Abstract
BackgroundGrowing physician maldistribution and population demographic shifts have contributed to large geographic variation in healthcare access and the emergence of advanced practice providers as contributors to the healthcare workforce. Current estimates of geographic accessibility of physicians and advanced practice providers rely on outdated “provider per capita” estimates that have shortcomings.PurposeTo apply state of the art methods to estimate spatial accessibility of physician and non-physician clinician groups and to examine factors associated with higher accessibility.MethodsWe used a combination of provider location, medical claims, and U.S. Census data to perform a national study of health provider accessibility. The National Plan and Provider Enumeration System was used along with Medicare claims to identify providers actively caring for patients in 2014 including: primary care physicians (i.e., internal medicine and family medicine), specialists, nurse practitioners, and chiropractors. For each U.S. ZIP code tabulation area, we estimated provider accessibility using the Variable-distance Enhanced 2 step Floating Catchment Area method and performed a Getis-Ord Gi* analysis for each provider group. Generalized linear models were used to examine associations between population characteristics and provider accessibility.ResultsNational spatial patterns of the provider groups differed considerably. Accessibility of internal medicine most resembled specialists with high accessibility in urban locales, whereas relative higher accessibility of family medicine physicians was concentrated in the upper Midwest. In our adjusted analyses independent factors associated with higher accessibility were very similar between internal medicine physicians and specialists–presence of a medical school in the county was associated with approximately 70% higher accessibility and higher accessibility was associated with urban locales. Nurse practitioners were similar to family medicine physicians with both having higher accessibility in rural locales.ConclusionsThe Variable-distance Enhanced 2 step Floating Catchment Area method is a viable approach to measure spatial accessibility at the national scale.
Highlights
By the year 2020, the Health Resources and Services Administration (HRSA) estimates that there will be a shortage of 20,400 primary care physicians in the United States.[1]
Accessibility of internal medicine most resembled specialists with high accessibility in urban locales, whereas relative higher accessibility of family medicine physicians was concentrated in the upper Midwest
In our adjusted analyses independent factors associated with higher accessibility were very similar between internal medicine physicians and specialists–presence of a medical school in the county was associated with approximately 70% higher accessibility and higher accessibility was associated with urban locales
Summary
By the year 2020, the Health Resources and Services Administration (HRSA) estimates that there will be a shortage of 20,400 primary care physicians in the United States.[1]. The healthcare workforce is not distributed across the United States–while some areas struggle to provide basic healthcare services others have an abundance of healthcare providers.[7] Such geographic imbalance in the healthcare workforce is not unique to the U.S.[8,9,10] and a common observation is the high concentration of providers within urban and/or affluent areas, versus a relative undersupply in rural and/or low-income areas This has been clearly demonstrated in the distribution of U.S surgical services.[11] Likewise, the number of primary care physicians increases with greater urbanization, from 39.8 per 100,000 residents in non-metropolitan areas to 53.3 in large central metropolitan areas.[12] Financial incentives, recruitment, career development opportunities, infrastructure and staffing, workload and autonomy, and professional work environment have all been shown to affect where physicians practice.[13] Yet, very little is known about the factors that influence where non-physicians such as nurse practitioners practice, nor the extent to which the workforce varies geographically. To apply state of the art methods to estimate spatial accessibility of physician and non-physician clinician groups and to examine factors associated with higher accessibility
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