Health Professional Shortage Areas and Physician Location Decisions

In order to address geographic disparities in healthcare provision, the U.S. government designates primary care Health Professional Shortage Areas (HPSAs), and the Centers for Medicare and Medicaid Services (CMS) provide ten percent bonus payments for Medicare services billed by physicians in these areas. We link together several sources of administrative data from CMS covering the near-universe of Medicare-billing physicians and employ a matched difference-in-differences design to identify the causal effects of shortage area designations on physician location decisions. We find evidence that counties designated as HPSAs experience a 23% increase in the number of early-career primary care physicians, many of whom are likely making initial location decisions for their practices. The increase is driven entirely by physicians who attended ranked medical schools, perhaps reflecting the ability of the program to attract high-quality physicians just completing residency. However, we find no evidence that HPSA designation induces physicians in later career stages to relocate to shortage areas. Overall, our findings suggest that targeting financial incentives to locate in shortage areas towards newer physicians may improve the effectiveness and cost-efficiency of policies aimed at addressing physician shortages.

Individuals with prediabetes living in hard-to-reach and underserved areas experience barriers to accessing traditional in-person preventive health services. The National Diabetes Prevention Program (DPP) is a preventive health care program designed to reduce the risk of developing type 2 diabetes. Although there have been increasing numbers of remote DPPs accessible, there are little data on the clinical outcomes of digital DPPs for members living in hard-to-reach and underserved areas. This study assessed whether living in a designated Health Professional Shortage Area (HPSA) and a rural versus urban area impacted the weight loss of N = 7266 members of a fully digital program called Lark DPP. Secondary analyses included between-group comparisons of program retention and member characteristics, demographics, and socioeconomics. Percent weight loss did not differ by HPSA (P = 0.16) or rural/urban status (P = 0.15), despite greater potential barriers for members residing in HPSAs (eg, highest starting body mass index, lowest income, lowest education). Mean percent weight loss for members residing in an HPSA and rural area was mean (M) = 4.75%, standard error (SE) = 0.09; for members in a non-HPSA, rural area M = 4.96%, SE = 0.16; for members in an HPSA, urban area M = 4.55%, SE = 0.13; and for members in a non-HPSA, urban area M = 4.77%, SE = 0.13. Members of a fully digital DPP achieved weight loss that did not differ by HPSA or urban/rural designation. Fully digital programs offer a solution to reduce the risk of type 2 diabetes in areas where residents may not otherwise have access to diabetes prevention services.

Low-quality journals are problematic for the scientific community. They may not provide thorough editorial and peer review services, and may spread low-quality information. Community pharmacists are limited in research time and resources, and are particularly at risk to access low-quality information published in some journals. This may negatively impact their professional decision-making and patient care. This study aimed to assess pharmaceutical journals readily accessible to community pharmacists and classify those journals using multiple quality criteria. A Google search was performed using defined English and German keywords. The following quality indicators were utilized: (i) whether the journal was listed on a blacklist or whitelist, (ii) whether the journal or its publisher was a member of a publishing organization, (iii) evaluation of details on the journal's website, (iv) indexation of the journal, and (v) use of journal metrics. Three hundred and eight journals were analysed; 105 (34%) were classified as "high-quality" and 203 (66%) were classified as "other". Forty-six journals (15%) were listed on a blacklist and 152 journals (49%) were listed on a whitelist. Most journals were headquartered in India (39%), followed by the USA (24%) and Europe (20%). Journals classified as "high-quality" charged higher open access article processing charges (APCs) (median APC: USD $960; interquartile range (IQR): USD $27 to USD $3,000) than journals classified as "other" (USD $100, IQR: USD $13 to USD $547), p = 0.003. Similarly, journals indexed in established databases (MEDICUS, MEDLINE, PUBMED, Embase, Science Citation Index Expanded, or SCOPUS) charged higher APCs (median APC: USD $600, IQR: USD $4 to USD $2,500) than journals indexed in non-standard databases (median APC: USD $100, IQR: USD $41 to USD $581), p = 0.001. The results indicate that community pharmacists are at risk of accessing journals of questionable quality. Patient care may be negatively impacted by community pharmacists basing their professional decisions on evidence gained from some sources of lower quality. Community pharmacists and other pharmacists and researchers can use the tools and quality indicators provided in this study to preliminarily determine the quality and reliability of a journal to assist their professional decision-making and patient care.

Along with high numbers of physicians, New York State also has 2.7 million people living in poverty and 3 million without health insurance who are likely to live in areas with few physicians.1,2 Nearly 4 million New Yorkers live in communities that have been designated as health professional shortage areas (HPSAs).3 We conducted a study to examine the physician workforce in New York State and its HPSAs. Data on federally designated primary medical HPSAs were obtained from the Bureau of Health Professions. Physician data obtained from the AMA Physician Masterfile were geocoded and cross-referenced with the HPSA file. A complete description of methods and findings are available in the full study report.4 Of the 47,981 physicians identified as practicing in New York State (NYS), 14.5% were found to practice in HPSAs. Most of these, 13.5% of all NYS physicians, practice in metropolitan HPSAs. Primary care physicians practice in HPSAs at only a slightly higher rate (16 vs. 15%) than non-primary care physicians, and also practice predominantly in metropolitan HPSAs (see Table 1). Table 1 New York State physicians in metropolitan and nonmetropolitan HPSAs, 2000 More than half (53%) of all primary care physicians practicing in NYS metropolitan HPSAs are international medical graduates (IMGs), compared to 33% of those in nonmetropolitan HPSAs and 44% of those practicing outside of HPSAs. Thus, NYS relies heavily on IMGs born outside of the USA to meet the need for physicians in underserved communities, particularly in metropolitan areas. Almost one in three black, non-Hispanic physicians in NYS were found to practice in metropolitan HPSAs, the highest prevalence of any racial/ethnic group. All non-white physicians had higher rates of metropolitan HPSA practice than white, non-Hispanic physicians. Overall, New York State has a small base of underrepresented minority physicians (8% of all physicians) who are disproportionately located in metropolitan HPSAs. The lack of growth in the number of minority students graduating from medical schools in NYS is out of sync with the state’s growing minority population. Thirty-six percent of NYS physicians are graduates of a medical school located in NYS, yet only 29% of physicians in HPSAs are graduates of these schools. Graduates of the four medical schools in the state university system comprise 13% of both the NYS physician workforce and the HPSA workforce. While the heavy concentration of NYS HPSA physicians in metropolitan HPSAs reflects, to a great extent, the distribution of the overall state population, it is disproportionate to the HPSA population which needs to be served. Seventy-eight percent of New York’s HPSA population is located in metropolitan HPSAs, while 94% of the state’s HPSA physicians practice there.5 New York’s nonmetropolitan HPSAs have lower physician to population ratios and higher unmet need. Given that family physicians are more likely to practice in the nation’s rural areas than other primary care physicians,6 the relatively small workforce and training pipeline for family physicians in NYS contributes to shortages in rural areas. Increased family medicine training, recruitment of minority physicians into training, and ensuring the continuing flow of IMGs into NYS are efforts most likely to increase the number of physicians practicing in New York’s HPSAs.

Association of Primary Care Shortage Areas with Adverse Outcomes after Pediatric Liver Transplant

Background: Over 65 million Americans live in Primary Care Health Professional Shortage Areas (HPSAs) which are associated with less preventive care, poorer general health and an increased risk for hospitalizations. However, little is known about how living in a HPSA impacts primary prevention for CVD. Methods: We used data from CARDIA, a multi-center cohort study of black and white men and women. Participants who had risk factor data and geocoded addresses available at year 20 (2005) were included in this analysis (n=3479). Primary care HPSAs were defined using data from US HRSA. Diabetes, hypertension and hyperlipidemia prevalence and control were defined according to ADA Guidelines 2000, JNC VI, and ATP III, respectively. Individuals who reported being diagnosed or reported use of medications were considered aware of the risk factor. The prevalence of smoking and obesity was also examined. Neighborhood (census block) characteristics were derived from Census 2000 and ACCRA. Multivariable Poisson models were used to examine the independent association of HPSA residence with each outcome. Results: Over 11% of CARDIA participants live in a HPSA. Residents of HPSAs were more likely to be female (64% vs 56%), African American (81% vs 43%), have low education, and low income. HPSA residents had more difficulty paying for food/basics and medical care, had poorer access to medical care and lived in areas with a higher cost of healthcare and low neighborhood SES. HPSA residents had a higher prevalence of hypertension (PR 1.39, 95% CI 1.18-1.65), obesity (1.30, 1.16-1.45) and smoking (1.72, 1.46-2.03) and were less likely to have their hypertension (0.79, 0.66-0.95) or hyperlipidemia (0.66, 0.44-0.99) controlled as compared to non-residents. The association between HPSA and risk factors prevalence was explained by race and neighborhood SES. The cost of medical care and having a usual source of care were the largest mediators of the association between HPSA residence and risk factor control. Conclusion: The increased prevalence and poorer control of CVD risk factors in HPSAs, can be explained by the demographic and neighborhood characteristics of their residents. Future interventions should be targeted to these high-risk populations found within HPSAs.

Trends in Behavioral Health Care Service Provision by Community Health Centers, 1998–2007

Americans who reside in health professional shortage areas currently have less than half of the needed physician workforce. While the shortage designation has been associated with poor outcomes for chronic medical conditions, far less is known about outcomes after high-risk surgical procedures. We performed a retrospective review of Medicare beneficiaries living in health professional shortage areas and nonshortage areas who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, esophagectomy, liver resection, pancreatectomy, or rectal resection between 2014 and 2018. Risk-adjusted multivariable logistic regression was used to determine whether rates of postoperative complications and 30-day mortality differed between patient cohorts. Beneficiary and hospital ZIP codes were used to quantify travel time to obtain care. Compared with patients living in nonshortage areas, patients living in health professional shortage areas traveled longer (median 60.0 vs 28.0 minutes, P<.001). There were no differences in risk-adjusted rates of complications (28.5%vs 28.6%, OR = 1.00, 95% CI 1.00-1.00, P = .59) and small differences in rates of 30-day mortality (4.2%vs 4.4%, OR = 0.95, 95% CI 0.95-0.95, P<.001) between beneficiaries living in shortage areas versus those not in shortage areas, respectively. Patients living in health professional shortage area undergoing high-risk surgery traveled more than 2 times longer for their care to obtain similar outcomes. While reassuring for clinical outcomes, additional efforts may be needed to mitigate the travel burden experienced by shortage area patients.

Surgical Procedures in Health Professional Shortage Areas: Impact of a Surgical Incentive Payment Plan

Background: Uninsured individuals and those living in federally designated Health Professional Shortage Areas (HPSA) face considerable access barriers and, consequently, may receive less cardiovascular disease (CVD) preventive care. Methods: REGARDS is a national cohort of 30,239 African American (AA) and White community dwelling individuals &gt;45 years of age recruited between 2003 and 2007. We investigated 5 CVD prevention guidelines: 1) aspirin in those with coronary heart disease (CHD), 2) beta-blockers (BB) following myocardial infarction, 3) angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers in those with diabetes or CVD and either hypertension or chronic kidney disease, 4) statins in those with diabetes or CHD, and 5) warfarin for atrial fibrillation. We compared use of these medications by insurance status and HPSA county residence, adjusting for sociodemographics, health behaviors, and health status. Counties with partial HPSA status were excluded. Results: Mean age of participants was 64±9 years, 42% were AA, 55% were women, 93% were insured; 2,548 participants resided in complete HPSA counties and 17,441 in non-HPSA counties, representing 340 of 842 complete HPSA and 1,145 of 1,792 non-HPSA counties nationally. The odds of receiving aspirin, BBs, and ACEI by were similar by HPSA county type and insurance status. However, the odds of receiving statin therapy were lower among uninsured participants, regardless of county type (Table). Conclusions: Residence in HPSA counties was not associated with less CVD prevention. However, a combination of lack of insurance and residence in a HPSA county defined those with the lowest recommended statin use, suggesting lack of access to newer, more expensive therapies among those with both financial and geographic barriers to primary care. Adjusted OR * (95% CI) for Recommended Medications Compared to Insured Residents of non-HPSA Counties Aspirin Beta-Blockers ACEI or ARB Statin Warfarin Insured residents of HPSA counties 1.19 (0.79-1.80) 1.05 (0.75-1.47) 1.08 (0.90-1.30) 1.01 (0.84-1.21) 1.42 (0.93-2.17) Uninsured residents of non-HPSA counties 1.33 (0.66-2.64) 1.47 (0.78-2.74) 0.98 (0.75-1.28) 0.74 (0.57-0.96) 1.44 (0.65-3.21) Uninsured residents of HPSA counties 0.92 (0.26-3.24) 1.01 (0.31-3.25) 0.98 (0.58-1.65) 0.54 (0.33-0.90) ** * Adjusted for age, race, gender, education, income, percent of county population below poverty, medication adherence, functional capacity, and depressive symptoms. ACEI=angiotensin converting enzyme inhibitor, ARB=angiotensin receptor blocker, CVD=Cardiovascular Disease, HPSA=Health Professional Shortage Area. ** Adjusted OR not available due to few available individuals; unadjusted OR=0.14 (0.02-1.08).

Supporting youth mental health during the COVID-19 pandemic.

Suicide is the second leading cause of death among US adolescents. Workforce shortages of mental health professionals in the US are widespread, but the association between mental health workforce shortages and youth suicides is not well understood. To assess the association between youth suicide rates and mental health professional workforce shortages at the county level, adjusting for county demographic and socioeconomic characteristics. This retrospective cross-sectional study included all US counties and used data of all US youlth suicides from January 2015, through December 31, 2016. Data were analyzed from July 1, 2021, through December 20, 2021. County health-professional shortage area designation for mental health, assigned by the US Health Resources and Services Administration based on mental health professionals relative to the population, level of need for mental health services, and service availability in contiguous areas. Designated shortage areas receive a score from 0 to 25, with higher scores indicating greater workforce shortages. Suicides by youth aged 5 to 19 years from 2015 to 2016 were identified from the US Centers for Disease Control and Prevention's Compressed Mortality File. A multivariable negative binomial regression model was used to analyze the association between youth suicide rates and mental health workforce shortage designation, adjusting for the presence of a children's mental health hospital and county-level markers of health insurance coverage, education, unemployment, income, poverty, urbanicity, racial and ethnic composition, and year. Similar models were performed for the subgroups of (1) firearm suicides and (2) counties assigned a numeric shortage score. During the study period, there were 5034 youth suicides (72.8% male and 68.2% non-Hispanic White) with an annual suicide rate of 3.99 per 100 000 youths. Of 3133 US counties, 2117 (67.6%) were designated as mental health workforce shortage areas. After adjusting for county characteristics, mental health workforce shortage designation was associated with an increased youth suicide rate (adjusted incidence rate ratio [aIRR], 1.16; 95% CI, 1.07-1.26) and an increased youth firearm suicide rate (aIRR, 1.27; 95% CI, 1.13-1.42). For counties with an assigned numeric workforce shortage score, the adjusted youth suicide rate increased 4% for every 1-point increase in the score (aIRR, 1.04; 95% CI, 1.02-1.06). In this cross-sectional study, US county mental health professional workforce shortages were associated with increased youth suicide rates. These findings may inform suicide prevention efforts.

Most policy-makers and researchers agree that although the United States is headed for a significant physician surplus, problems of equity in access to care still remain. To help meet this challenge, Title VII of the Public Health Service Act focuses on producing generalist physicians to serve in medically underserved areas (MUAs). This study estimates the impact Title VII support for generalist training has on reducing and eliminating health professional shortage areas (HPSAs) under multiple scenarios that vary either the Title VII funding level or the percentage of Title VII-funded program graduates who practice in MUAs. For each scenario, the number of Title VII-funded residency graduates who initially practice in MUAs and the time it would take to eliminate HPSAs are estimated. Using 1996 rates, the analysis predicts that 1,214 generalist physicians will enter practice in HPSAs annually, leading to elimination of HPSAs in 24 years. In 1997, Title VII-funded programs increased the rate of graduates entering HPSAs, resulting in 1,357 providers and reducing the time for HPSA elimination to 15 years. Doubling the funding for these programs would increase the number of Title VII-funded generalist physicians entering MUAs and could decrease the time for HPSA elimination to as little as 6 years. The study concludes that eliminating HPSAs requires broader Title VII influence and continuous improvement in rates of production of graduates who practice in MUAs. Without Title VII graduates and continuous improvement of Title VII program, MUA rates, the number of HPSAs and the number of Americans with reduced access to essential health care will continue to expand.

Medical Student Distress: Causes, Consequences, and Proposed Solutions

Although areas designated as Health Professional Shortage Areas (HPSAs) have fewer primary care physicians than non-HPSAs, few studies have tested whether HPSA designation is related to health status and medical service access. This study examined whether residents living in HPSAs were more likely to report worse health status and to be more likely to have difficulty in getting access medical services than residents living in non-HPSAs, with survey data of 10,940 adult West Virginians. Multiple regression results indicate that HPSA is associated with worse general health status and poor physical health, and less access to medical services (measured by had usual place for medical care, experienced not getting needed health care and had outpatient care) but not to inpatient care. These findings indicate that the current HPSA designation system does capture the significant differences between residents of HPSAs and residents of non-HPSAs in health status and medical services access.