school graduates who can train in the U.S. is limited by U.S. immigration policy. They often are required to return to their home country after completing their training. After completion of a residency, additional training is required if a physician wishes to practice in a medical or pediatric subspecialty such as cardiology, gastroenterology, pulmonary medicine, or in most surgical specialties (e.g., pediatric surgery) (Figure 3). In summary, the number of entrants into practice in any year is determined by the capacity of U.S. medical schools from five to 13 years in the past, the number of positions available in residencies and fellowships, U.S. immigration policies towards foreign medical school graduates, and, for any given specialty, the ability to fill the residency slots in previous years. All these influences interact to make it extremely difficult to adjust the supply of new physicians to meet the expected challenges of physician shortages. The failure to adequately predict the 2 To obtain detailed information regarding the current numbers of residents in training and specialty residency training programs please consult the National Residency Matching Program (NRMP) website at www.nrmp.org . The NRMP is a private not-for-profit organization that tries to match residents with appropriate training programs. 14 shortages has made the problem more difficult by delaying the attempts to expand the supply of physicians. Figure 3. A Model of the Supply of New Physicians 1 Year Internship* 4 Year Medical School 3 Year Primary Residency (e.g., Emergency Medicine, Pediatrics, Internal Medicine, or Family Medicine) 4 Year Primary Residency (e.g., Ob/Gyn, Psychiatry, Dermatology, Ophthalmology) 5 Year Primary Residency (e.g., General Surgery, Otolaryngology, Colorectal Surgery, Radiology, Orthopedics) General Practice 3 Year Sub-specialty Residency (e.g., Pediatrics, Internal Medicine) 1 to 3 Years Sub-specialty Residency Specialty Practice (e.g., Family Medicine, General Pediatrics, Internal Medicine) 1 to 3 Years Sub-specialty Residency Specialty Practice (e.g., Obstetrics, Psychiatry) Specialty Practice (e.g., Radiology, Orthopedics) Sub-specialty Practice (e.g., Pediatric or Adult Cardiology, Gastroenterology) Sub-specialty Practice (e.g., Child Psychiatry, Perinatology) Sub-specialty Practice (e.g., Pediatric Orthopedics, Neuroradiology) *Internship may be done as part of primary residency Departures The number of physicians in the workforce is decreased by physician separation from practice due to death, retirement, or career change. Some studies report that retirement rates for physicians are similar across all specialties but others show that surgeons, internists, and family physicians are likely to retire sooner than other physicians (Reschovskyet al., 2005). Although data from the American Medical Association (AMA) Masterfile suggests that physicians are retiring earlier than their predecessors and other studies find that the retirement age of physicians has not changed (Konrad & Sheps, 2005). A study of over 16,000 physicians conducted by the Center for Studying Health System Change, compared career satisfaction, professional autonomy, practice environment, and personal characteristics of physicians who retired during the study period (1996-1999) to those who did not retire. Factors associated with earlier retirement included age, working in large organizations 15 (e.g., health center), and having low career satisfaction. Physicians who owned their own practice had a lower income and had good relationships with office staff and were less likely to leave medicine than others (Reschovsky et al., 2005). Practice autonomy (e.g., ability to make your own clinical decisions, obtain services for your patients) and managed care penetration did not seem to influence retirement age. Higher income was associated with earlier retirement. In fact, physicians in the highest income quartile retired 4.4 years earlier than those in the lowest quartile (Reschovsky et al., 2005). The Demand for Physician Services The demand for health care is influenced by many factors, including public demand for the use of new technology, a public desire to have life-sustaining and life-enhancing care, and consumer responses to direct advertising of drugs and other remedies. The demand for health care is also affected by the economic status and insurance rates since patients must have sufficient income to pay for services. Thus, the demand for physician services will, all else equal, increase if more Americans have health insurance. Experts estimate that we would need to increase the physician workforce by 95% if the 45 million uninsured Americans had health insurance due to changes in national health policy (Health Resources and Services Administration, 2005). This assumes that the currently uninsured utilize health care in a similar manner as the currently insured U.S. population. Recent trends in health insurance coverage suggest that insurance coverage is decreasing rather than expanding, making it difficult to predict the future. The rapid aging of the population is one of the most important influences on the demand for health care. Although subject to dispute, the effect of population growth on the demand of health care may be compounded by the increase of diseases related to life style, such as obesity. A new approach to health and rehabilitation will be needed to deal with the effects of the aging population during the next 20 years. At each point in their life cycle, the baby boomers revolutionized the institutions that were part of their common experience: first in primary and secondary schools and then in colleges and universities. Although the impact was predictable, preparations were incomplete. Baby boomers will substantially increase the demand for health care and increase the number of persons with disabilities but efforts to deal with these situations are equally incomplete. 16 The incidence of illnesses increases in each subsequent year after people reach the age of 50. The baby boomers 9 journey through the life cycle will create one of the oldest work forces in contemporary history and a subsequent expansion of the retired population. The number of persons with disabilities will also increase to a historic high. The aging of the baby boomers will add approximately 535,000 persons per year to the population of disabled persons for the next 15 years. Nearly 27 million Americans age 50 through 69 will be disabled in 2020 or slightly less than twice the number in 1997 (W.G. Johnson et al. , 2004). Much attention has been devoted to the effects of aging on the baby boomer generation as they enter the 65 years old or older age group. A recent report to the Social Security Administration finds that health care utilization will also increase substantially among members of the baby boomer generation under the age 65 (W. G. Johnson & Johnson, 2005). The report projects that the number of people with disabilities under age 65 will increase by 1.0% annually, for an overall increase of nearly 30% over 25 years (2000-2025). Total health care expenditures and Medicare expenditures for the under 65 age group will increase by 1.3% annually, for an overall increase of 37%. Seventy percent of persons with disabilities in 2025 will not qualify for Social Security Disability Insurance (SSDI) or Medicare benefits, and over 75% of the health care expenditures will be consumed by these persons. The persons most at-risk for the lack of planning regarding the needs of the older baby boomers are persons with disabilities who are not eligible for SSDI or Medicare. The at-risk group is primarily composed of women with work histories either too short or too far in the past to allow them to qualify for SSDI but with assets that make them ineligible for Medicaid (W. G. Johnson & Johnson, 2005). Predicting the effects of the aging on baby boomers on the demand for physician services in Arizona is complicated because a substantial number of older persons live in Arizona only during the winter. These numbers will presumably grow with the increase in the older population. Many winter residents are citizens of Canada who are not likely to be counted by U.S. population surveys. It is likely, therefore, that the seasonal residents are not reflected by the physician to population ratios that we report. Our subsequent analysis (Part II) may include some estimates of the effects of baby boom generation residents and winter residents on the utilization of health care from the Arizona 17 HealthQuery (AZHQ) community health data system. The AZHQ is a patient level data base that records health care encounters for a large part of the state (described in detail in a subsequent section of this report). In summary, the demand for physician services is affected by the economy, availability of affordable health insurance, new technology, and health status of a population. As Arizona 9s economy grows and increasing numbers of Arizonans can afford more health care, it is likely that the demand for physicians will increase. Even if economic growth were to slow the increased numbers of elderly residents as well as the annual in-migration of seasonal residents (snowbirds) will increase the demand for physicians. New technologies in health care can decrease health care utilization for the treatment of current conditions by increasing physician productivity, but the reductions may be offset by increasing demand for care as new technologies make it possible to diagnose and treat more diseases than in the past. Some potential changes that could decrease the demand for physicians, all else equal, include increasing numbers of non-practicing clinicians, decreased utilization of ineffective health care services, and improved health status due to changes in personal lifestyles (e.g., diet, exercise). An understanding of the probable future of the physician workforce and its relationship to health and health care requires an understanding of the current situation and the nature of the process by which it evolved. The next section describes the Arizona physician workforce in the year 2004 and the dynamic changes that lead to the current situation. Studies of the Physician Workforce in Arizona The reports of expected shortages of physicians in the U.S. are echoed for Arizona by a series of similar reports that have been published over the last 14 years. Next, we consider the problem in terms of the state of Arizona. cArizona Physicians Today and Tomorrow d (1989) The first report on the supply of physicians in Arizona was published in 1989. The report, "Arizona Physicians Today and Tomorrow, d estimated the number of physicians needed in Arizona by 2000 (Flinn Foundation, 1989). The estimates combined population projections from 18 the Arizona Department of Economic Security (DES) 3 with targeted physician to population ratios. Two alternative criteria were used to make the projections. The first criterion was the Bureau of Health Professions' (BHP) ratio of 231 physicians per 100,000 people. The second criterion was the recommendation of the GMENAC that 195 physicians are required for each 100,000 people. The two ratios, applied to the DES estimate (1989) of an Arizona population of 4.7 million in 2000, projected needs for 10,800 (BHP) and 9,100 (GMENAC) physicians, respectively. The application of the BHP ratio (231) produced an estimate that 8,300 urban physicians would be needed in 2000. Using the GMENAC criterion (195) and an estimated urban population of 3.6 million, the report predicted that 7,000 physicians would be needed in the urban areas in 2000. If the trends between 1987-1992 had continued, approximately 9,700 physicians in Arizona would have been in practice in urban areas in 2000 and that number would have increased to 15,500 by 2010. The report also applied the BHP and GMENAC ratios to the DES rural population projection, producing a projected need between 2,500 and 2,100 physicians in rural areas by the year 2000. However, if the 1987-1992 trends had continued an estimated 1,000 physicians would have practiced in rural Arizona in the year 2000 (Figure 4). Thus, although the projected number of physicians in practice in Arizona met or exceeded the projected total needs, the report predicted a shortage of between 1,200 and 1,600 physicians practicing in rural areas and a surplus of physicians practicing in urban areas. Arizona State University/Arizona Council for Graduate Medical Education Reports (1992-1997) A series of seven reports on physician supply and graduate medical education in Arizona was published between 1992 and 1997 (Lewis et al. , 1992). These reports were based on survey data and licensing data collected as part of the process of licensing physicians. The data were collected by the Arizona State University (ASU) School of Health Management and Policy (SHMP) under the auspices of the Arizona Council for Graduate Medical Education (AzCGME) 3 DES estimate from: Arizona Business, February 1992. 19 and sponsored by the Flinn Foundation. The studies showed that the growth in the number of Arizona physicians kept pace with population growth, but there were disparities in the distribution of physicians between rural and urban areas such that there would be a shortage of 1,400 physicians outside of Maricopa and Pima counties by 2000 relative to the levels suggested by GMENAC or BHP (W. G. Johnson et al., 1992). The 1996 report also predicted that the number of specialty physicians would decrease in future years (W. G. Johnson, 1997). Goldwater Institute Report (2001) In 2001, the Goldwater Institute published a report on the Arizona physician workforce. The report used 2000 data from the Arizona Board of Medical Examiners which licenses allopathic physicians. The authors made several adjustments to the data to distinguish physicians who provide direct care from physicians who were licensed but retired or employed in administrative positions. The adjusted physician to population ratios were then compared to the ratios that had been published in the 1990s by Johnson et al. (1992). The report concluded that the ratio of physicians to 100,000 people had declined from 198 in 1990 to 185 in 2000. Furthermore, they calculated that the actual number of practicing physicians in 2000 was even lower because 6% (513) of the physicians listed were retired and 1% (120) of the physicians were in administrative practice. They reported that the cadjusted d number of practicing physicians per 100,000 people ratio in 2000 was only 172. However, the Goldwater Institute report data do not include osteopathic physicians, and thus cannot be directly compared with the AzCGME reports which included both osteopathic and allopathic physicians. The report concluded that cArizona has a shortage of physicians, a situation that will worsen unless government policies and regulation that caused the shortage are revised or rescinded d (J. A. Singer & Cantoni, 2001). The relatively high penetration of managed care into the health care market in Arizona was cited as another reason for the shortage of physicians. However, no data were offered to show that the physician supply in states with relative low market penetration by managed care was higher than Arizona; nor was any financial data supplied to support the contention that the compensation of Arizona physicians is less than that of physicians in other states. The assertion that government regulation was one cause of the cshortage d was supported by claiming that the effect of EMTALA regulation lead physicians to abandon practice in Arizona. 20 Information on the compensation of Arizona physicians and premiums for medical liability is presented later in this report. U.S. General Accounting Office Report (2001) The U.S. General Accounting Office (GAO) reported that the number of physicians in the U.S. increased by 26% from 1991-2001, twice that of the national population during the same period. The physician to population ratio for Arizona metropolitan areas in 1991-2001 decreased from 214/100,000 in 1991 to 207/100,000 in 2001. Although the ratio in non-metropolitan areas of Arizona increased from 90 to 111, the 2001 ratio is higher than the expected ratio based on the Goldwater Institute report. The two reports agree, however, that the ratios in the early 2000s were lower than in the early 1990s in metropolitan areas of the state. A decrease in the physician to population ratio in an area of population growth may be due to either a decrease in the physician workforce or an increase in the physician workforce that is less than the growth rate of the population. The GAO reported that 17 U.S. metropolitan areas experienced declines in the physician to population ratio from 1991-2001. Three of the communities were in Arizona (Phoenix-Mesa, Tucson, and Yuma). There were large population increases in all three communities from 1991-2001. The physician workforce increased in all these communities, but the rate of increase was less than the rate of population growth. The GAO report was based on the AMA Physician Masterfile and the American Osteopathic Association (AOA) Physician Masterfile and included non-federal physicians, with known Arizona addresses, who stated they provided patient care services. These masterfiles are widely used in studies of physician supply (GAO). The AMA Physician Masterfile record is established when individuals enter medical schools accredited by the Liaison Committee on Medical Education (LCME) or, in the case of international medical graduates, upon entry into ACGME-accredited programs; and, the AMA data are likely to be less accurate than the ASU/AzCGME data because some of the AMA Physician Masterfile data are obtained from surveys rather than licensing data. Therefore, because these studies were suspended in 1997, there are no data available that can be directly compared with the 2001 GAO report. 21 Summary In 1987, the first of a series of reports on the Arizona physician workforce was completed. At the time of the first report, 3.5 million people lived in Arizona and 6,400 physicians were in active practice for a physician to 100,000 people ratio of 187 (Table 1). Three years later, the population had grown to 3.7 million and the physician population had increased to 7,315, increasing the physician to population ratio to 197 (Table 1). From 1990 to 1996 the Arizona population increased dramatically and the number of physicians increased as well. Unfortunately, the Arizona physician workforce studies were discontinued in 1997, and it is difficult to establish comparability between the workforce studies and studies of the physician workforce by HRSA and the Goldwater Institute. The HRSA reported in 1998 that the number of active physicians in Arizona was 8,301 and the physician to 100,000 people ratio was 176 (Table 1). In 2000, the Goldwater Institute reported that the physician to population ratio had further decreased to 172/100,000 (Table 1). In reviewing their methodology, however, their report failed to include osteopathic physicians which would lead to an underestimate in the number of practicing physicians in the state. If, as seems likely, there were approximately 1,000 DOs in active practice in 2000 and they had been included in the Goldwater Institute report, the physician to population ratio would have been 200/100,000. Table 1 summarizes the available historical data on the Arizona physician workforce from 1987 to 2004. Unfortunately, data are not available for many of the years because this information was not retained by the licensing agencies (AMBs). From 1990 to 1997, data are available from the Survey of Arizona Physicians sponsored by the Flinn Foundation and from the licensing data acquired and retained by ASU as part of that study. 22 Table 1. Comparison between the Numbers of Arizona Physicians to Population 1987-2004 Year Active MD 9s Active DO 9s Active Physicians (000 9s)* Population (000,000 9s) Physicians Per 100,000 People* 1987 -- -- 6.4 3.4 187 1990 6,617 698 7.3 3.7 197 1992 6,923 758 7.7 3.9 197 1993 -- -- 7.9 4.0 -- 1994 7,193 833 8.0 4.2 190 1995 7,814 -- -- 4.4 -- 1996 8,047 -- -- 4.6 -- 1997 8,421 -- -- 4.7 -- 1998 8,301 (HRSA) -- 8.2 (HRSA) 4.9 176 (HRSA) 1999 8,428 -- -- 5.0 -- 2000 -- -- 8.8 (GW) 5.1 172 (GW) 2001 -- -- -- 5.3 -- 2002 8,976 -- -- 5.4 -- 2003 9,228 -- -- 5.6 -- 2004 10,787 1,237 12.0 5.8 207 Sources: Population estimates acquired from the Arizona Department of Economic Security, US Census. Active Physicians estimates acquired from the 1990 Arizona 9s Physician Supply, 1992, 1995, 1996, 1997; MBD, 2004; Survey of Arizona Physicians (SAP); Health Resources Administration (HRSA), 2004; and the Goldwater Institute Report (GW), 2001. Note: *For some of the years between 1997 to 2003, data have been obtained from other sources (HRSA, GW). The information presented in Table 1 is, therefore, subject to considerable uncertainty during that time period. Data Sources The results in this report are based on six different data sets. The data sets include the 2003 MGMA Survey; the statewide Medical Board Database (MBD); several statewide HDRG survey databases including the PPS, the NPS, the GRS, and the AZHQ database (Table 2). The MGMA Survey provides information on the average compensation and productivity by medical specialty for states and regions in the U.S. The MGMA data are from a national survey that includes information on specialty income by state and region as well as workloads by region. The average salary data are particularly useful because they permit comparisons of physician compensation in Arizona relative to compensation for physician compensation in other states. 23 The MBD data include demographic data on all licensed Arizona physicians as well as their self- reported specialty and office location. The MBD was compiled from past and present files that the ASU HDRG obtained from the AMB and the AOB. The database contains demographic information on every physician licensed in Arizona as well as their medical specialty, board certification, office location, practice changes, retirement status, and hours of work. The practicing physician 9s medical school, date of graduation from medical school, and graduate training experiences are also collected. The PPS is a survey sent to all Arizona physicians by the AMB and AOB at the time of relicensure. The survey instrument is nearly identical for both groups of physicians in a survey cycle except the osteopathic survey did not ask practicing physicians to provide a breakdown of their work distribution. Osteopathic physicians renew their licenses annually whereas allopathic physicians renew their license every two years on their birthday. All osteopathic physicians have completed the 2003-2004 survey, but because MDs renew their license every two years only approximately 50% of the MDs have completed the survey as of January 2005. The NPS is a survey sent to all physicians at the time of their initial application for an Arizona medical license. The physicians are asked to identify the most important reasons for their decision to practice medicine in Arizona. This survey is ongoing and to date 453 surveys have been analyzed. The current PPS and NPS survey instruments are included in Appendices 1-4. The GRS was distributed to graduating residents from 1993 to 1995 and is being distributed currently to the physicians completing residency training this academic year. The GRS identifies the reasons that residents decide to remain in Arizona or, alternatively, to practice in other states. The results of the 2005 GRS will be compared to the surveys of graduating residents that we conducted in 1993, 1994, and 1995. 24 Table 2. Data Sources Data Source and Coverage Measures of Interest Status 1. Average specialty income by region. 2. Average specialty income by state. MGMA Survey 4National, 2003 3. Work loads by region. Received. 1. Office locations. 2. Medical specialties. MBD 4Statewide, 1990-91; 1992-97, 2002-05 3. Demographic data. Received. 1. Productivity measures. 2. Characteristics of practice. 3. Effects of managed care. PPS 4Statewide, 1992-97, 2003-04 4. Other changes over time. DO: Completed. MD: Approximately ½ complete. 1. Reasons for application for licensure in AZ. 2. Reasons for choosing to practice in AZ. NPS 4Statewide, 2004 3. Region they left to come to AZ. In the field. 1. Intent to practice in AZ. 2. Reasons for leaving. GRS 4Statewide, 1993-95, 2005 3. Reasons for staying. 1993-1995: Complete. 2005: In the field. 1. Health encounter data. 2. Diagnoses. 3. Procedures. 4. Patient demographics. AZHQ Database 4Yuma County, 1999-04; Maricopa County, 2001-04; AHCCCS 3 Statewide, 2000-04; Statewide Immunizations, 1999-04 5. Patient profiles over time. Ongoing. AZHQ is the Arizona HealthQuery, a community health data system that houses essential and comprehensive health information on Arizona residents. This data system is located at ASU and managed by the HDRG. It serves as a community resource for assessing the health status and health care needs of the state. The AZHQ data system is unique for its ability to provide vast amounts of continuously updated health care information and link patients across systems and over time. The data is voluntarily donated to AZHQ by health systems, physician groups, hospitals, and governmental agencies such as AHCCCS. Currently AZHQ contains information on over 5.2 million people who have obtained health care in Arizona. AZHQ helps the 25 community by putting actionable information from millions of health records at the fingertips of health care researchers and policy makers. We will utilize AZHQ for the second phase of this study to help us determine the health care needs and demands of Arizona residents. Arizona Physician Workforce, 2004 There were 10,787 allopathic physicians and 1,237 osteopathic physicians practicing in Arizona in 2004 (Table 1, Appendix 5). In 2004, 72% of Arizona physicians were board certified; approximately 78% graduated from a U.S. medical school; 24% are women; and 44% are over 50 years old. 4 The Nature of Physician Practices One of the important links between the number of physicians in practice and the quantity of physician services to patients is the proportion of physicians who are either retired or engaged in activities that do not involve services to patients. The physician license renewal surveys asked physicians to describe the nature of their current practice. The distribution of physicians by the nature of their practice in 2004 is described in Table 3. Allopathic physicians renew their licenses every two years on their birthdays. The data presented in Table 3 for the allopathic physicians represents approximately one-half of the allopathic physicians in the state, so surveys continue to be collected. Osteopathic physicians renew their licenses every two years en bloc so the data presented in Table 3 for the osteopathic physicians are complete. 4 Estimates acquired from the MBD, 1994-2004. 26 Table 3. Practicing Physicians, 2004 MD Sample DO Census Total Practice Number of Respondents Percent (%) Number of Respondents Percent (%) Number of Respondents Percent (%) Academic/Teaching/Research252 5% 24 2% 276 4% Administrative Medicine 63 1% 14 1% 77 1% Government 239 4% 44 3% 283 4% Group Practice 2,776 50% 696 52% 3,472 51% Hospitalist 420 8% 44 3% 464 7% In training* 77 1% 43 3% 120 2% Non-profit Community Health Center 89 2% 27 2% 116 2% Retired/On leave 86 2% 105 8% 191 3% Semi-retired/On leave 189 3% 1 0% 190 3% Solo Practice 1,337 24% 341 25% 1,678 24% Total 5,528 100% 1,339 100% 6,867 100% Source: MBD Practicing Physician Surveys completed by osteopathic and allopathic physicians. Note: Because osteopathic physicians are re-licensed annually and allopathic physicians are only re-licensed every two years, the Practicing Physician Surveys have been completed by all osteopathic physicians but are not yet completed by all allopathic physicians. Missing osteopathic respondents = 3. The results in Table 3 show that approximately 75% of Arizona physicians work in a private practice organized as either group or solo practice. Only 4% work in an academic setting which might include medical research and/or teaching. The number of physicians in training is underestimated because most physicians in training have a training license which limits their medical practice to the hospitals in which they are training. Data from other sources (e.g., ACGME) indicate that there are approximately 1,076 physicians in training in Arizona. Physicians employed as hospitalists represent a small but increasing type of medical practice as an employee of the hospital. Physician Specialty 2004 Table 4 describes the distribution of practicing physicians by primary specialty in 2004. The listed physician specialty is the specialty reported by physicians on their license renewal applications. The self report of specialty is not required to represent the specialty in which a physician received residency training and obtained board certification or the field of medicine in which they provide care. Appendix 6 provides a more detailed description of the specialties. 27 Approximately 41% of Arizona physicians were primary care specialists in 2004 (Table 4). (Primary care includes family/general practice, geriatrics, internal medicine, and pediatrics.) Approximately 18% of Arizona physicians work in hospital-based specialties, 20% are surgical specialists, 7% are medical specialists, and 1% are pediatric specialists (Table 4). Other specialties includes psychiatry, occupational medicine, physical medicine, and others (Appendix 6). Table 4. Distribution of Practicing Physicians by Primary Specialty, 2004 Total Physicians, 2004 Primary Specialty N % All Specialties 12,013* 100% Primary Care 4,962 41% Surgical Specialties 2,457 20% Hospital-Based Specialties 2,204 18% Other Specialties ! 1,451 12% Medical Specialties 829 7% Pediatric Specialties 110 1% Source: January 5, 2005 MBD. Note: Primary specialty reported by physician at the time of licensure. Primary specialties were grouped into general categories as shown in Appendix 6. *Missing = 11 cases. Primary care includes family/general practice, geriatrics, internal medicine, and pediatrics. ! Specialties with < 20 physicians. The profile of Arizona practicing physicians in 2004 is the outcome of events that have occurred over the past quarter century. An understanding of the historical trends is the first step in beginning to understand and predict the future of the Arizona physician workforce. Trends in the Numbers of Practicing Physicians The 10,787 practicing Arizona allopathic physicians in 2004 reflect an increase of approximately 17% between 2003 and 2004 (Table 1). The increase in the number of practicing osteopathic physicians between the two years is not known, but osteopathic physicians are a slightly higher percentage of the physician workforce than in the 1990 9s. The Goldwater Institute report and the GAO report concluded that the increase in the supply of physicians had not kept pace with Arizona 9s rapid population growth. Our comparisons of the licensing data from the late 1990s to 28 the licensing and survey data for 2003-2004 show, instead, that increases in physician supply modestly exceeded population growth. The long term increase, however, is influenced by above average increases in supply between 2003 and 2004. This one year change in the number of practicing physicians is substantially more than the average annual increase from 1992 to 2003. The uncertainty concerning trends in the data is in part due to the absence of annual data from the licensing agencies for many years. Although the practice is, we understand, being changed, it has been traditional for the licensing agencies to simply overwrite existing records when a renewal is received. Thus, no annual data were maintained for many years by the licensing boards. The historical information presented here on trends mainly is obtained from the previous ASU study in which annual licensing records were saved. In 1990 an estimated 9% (698/7,315) of the physicians in active practice in Arizona were osteopaths. However, in 2004 the number of osteopathic physicians increased to 1,237 and now represents approximately 10% (1,237/12,024) of the physician workforce (W. G. Johnson et al., 1992) (Table 1). In 1992, we predicted that the supply of physicians in Arizona would keep pace with the growth in the population, but disparities would continue in the physician to population ratio in rural Arizona (Lewis et al., 1992). The 2004 data show that there are still large geographic disparities in the physician to population ratio between urban and rural counties (Figure 7, 8). In 2004, 86% of Arizona physicians practice medicine in Pima or Maricopa County, and the physician to population ratio ranges from a high of 276 in Pima County to a low of 48 in Apache County (Figure 7, 8). 29 Figure 4. MDs in Practice in Rural Areas of Arizona (1994-2004) 812 989 1,097 1,044 1,098 1,187 1,473 500 1,000 1,500 19941995199619971998199920002001200220032004 Number of MDs 1995 Unknown 2000-2002 Unknown Source: MBD, 1994-2005 Figure 5. MDs in Practice in Urban Areas of Arizona (1994-2004) 6,381 7,058 7,324 7,257 7,330 8,041 9,307 5,000 7,500 10,000 19941995199619971998199920002001200220032004 Number of MDs 1995 Unknown 2000-2002 Unknown Source: MBD, 1994-2005 30 Figure 6. Physician to Population Ratio for Arizona and the U.S. (1990-2004) 197197 190 207 238 260 276 283 100 200 300 199019911992199319941995199619971998199920002001200220032004 Physician to popluation ratio Arizona United States Source: MBD, 2004; Census Data, 1990-2004 31 Figure 7. Physicians per 100,000 People, 1992 and 2004* Coconino 160 249 Mohave 97 138 Yavapai 130 161 Navajo 62 96 Apache 43 48 Graham 43 61 Greenlee 47 84 Cochise 95 111 Santa Cruz 72 76 Pima 277 276 Pinal 55 67 Gila 103 161 Maricopa 216 220 La Paz 95 80 Yuma 97 121 Percent change in the physician to population ratio 1992-2004 -15% to 0% 22% to 42% 2% to 16% 55% to 77% Source: MBD, January 5, 2005 and 1992; Arizona Department of Economic Security Population Projections, July 1, 2004; and Census Population Estimates, July 1, 1992. Data compiled by the ASU HDRG. Note: Physician is defined as a MD or DO who practices medicine in Arizona, as of January 5, 2005. Map excludes retired physicians. Physicians practicing solely in a federal facility may be excluded because they are not required to have an Arizona license. *Lightface numbers represent the number of physicians in 1992. Boldface numbers represent number of physicians in 2004. 32 Figure 8. Number of Physicians by County, 1992 and 2004* Coconino 164 323 Mohave 105 249 Yavapai 154 317 Navajo 50 103 Apache 27 34 Graham 12 22 Greenlee 4 7 Cochise 96 144 Santa Cruz 22 32 Pima 1,934 2,569 Pinal 69 147 Gila 43 87 Maricopa 4,903 7,745 La Paz 14 17 Yuma 115 220 Percent change in total number of physicians 1992-2004 21% to 32% 75% to 97% 45% to 57% 102% to 137% Source: MBD, January 5, 2005 and 1992. Data compiled by the ASU HDRG. Note: Physician is defined as a MD or DO practicing medicine in Arizona, January 5, 2005. Map excludes retired physicians; and physicians practicing solely in a federal facility may not be included because they are not required to have an Arizona license. Seven allopathic physicians and one osteopathic physician are missing county location. Consult Appendix 5 table for detailed information regarding the distribution of the allopathic and osteopathic physician population by county for Arizona in 2004. *Lightface numbers represent the number of physicians in 1992. Boldface numbers represent number of physicians in 2004. 33 Trends in Physician to Population Ratios The number of physicians per 100,000 people for Arizona increased from 197 in 1992 to 207 in 2004. The rate of increase in the number of physicians exceeded the rate of increase in the population in both rural and urban areas, but did not eliminate the existing rural to urban disparities in physician to population ratios (Table 5, Figure 7). The past reports on Arizona 9s physician workforce differ in many respects, but agree that the statewide ratio of physicians to population has been below the national average. The reasons for the persistent shortage of physicians, at least by reference to the physician to population ratios, are less well known. Much of the difference may simply reflect the rather marked differences in population density between Arizona 9s urban and rural counties. Approximately 86% of the Arizona population lives in urban areas compared to 81% of the U.S. population. The physician to population ratios in one urban area of Arizona (Pima County) is historically much closer to the national averages than the ratios in the rural counties. Indeed, the data for 2004 show that the ratio in Pima County is similar to the national averages (Table 5, Figure 6). One must be cautious in using national averages as a basis for comparison. Differences among the states in needs for care and the health care environment can, if not controlled, bias the conclusions drawn by comparing Arizona 9s physician to population ratios with the national averages. The bias could be in either direction, possibly understating or overstating the adequacy of the physician workforce in Arizona. We will address this question in Part II of this report, to be issued later this year. 34 Table 5. Arizona Physician to Population Ratios by County, 1992 and 2004 1992 2004 County Total Physicians Per 100,000 People Total Physicians Per 100,000 People All Physicians 197 207 Urban 230231 Marico p a 216220 Pima 277276 Rura l 9 3 124 Ap ache 4348 Cochise 95111 Coconino 160249 Gila 103161 Graham 4361 Greenlee 4784 La Paz 9580 Mohave 97138 Nava j o 6296 Pinal 5567 Santa Cruz 7276 Yava p ai 130161 Yuma 97121 Source: January 5, 2005 and 1992 MBD; July 1, 2004 Arizona Department of Economic Security Population Projections; and July 1, 1992 Census Population Estimates. Note: Consult Appendix 5 table for detailed information regarding the distribution of the allopathic and osteopathic physician population by county for Arizona in 2004. Trends in Types of Practice Physicians who respond to the 2004 PPS are asked to compare the nature of their pr

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