Changing Demographics and the Implications for Physicians, Nurses, and Other Health Workers

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Changing Racial and Ethnic Composition of the Population

1. Population Forecasts
2. Implications of the Changing Racial and Ethnic Composition of the Population for the Supply of Health Workers
3. Implications of the Changing Racial and Ethnic Composition of the Population for the Supply of Health Workers
   1. Physician Supply
   2. Nurse Supply

Advocates for increased minority representation in the health workforce argue that increasing the number of minority physicians will improve access to care for minorities and vulnerable, underserved populations. These advocates argue that increased representation of minorities in the health workforce not only will increase equity, but will also improve the efficiency of the health care delivery system.

This section explores the changing racial and ethnic composition of the population and its implications for the future demand for and supply of health professionals. The four main findings are the following.

First, Hispanics and non-whites have different patterns of health care use compared to non-Hispanic whites. Some of the disparities in use can be attributed to differences in access to care. The literature suggests that cultural differences regarding appropriate use of health care services also help explain differences in health care use.

Second, as minorities increase as a percentage of the U.S. population, the percentage of total health care services provided to minority patients will also increase. In 2000, physicians spent an estimated 31 percent of patient-care hours providing services to minorities. By 2020, physicians will spend an estimated 40 percent of patient-care hours with minority patients.

Third, minorities are underrepresented in the physician and nurse workforces relative to their proportion of the total population, and are overrepresented in lower-paying health professions such as nurse aides and home health aides. As minorities constitute a growing percentage of the working-age population, their representation in the professional health workforce will naturally rise. The U.S. will increasingly rely on minority caregivers.

Fourth, the literature suggests that minority physicians have a greater propensity than do non-Hispanic white physicians to practice in urban communities designated as physician shortage areas. An increase in minority representation in the physician workforce could improve access to care for the population in some underserved areas.

3.1 Population Forecasts

The latest census figures highlight the fact that the United States is becoming increasingly racially and ethnically diverse. Furthermore, higher birth rates among racial and ethnic minority groups, relative to non-Hispanic whites, and immigration suggest that this trend will continue. Exhibit 3.1 contains population forecasts used in the PARM that show the current and projected distribution of the population across the three race/ethnic groups modeled in the PARM. Whereas non-Hispanic whites constituted approximately 69 percent of the population in 2000, they will constitute an estimated 61 percent of the population in 2020. Between 2000 and 2020, African Americans (both Hispanic and non-Hispanic) will increase from approximately 12.3 percent to 13.1 percent of the population; all other minorities (including Hispanic whites) will increase from approximately 19 percent to 26 percent of the population. Growth in the Hispanic population is the major contributor to growth in the minority population.

Exhibit 3.1. Population Distribution by Race

Source: Modified version of Census Bureau middle series projections.

Racial and ethnic minority populations are unevenly distributed geographically. The proportion of a State's population that is minority varies substantially by State, and minorities are disproportionately located in inner cities.

3.2 Implications of the Changing Racial and Ethnic Composition of the Population for the Demand for Health Workers

The extant literature explores the degree to which and reasons why race and ethnicity may affect health care use. Differences between racial and ethnic groups in use of a wide range of health care services have been documented in the literature. Much of these utilization differences are attributed to differences in access to care and cultural differences regarding the use of health care services. A better understanding of differences in health care utilization by race and ethnicity, the causal factors of these differences, and whether these differences will persist in the future allows for better predictions of future demand for health workers.

Below is a sample of the literature that describes differences in health care utilization by race or ethnicity.

• Mueller, Patil and Boilesen (1998) analyzed data from the 1992 National Health Interview Survey (NHIS) and found racial disparities in use of physician services even after controlling for factors such as insurance status, geographic location and other patient characteristics. The disparity in use of physician services by race was not statistically different from zero for those patients living in urban areas, but the disparity was statistically different from zero for patients living in rural areas. Insurance status and location (urban versus rural) are greater determinants of use of physician services than is patient race.
  
• Hargraves, Cunningham and Hughes (2001) found small differences in access to care and health care use of non-Hispanic whites and minorities enrolled in managed care plans. Whereas approximately 78 percent of non-Hispanic whites have a regular provider, only 74 percent of Hispanics and African Americans have a regular provider. Whites have slightly higher use of specialists. In their last physician visit, 28 percent of non-Hispanic whites saw a specialist compared to 26 percent for African Americans and 22 percent for Hispanics.
  
• Burns et al. (1996) use Medicare claims from ten States to examine differences in mammography use between elderly African American and white women. They find that African American women had lower use rates than white women across all levels of primary care. These authors cite additional research that finds that physicians are more likely to encourage elderly white women to obtain mammograms than elderly African American women, highlighting concerns about provider attitudes.
  
• Peterson et al. (1994) analyzed the use of cardiac procedures of men treated at Veterans Affairs Medical Centers. These authors find that African Americans are less likely than their white counterparts to undergo selected cardiac procedures. The authors suggest several reasons for the differences in treatment, including: (1) differences in severity, (2) consumer preferences, and (3) differences in how providers may weigh the risk and benefit of invasive procedures differently for African Americans than for whites.
  
• Todd et al. (1993) studied analgesic use in emergency departments and find that ethnicity was a strong predictor of the lack of use of analgesics.
  
• Mitchell et al. (2000) analyzed Medicare inpatient data to compare differences between African Americans and whites in the use of diagnostic and therapeutic services for cerebrovascular disease. These authors control for differences in factors such as health care needs and ability to pay. Still, they find that "black patients were significantly less likely to receive non-invasive cerebrovascular testing, cerebral angiography, or carotid endarterectomy compared to white patients (p. 1413)."

Not all studies find differences by race or ethnicity in use of health care services. For example, Horner et al. (1997) found no differences by race and ethnicity in the use of inpatient rehabilitation services for elderly stroke victims after adjusting for differences in patient risk.

Access to affordable medical insurance is often cited as a major determinant of access to care. People in racial and ethnic minority groups in 1999 were more than twice as likely as nonminorities to be uninsured. The Census Bureau estimates that, in 1999, 89 percent of non-Hispanic whites had some form of medical insurance while only 79 percent of African Americans and 67 percent of Hispanics were insured. ^[7] US Census, http://www.census.gov/hhes/hlthins/hlthin99/hi99tc.html These statistics are important because the literature has established a link between access to care and health status (e.g., Drake and Lowenstein, 1998). Specifically, people without medical insurance tend to receive less preventative care and have higher rates of hospitalization for potentially avoidable problems. Drake and Lowenstein note that in California during the year of their study (1993), approximately 14 percent of African Americans and 37 percent of Latinos were uninsured, compared to 12.5 percent of whites.

An analysis of the 1999 NHIS found that 9 percent of non-Hispanic whites, 16.4 percent of African Americans, and 26.3 percent of other minorities (including Hispanic whites) were without health insurance on the date surveyed in 1999. The PARM divides the population into three insurance categories: insured in a fee-for-service arrangement, insured in an HMO, and uninsured. Exhibit 3.2 shows that the proportion of each racial/ethnic group in an HMO is relatively similar, controlling for age and sex, but the percentage insured in a fee-for-service arrangement and uninsured vary substantially by race/ethnicity.

Language and cultural differences also are cited as factors affecting health care utilization. With the growing population of Hispanics in the U.S. and immigration from non-English speaking countries, language is playing an increasingly important role in the provision of health care services. Consider the following findings in recent studies.

• Kravitz et al. (2000) found that Spanish-speaking patients who visited the General Medicine and Family Practice Clinics at the UC Davis Medical Center were less likely to follow up with recommended laboratory studies compared to English-speaking patients. In addition, patients needing a translator required more physician time per visit. The authors applied regression models to estimate the impact of language on physician time per visit. They found that Spanish- and Russian-speaking patients averaged 9.1 and 5.6 additional minutes of physician time, respectively, compared to English-speaking patients after controlling for other determinants of physician time per visit.

Exhibit 3.2. Percent Distribution of the Population by Demographic Group Across Three Insurance Categories

Source: Analysis of the 1999 NHIS.

• Derose and Baker (2000) analyzed survey data for 465 Spanish-speaking Latinos and 259 English speakers of various ethnicity who presented to a public hospital emergency department in Los Angeles. The survey asked participants to assess their English-speaking ability; indicate the number of visits to a physician during the prior three months; and provide information on the participants' health status, socioeconomic status, and demographic characteristics. The authors found that of participants who had at least one visit to a doctor during the previous three months, those with limited English proficiency had 22 percent fewer visits, on average, compared to participants with good-to-excellent English proficiency. The study controlled for patient characteristics that could be correlated with the use of physician services such as health conditions and insurance status. In practice, therefore, language and communication may be significant barriers to access to care.

In addition to differences across racial groups and English/non-English speakers in access to and use of health care services, there are significant differences in measures of health status that affect the type of care demanded. Keppel, Pearcy, and Wagener (2002) find that compared to non-Hispanic whites, many minority populations have higher infant mortality rates, higher rates of infants with low birth weight, higher age-adjusted rates of heart disease death, higher rates of tuberculosis, and disparities in many other measures of health care.

Freiman (1998) argues that the relationship between race or ethnicity and demand for health care services is a complex function of cultural, socioeconomic, and other considerations. Consequently, Freiman concludes that separate demand equations should be estimated for people in different racial or ethnic groups. To support his conclusions, Freiman presents findings from a multiple regression analysis of the 1987 National Medical Expenditure Survey where statistical tests performed indicate significant differences in the estimated coefficients of demand equations-estimated separately for non-Hispanic whites, African Americans, and Hispanics-that control for important determinants of health care use.

The PARM provides insight on the proportion of patient care hours that physicians spend providing care to patients in three race/ethnic groups. These estimates, like those described for people in different age categories in the preceding section, are based on patterns of health care use, the size of the population in each demographic group, and the average amount of time physicians spend with patients per encounter. In physicians' offices and in hospital outpatient settings, the average time spent per visit can differ by patient depending on the patient's demographic characteristics and insurance status. In the other settings, however, there are insufficient data to test the hypothesis that physician time per visit is independent of patient demographics and insurance status. Note that differences in the age and sex distribution of the population, by race, contribute to differences in the proportion of patient care hours spent with patients of different races.

In 2000, physicians spent approximately 69 percent of patient care hours with non-Hispanic whites, 13 percent with African Americans, and 18 percent with other minorities (Exhibits 3.3 and 3.4). Although the proportion of total patient care hours approximated the proportion of the population in each racial group, the distribution of hours varied by physician specialty. African Americans, who constituted approximately 12 percent of the U.S. population in 2000, used a disproportionately higher percentage of total patient care hours of emergency medicine physicians (38 percent), obstetrician/ gynecologists (17 percent), and pediatricians (16 percent). They received proportionately fewer hours from "other" surgical specialties (8 percent) and general surgeons (9 percent). The population in the "other" race/ethnicity category, which constituted approximately 19 percent of the total population in 2000, received a relatively larger proportion of radiology (31 percent) and pathology (29 percent) services, but a relatively smaller proportion of patient care hours from urologists (11 percent), ophthalmologists (11 percent), and general and family practitioners (13 percent).

If the distribution of insurance status for non-Hispanic whites were applied to other racial minorities, the total demand for physicians in 2000 would have risen significantly (see Section 5, Scenario 5) but the percentage of patient care hours by racial group would have remained relatively unchanged. The percentage of total physician patient care hours spent with non-Hispanic whites would decline by two percentage points while the percentage spent with African Americans and other minorities would rise by one percentage point for each group. For most specialties, the change in percent of time spent with patients in each race/ethnicity group changes by less than two percentage points. The largest change is for obstetrics/gynecology services. Under this scenario, the percentage of hours spent with non-Hispanic white patients would fall by three percentage points while the percentage of hours spent with patients in the "other" category (which includes Hispanics) would rise by three percentage points.

If health care utilization patterns and physician productivity patterns remain constant over time, in 2020 physicians will be spending approximately 14 percent of patient care hours with African Americans and 26 percent of hours with patients of other minority groups, again percentages roughly comparable to each group's share of the total population.

Physical therapists, optometrists, and podiatrists are seen to spend a disproportionate amount of time with non-Hispanic whites relative to their share of the population (Exhibit 3.4). While the gap for African Americans is small (and non-existent in the case of podiatrists), the gap for other minority groups was large in 2000 and projected to remain so in 2020.

Exhibit 3.3: Distribution of Total Patient Care Hours, by Patient Race: Total Active Physicians in Patient Care

Exhibit 3.3: Distribution of Total Patient Care Hours, by Patient Race: Total Active Physicians in Patient Care (Text Only)

Exhibit 3.4. Estimated Percentage of Patient Care Hours, by Race of Patient

These forecasts from the Physician Aggregate Requirements Model assume no change over time in per capita utilization, physician productivity or mix, or the health care operating environment.

Note: percentages might not sum to 100 percent due to rounding.

3.3 Implications of the Changing Racial and Ethnic Composition of the Population for the Supply of Health Workers

One of the five major recommendations of the Pew Health Professions Commission is to "ensure that the health profession workforce reflects the diversity of the nation's population." (O'Neil et al., 1998, p. iv). Currently, minorities are underrepresented in the physician and registered nurse workforce. The Pew Commission and numerous others argue that increasing minority representation in the health workforce is not only a commitment to diversity, but will also improve the health care delivery system. The two main arguments that diversity improves health care delivery are (1) minority health professionals express a greater propensity than do non-minority professionals to practice in underserved areas, and (2) health professionals who share the same culture and language with the patients they serve can provide more effective care (see, for example, Trevino, 1994). Much of the literature on willingness to practice in underserved areas pertains to physicians.

Supply models generally do not have a race/ethnicity component. Possible reasons include data limitations and the lack of priority this topic has received. Consequently, our understanding of the relationship between supply of health workers and race/ethnicity consists of snapshots of the racial and ethnic distribution through surveys and periodic efforts to survey health workers regarding the relationship between race/ethnicity and workforce issues (e.g., workforce participation, retention, and productivity). The following are important factors and questions to consider regarding the relationship between race/ethnicity and the supply of health workers:

1. Minorities have historically been underrepresented in higher-paying health care occupations and overrepresented in lower-paying health care occupations relative to their percentage of the U.S. population. As minorities constitute an increasing proportion of the population entering the workforce for the first time, minority representation in higher-paying health care occupations will naturally increase. As a result, the U.S. will increasingly rely on minority health workers.
2. One area where additional research is needed is whether lifetime labor force participation patterns of health workers differ by race or ethnicity. For example, minorities have historically had a shorter life span than non-minorities, although in recent years longevity of minorities has increased to more closely resemble longevity of whites. Do differences in longevity affect retirement rates?
3. Does race or ethnicity affect the health worker's choice of profession or medical specialty?
4. Does race or ethnicity affect the education and training opportunities of persons desiring to enter a health care profession?
5. Empirical research suggests that physician race and ethnicity are significant determinants of where the physician will practice, and minority physicians have a greater propensity than do non-minority physicians to practice in underserved locations.
6. Does physician race or ethnicity affect the quality of care that patients receive? A large body of literature explores the issue of "cultural competence," which is that health professionals can provide more effective and efficient services if they are sensitive to their patients' cultural background. ^[8] Cross et al. (1999) define cultural competence as ? set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.?It should be noted that culture is defined by more than race and ethnicity, it also encompasses economic and social factors. Often, race and ethnicity are correlated with these economic and social factors, which can obscure the relationship between health care and race or ethnicity. For example, Kington and Smith (1997) analyzed the relationship between socioeconomic status and racial and ethnic differences in the prevalence of diabetes, heart conditions, hypertension, and arthritis.They find that socioeconomic status plays a greater role in explaining racial and ethnic differences in individuals?ability to function once someone is ill, rather than explaining the differences in the probability of becoming ill. A recent literature review analyzed over 120 works in the field of cultural competence in health care to develop a measurement profile for cultural competence in health care delivery settings (The Lewin Group, 2001). Several articles reviewed discuss the need to emphasize the value of diversity and the importance of involving people from diverse backgrounds in the decision-making process of what care to provide to underrepresented groups. Much of the literature discusses the importance of educating health workers to be sensitive to differences in the needs of their patients resulting from differences in culture.

Brown and Nichols-English (1999) discuss the implications of patient diversity for pharmacists. People of different cultures-which they broadly defined by race and ethnicity, language, socioeconomic group, family structure, and geographic location-have different perceptions, on average, of health care issues. Their perceptions might differ in the following: "(1) [the constitution of] disease and its causation; (2) appropriate health-care-seeking behavior; (3) the quality and usefulness of medical encounters; (4) effective approaches to healing, including both conventional and alternative practices; and (5) the role of family in health care (p. 61)." Brown and Nichols-English discuss the importance of educating pharmacists on providing culturally competent care to reduce drug-related problems-e.g., noncompliance, adverse effects, and sub-optimal dosing.

3.3.1 Physician Supply

Relative to the overall population, minorities are underrepresented in the physician workforce for all races and Hispanic ethnicity with the exception of the population of Asian descent. Exhibit 3.5 shows the distribution of the physician workforce by race and ethnicity in 1999. For those physicians whose race and ethnicity is recorded in the AMA master file, 75.4 percent are non-Hispanic white, 3.6 percent are African American, 4.9 percent are Hispanic, 12.6 percent are Asian, 0.1 percent are American Indian or Alaskan Native, and the remaining 3.5 percent are of various other races.

Exhibit 3.5. Race Distribution of the Physician Workforce, 1999

Exhibit 3.5. Race Distribution of the Physician Workforce, 1999 (Text Only)

Source: American Medical Association, Physician Characteristics and Distribution in the U.S., 2001-2002 Edition.

The racial and ethnic composition of the physician workforce, however, varies substantially by specialty (Exhibit 3.6). The percent non-Hispanic white ranges from a high of 91.1 percent in aerospace medicine to a low of 65.2 percent in physical medicine and rehabilitation. Specialties with the highest representation of physicians of Asian descent are physical medicine and rehabilitation (20.6 percent), internal medicine (17.9 percent) and radiation oncology (17.4 percent). African Americans have the highest representation in general preventive medicine (6.3 percent), obstetrics/gynecology (6.2 percent) and pediatrics (4.8 percent). Hispanics have the highest representation in general practice (7.9 percent), child psychiatry (7.0 percent) and pediatrics (6.7 percent). A visual inspection of the specialties where physicians spend relatively more (less) time with African American and other minority patients (Exhibit 3.4) finds that these specialties tend to have higher (lower) minority representation in the physician workforce. The three specialties, for example, shown in Exhibit 3.4 to have spent the greatest percentage of time with African American patients in the year 2000 were emergency medicine, obstetrics/gynecology, and pediatrics; from Exhibit 3.6, we see that each of these specialties had in 1999 an above-average representation of African American physicians compared to the workforce at large (4.1, 6.2, and 4.8 percent respectively, compared to an overall average of 3.6 percent for all specialties combined). The two specialties shown in Exhibit 3.4 to have spent the lowest percentage of time with African American patients in the year 2000 were general surgery and other surgical specialties, groups characterized in Exhibit 3.6 by a below-average representation of African Americans. Similar observations apply, with some exceptions, to Hispanics and other minorities. The exceptions are as follows: (a) radiologists spent a large percentage of time with "other minority" patients (31 percent) despite the fact that other minorities constituted a distinctly below-average percentage of the radiologist workforce (12.7 percent as against an overall average of 21 percent), and (b) cardiologists spent a low percentage of time with other minority patients (15 percent) despite the fact that other minorities constituted an above-average percentage of the cardiologist workforce (26.3 percent compared to 21 percent for all specialties combined).Advocates for increased representation of minorities in the physician workforce cite both equity and efficiency reasons. One equity issue cited is providing greater access to care for minority populations who are disproportionately in designated physician shortage areas. Defining a "physician shortage area" as an area with fewer than 30 office-based primary care physicians per 100,000 population, Komaromy et al. (1996) found that 57 percent of poor areas with a high percentage of African American and Latino residents could be classified as physician shortage areas. In comparison, Komaromy et al. found that only 13 percent of poor areas with a high percentage of non-Hispanic white residents could be classified as physician shortage areas. Intuitively, one might expect that poorer urban neighborhoods might naturally have fewer physicians per population. Komaromy et al. found, however, a stronger correlation between the physician supply and the proportion of residents in the community who are African American or Hispanic residents than the correlation between physician supply and an area's average income level.

  Exhibit 3.6. Percent Distribution of Physicians by Race and Ethnicity, in 1999

Specialty	Non-Hispanic White	African American	Hispanic	Asian	Other	American Indian/ Alaskan Native
Total MDs	75.4	3.6	4.9	12.6	3.5	0.1
Aerospace Medicine	91.1	2.1	3.4	2.1	1.3	0.0
Allergy & Immunology	79.0	1.4	3.7	12.2	3.6	0.1
Anesthesiology	71.5	3.4	4.2	16.9	4.1	0.1
Cardiovascular Disease	71.1	2.4	4.9	15.2	6.2	0.1
Child Psychiatry	73.5	4.8	7.0	10.2	4.3	0.2
Colon/Rectal Surgery	81.6	1.8	5.1	9.8	1.7	0.0
Dermatology	87.4	2.5	2.7	5.9	1.4	0.0
Diagnostic Radiology	80.2	2.0	3.5	11.5	2.7	0.1
Emergency Medicine	82.4	4.1	4.2	7.3	1.8	0.1
Family Practice	79.2	4.1	5.4	8.8	2.3	0.2
Forensic Pathology	82.2	3.7	4.7	8.3	0.7	0.3
Gastroenterology	71.5	3.1	4.8	14.8	5.8	0.0
General Practice	75.5	2.2	7.9	13.6	0.7	0.0
General Preventive Med.	82.1	6.3	3.5	6.6	1.4	0.1
General Surgery	78.3	3.4	4.6	10.9	2.7	0.1
Internal Medicine	67.0	4.1	5.1	17.9	5.8	0.1
Medical Genetics	84.6	1.9	3.4	8.0	2.2	0.0
Neurology	72.8	1.9	5.2	14.1	5.9	0.0
Neurological Surgery	82.7	2.5	3.9	7.8	3.1	0.1
Nuclear medicine	71.0	2.0	5.7	16.8	4.4	0.0
Obstetrics/Gynecology	77.2	6.2	5.3	9.3	2.0	0.1
Occupational Med.	88.6	2.9	3.0	4.6	0.9	0.1
Ophthalmology	84.6	2.2	2.9	7.9	2.4	0.1
Orthopedic Surgery	88.7	2.4	2.4	4.7	1.7	0.1
Otolaryngology	84.3	2.0	3.2	8.7	1.7	0.0
Pathology-Anat/Clin	74.5	1.9	4.9	15.5	3.3	0.0
Pediatrics	68.6	4.8	6.7	15.7	4.0	0.1
Pediatric Cardiology	75.7	2.0	5.6	11.5	5.0	0.1
Physical Med/Rehab	65.2	4.4	6.2	20.6	3.7	0.1
Plastic Surgery	84.8	1.8	3.6	7.5	2.3	0.0
Psychiatry	75.0	3.2	5.6	12.7	3.4	0.1
Pulmonary Diseases	75.7	2.6	5.2	12.3	4.2	0.1
Radiology	85.7	1.4	2.2	8.8	1.7	0.0
Radiation Oncology	73.5	2.7	3.2	17.4	3.2	0.0
Thoracic Surgery	67.2	4.2	5.6	10.5	12.2	0.3
Urological Surgery	82.7	2.8	3.5	8.7	2.2	0.1
Other	88.2	2.0	3.4	5.5	0.9	0.0

Source: American Medical Association, Physician Characteristics and Distribution in the U.S., 2001-2002 Edition.

The Komaromy et al. study found that of many possible characteristics of a physician, the best predictor for whether the physician cared for a high percentage of African American patients was whether the physician was African American. After controlling for the proportion of African American residents in the community, this analysis indicated that the proportion of African American patients cared for by African American physicians was 25 percentage points higher than the average proportion of African American patients cared for by physicians of other races.

Other variables, such as the ranking of the physician's medical school, experience, and type of hospital had insignificant effects. The authors suggest that the personal choice of the physician is the most likely explanation for the phenomenon that African American physicians are more likely than non-Hispanic white physicians to treat African American patients. Given that the ranking of the physician's medical school is not significant in predicting the race of the physician's patients, the authors conclude that top African American medical school graduates are themselves choosing to practice in poorer, predominantly minority areas.

A study by Moy and Bartman (1995) found that minority patients were more than 4 times as likely as non-Hispanic white patients to receive care from minority physicians. Moy and Bartman note that any solution that attempts to increase the proportion of minority physicians must also take into account the financial hardships they face. On average, minority physicians tend to treat lower-paying uninsured and Medicaid patients. Moy and Bartman estimate Medicaid fees for physician services as averaging only 47 percent of private insurance fees. Because up to 29 percent of low-income patients are receiving care from minority physicians, these physicians must bear a disproportionately higher share of the financial burden associated with poorer patients. Medicaid insured 45 percent of the patients seen by African American physicians and only 18 percent of patients seen by non-Hispanic white physicians. Hispanic physicians cared for more uninsured patients than physicians of other ethnic groups. On average, 9 percent of their patients were uninsured compared to 6 percent for non-Hispanic white physicians.

Physicians whose clientele is composed of a high percentage of Medicaid and uninsured patients may also have a more difficult time securing managed care contracts. Bindman et al. (1998) studied the frequency of denials or terminations of managed care contracts experienced by primary care physicians. They found that physicians with higher proportions of uninsured patients were 4 times more likely to have a contract terminated or denied. There was also a significant positive correlation between the number of uninsured patients a physician saw and the frequency of denials from managed care contracts for these physicians. Latino physicians had significantly lower odds of having more than 10 percent of their patients enrolled in a managed care plan: 23 percent of Latino physicians in group practice are in no way affiliated with an HMO.

One reason for the imbalance, noted by Mackenzie et al. (1999), might be that solo practices are associated with lower levels of participation in managed care, and minority physicians tend to have solo practice settings. MacKenzie et al., through a survey of physicians who tended to treat managed care patients, found that 56 percent claimed they had difficulty referring patients of varied ethnic backgrounds to specialists who met those patients' cultural needs. The author expresses guarded optimism that as the idea of cultural competency within managed care gains momentum, managed care organizations will become increasingly aware of the importance of 'ethnic matching'. As a result, they may attempt to recruit ethnic minority physicians as a way to attract and retain ethnic minority members.

In 2000, minorities constituted 27 percent of the population age 18-34-the age group that reflects the population entering the workforce. By 2020, minorities will constitute approximately 45 percent of the age 18-34 population. An estimated 15 percent of the population in this age group will be African American, and 30 percent will be Hispanic or a non-African American minority. As minorities constitute a larger portion of the population from which new health workers are drawn, minority representation in the physician workforce will naturally rise.

Also, as noted by Libby, Zhou, and Kindig (1997), organizations such as the Bureau of Health Professions, the Institute of Medicine, the Association of American Medical Colleges, and others have made racial/ethnic equity in the physician workforce a high priority.

As shown by Libby et al., however, racial parity in the physician workforce will likely not occur in the next few decades, although some gains in parity will be made. For five race/ethnicity groups, these authors forecast the number of physicians per 100,000 population of the same race or ethnicity as the physician. Their projection model constrains the race-specific physician-to-population ratios to converge over time to an equilibrium of 218 physicians per 100,000 population by adjusting the racial composition of first-year graduate medical education cohorts. The soonest that racial parity is reached, given projected demographics, is around 2040.

In summary, the literature and changing demographics suggests that increasing minority representation in the physician workforce will improve access to care for minority and vulnerable populations. Minorities face financial obstacles to become physicians, and once they become physicians may face greater financial obstacles than non-minority physicians because of practice location or other factors. Increased racial/ethnic diversity of the U.S. population over the next few decades will naturally increase minority representation in the physician workforce.

3.3.2 Nurse Supply

Estimates from the 2000 Sample Survey of Registered Nurses (HRSA, 2001) indicate that approximately 86.6 percent of RNs are non-Hispanic white, 4.9 percent are non-Hispanic African American, 3.5 percent are Asian; 2 percent are Hispanic; 0.5 percent are American Indian or Alaskan Native, 0.2 percent are Native Hawaiian or Pacific Islander, and 1.2 percent are of two or more racial backgrounds (see Exhibit 3.7). Among minorities, Hispanics and African Americans are underrepresented in the registered nurse workforce relative to their proportion in the overall population.

Exhibit 3.7 Racial/Ethnic Distribution of the Registered Nurse Workforce in 2000

Exhibit 3.7 Racial/Ethnic Distribution of the Registered Nurse Workforce in 2000 (Text Only)

Source: 2000 Sample Survey of RNs (HRSA, 2001).

The literature on the relationship between race or ethnicity and the supply of nurses is substantially smaller than the corresponding literature for physicians.

Sechrist, Lewis, and Rutledge (1999) report that the nurse workforce in California is becoming more ethnically diverse. Although minorities are underrepresented in the current nurse workforce in California, the racial and ethnic mix of nursing school entrants more closely parallels the diversity of California’s population. The authors report that minority students, however, are less likely to graduate from nursing programs than their non-Hispanic white counterparts.

The authors make several recommendations to improve ethnic diversity of the nurse workforce including outreach efforts to increase the number of minorities in nursing programs. They cite an unpublished study by Martin-Holland et al. that looks at strategies to improve ethnic diversity in the nurse workforce. Specifically, the study looks at (1) strategies that have been successful in recruiting and retaining ethnically diverse students in nursing programs, (2) barriers to nursing program success for ethnically diverse students, and (3) activities incorporated into nursing programs to improve cultural sensitivity of nursing school graduates.

In 2000, approximately 61 percent of the female population age 18-34—the main source of new nurses—was non-Hispanic white. By 2020, the percentage will have decreased. Only half of all women age 18-34 will be non-Hispanic white; African Americans and all other minorities (including white Hispanics) will constitute 16 percent and 33 percent, respectively, of the female population age 18-34. As minorities constitute a growing proportion of the female population in this group, minority representation in the nurse workforce will naturally rise.

Furthermore, the growing nurse shortage in the U.S. has encouraged some employers to recruit foreign nurses. Recruiting foreign nurses will increase the diversity of the nurse workforce; however, many of the countries exporting nurses to the U.S. may themselves in turn face an inadequate supply of nurses. ^[9] Wall Street Journal article: Shortage of Nurses Hits Hardest Where They Are Needed the Most: Nurse Shortage Shows How Labor Markets Go Global (Zachary, 2001).

Executive Summary | Introduction | Changing Racial and Ethnic Composition of the Population | Aging of the Population | Geographic Location of the Population | Modeling the Impact of Changing Demographics on the Future Demand for Health Professionals | Summary and Conclusions | References