Reports > The Health Care Workforce in Eight States: Education, Practice & Policy > Missouri

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On this page: Project Description | Study Methodology | State Summary | Workforce Supply and Demand | Health Professions Education | Physician Practice Location | Licensure and Regulation of Practice | Improving the Practice Environment | Exemplary Workforce Legislation, Programs and Studies | Policy Analysis | Data Sources

PROJECT DESCRIPTION

Historically, both federal and state governments have had a role in developing policy to shape the health care workforce.  The need for government involvement in this area persists as the private market typically fails to distribute the health workforce to medically underserved and uninsured areas, provide adequate information and analysis on the nature of the workforce, improve the racial and ethnic cultural diversity and cultural competence of the workforce, promote adequate dental health of children, and assess the quality of education and practice. 

It is widely agreed that the greatest opportunities for influencing the various environments affecting the health workforce lie within state governments. States are the key actors in shaping these environments, as they are responsible for:

§ financing and governing health professions education;

§ licensing and regulating health professions practice and private health insurance;

§ purchasing services and paying providers under the Medicaid program; and

§ designing a variety of subsidy and regulatory programs providing incentives for health professionals to choose certain specialties and practice locations.

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  This initiative to compile in-depth assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues, influences and policies. 

Products of this study include individual health workforce assessments for each of the eight states and a single assessment that compares various data and influences across the eight states.  In general, each state assessment provides the following:

1)      A summary of health workforce data, available resources and a description of the extent the state invests in collecting workforce data.  [Part of this information has been provided by the Bureau of Health Professions];

2)      A description of various issues and influences affecting the health workforce, including the state’s legislative and regulatory history and its current programs, financing and policies affecting health professions education, service placement and reimbursement, planning and monitoring, and licensure/regulation;

3)      An assessment of the state’s internal capacity and existing strategies for addressing the above workforce issues and influences; and

4)      An analysis of the policy implications of the state’s current workforce data, issues, capacity and strategies.

The development of the project’s data assimilation strategy, content and structure was guided by an expert advisory panel.  Members of the advisory panel included both experts in state workforce policy (i.e., workforce planners, researchers and educators) and, more broadly, influential state health policymakers (i.e., state legislative staff, health department officials).  The advisory panel has helped to ensure the workforce assessments have an appropriate content and effective format for dissemination and use by both state policymakers and workforce experts/officials.

STUDY METHODOLOGY

Study Purpose and Audience

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  Because states increasingly are being looked to by the federal government and others as proving grounds for successful health care reform initiatives, new and dynamic mechanisms for sharing innovative and effective state workforce strategies between states and with the federal government must be implemented in a more frequent and far reaching manner.  This initiative to compile comprehensive capacity assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues and influences.

Each state workforce assessment report is not intended to be voluminous; rather, information is presented in a concise, easy-to-read format that is clearly applicable and easily digestible by busy state policymakers as well as by workforce planners, researchers, educators and regulators.

Selection of States

NCSL, with input from HRSA staff, developed a methodology for identifying and selecting 8 states to assess their health workforce capacity.  The methodology included, but was not limited to, using the following criteria:

a.       States with limited as well as substantial involvement in one or more of the following areas: statewide health workforce planning, monitoring, policymaking and research;

b.       States with presence of unique or especially challenging health workforce concerns or issues requiring policy attention;

c.       States with little involvement in assessing health workforce capacity despite the presence of unique or especially challenging health workforce concerns or issues requiring policy attention;

d.       Distribution of states across Department of Health and Human Services regions;

e.       States with Bureau of Health Professions (BHPr) - supported centers for health workforce research and distribution studies;

f.        States with primarily urban and primarily rural health workforce requirements; and

g.       States in attendance at BHPr workforce planning workshops or states that generally have interest in workforce modeling.

Collection of Data

NCSL used various means of collecting information for this study.  Methods exercised included:

a. Phone and mail interviews with state higher education, professions regulation, and recruitment/retention program officials;

b. Custom data tabulations by national professional trade associations and others (i.e., Quality Resource Systems, Inc.; Johns Hopkins University School of Public Health) with access to national data bases;

c. Tabulations of data from the most recent edition of federal and state government databases (e.g., National Health Service Corps field strength);

d. Site visit interviews with various officials in the ten  profile states;

e. Personal phone conversations with other various state and federal government officials;

f.   Most recently available secondary data sources from printed and online reports, journal articles, etc.; and

g. Comments and guidance from members of the study’s expert advisory panel.

STATE SUMMARY

With the exception of two major metropolitan areas, Missouri remains largely a very rural state with a lower than average minority/ethnic population.  Missouri is a good example of a state where having health insurance does not guarantee access to health services.  The good news is that the proportion of the state’s population without health insurance is substantially below the national average.  The bad news is that the percentage of the population residing in health professional shortage areas (HPSAs) is well above U.S. figures.  In fact, just four counties in Missouri are not designated as HPSAs. 

The proportion of the state’s population living in dental HPSAs is twice the national average, and statewide, Missouri has a significantly smaller ratio of dentists and dental hygienists than the U.S. as a whole.  Furthermore, just over a fourth of all practicing dentists in the state participate in the Medicaid program.  In part, low participation rates can be attributed to Medicaid payment rates that are less than 50 percent of usual and customary charges.  Medicaid in Missouri is covered by mandatory managed care enrollment only in urban areas, in part because there are not enough health professionals in largely-HPSA rural areas to staff the managed care plans.  Only urban Medicaid providers are required to deliver oral health services.  Such services for rural providers remain reimbursable on a fee-for-service basis.  Recently, Missouri’s governor, in an effort to curb rising Medicaid costs, proposed cutting adult dental care as a covered service.

Recently, the state has taken some steps to address health workforce shortages in dentistry and rural underserved areas.  A 2001 law 1) adds dentists to the state’ health professional loan program, which will support access to dental services in underserved communities, 2) allows dental hygienists practicing in public health settings to provide certain services to Medicaid-eligible children without the supervision of a dentist (regulations not yet published as of early 2002), and 3) requires the creation of a donated dental services program, through which volunteer licensed dentists will provide comprehensive dental care to needy, disabled, elderly and medically-compromised individuals.  The measure also granted a significant Medicaid fee increase to dental providers.

In 2002, a rapidly declining fiscal climate in the state has made further significant efforts to address workforce shortages unlikely.  Missouri faces a $612 million budget deficit in fiscal year 2003 in addition to a $340 million shortfall in the previous budget period.  Major across-the-board cuts in state agency spending are expected.

Otherwise, Missouri has several health professions loan repayment and primary care grant programs that in general have a good track record of retaining a significant proportion of service-obligated primary care physicians and nurses in medically underserved communities in the state.  However, the state has placed little attention to the need to better understand the health workforce supply issue and to collect additional information.  Thus, there appears to be gaps in awareness and understanding of the problems.

Despite the fact that Missouri’s ratio of physicians is lower than the national average, major attention to address this problem appears nonexistent.  Less than half of newly entering medical students to the state’s 4 allopathic medical schools (the state has two additional osteopathic schools) are state residents.  Just 40 percent of all physicians completing their graduate medical education in Missouri now practice in the state.

Existing data suggests that Missouri faces less of a shortage of nurses than many states.  However, expected demand for nurses is a major component of the state’s workforce.  Registered nurses as an occupation have the third highest number of projected openings in the coming years, according to state estimates.  However, graduations of baccalaureate-trained nurses have been flat or in decline in recent years, and data suggest that there are only a small percent of nurses licensed but not working as nurses in the state.  The market for nurse practitioners appears to be saturated with reports that recent graduates are still looking for work.

I.  WORKFORCE SUPPLY AND DEMAND

Arguably, it is most important initially to understand the marketplace for a state’s health care workforce.  How many health professionals are in practice statewide and in medically underserved communities?  What are the demographics of the population served?  How is health care organized and paid for in the state?  This section attempts to answer some of these questions by presenting state-level data collected from various sources.

* As defined by the U.S. Office of Management and Budget

Sources:  U.S. Census Bureau, AARP.

Only 15% of Missouri’s population are minorities—about half the national average.

Sources: CDC, AARP, GAO.

Fewer than half of Missouri adults with annual family incomes less than $15,000 made a dental visit in 1999.

HPSA = Health Professional Shortage Area

* It is commonly believed that there are additional areas in the state that may be eligible to receive HPSA designation.

Sources: KFF, AARP, BPHC-DSD.

Missouri’s proportion of children and non-elderly who are uninsured is less than the U.S. average.  In contrast, the state has a higher proportion of persons living in dental and primary care HPSAs than the U.S. as a whole.

RN= Registered Nurse, LPN= Licensed Practical Nurse, CNM= Certified Nurse Midwife, NP= Nurse Practitioner

CRNA= Certified Registered Nurse Anesthetist

Source: HRSA-BHPr.

Missouri has more pharmacists and nurses per 100,000 population than the U.S. as a whole.

Table I-e.
NATIONAL HEALTH SERVICE CORPS (NHSC) FIELD STRENGTH
Total Field Strength (FY 2001) * Includes mental/behavioral health officials		% in Urban Areas	% in Rural Areas	# Per 10,000 Population Living in HPSAs
73		44	56	0.39 (0.49 U.S.)
Field Strength by Profession
Physicians	42
Nurses	14
Physician Assistants	2
Dentists/Hygienists	7

HPSA= Health Professional Shortage Area

Source: BHPr-NHSC.

Missouri has less NHSC professionals per 10,000 population living in HPSAs than the U.S. as a whole.

MCOs = Managed Care Organizations    HMOs = Health Maintenance Organizations    OB/GYN = Obstetrician/Gynecologist

* This requirement does not preclude MCOs from including additional professions on their provider panels.

Sources: HPTS, AARP.

One-third of Missouri residents receive their health care from an HMO.

¹ Generally seen as an indicator of significant participation in the Medicaid program.

² Denominator number from HRSA State Health Workforce Profile, December 2000.

*  Numerator data for physicians and nurse practitioners from state Medicaid agencies were unusable: many professionals were apparently double-counted, perhaps due to varying participation in different health plans.

N/A = Data was not available

Sources: State Medicaid programs, Norton and Zuckerman “Trends”, HPTS, AARP.

Physicians, nurse practitioners and dentists all received payment rate increases of more than 10% from 1995-2000.

II.  HEALTH PROFESSIONS EDUCATION

State efforts to help ensure an adequate supply of health professionals can be understood in part by examining data on the state’s health professions education programs–counts of recent students and graduates, amounts of state resources invested in education, and other factors.  State officials can gauge how well these providers reflect the state’s population by also examining how many students and graduates are state residents or minorities.  Knowing to what extent states are also investing in primary care education and how many medical school graduates remain in-state to complete residencies in family medicine is also important.

¹ Denominator number is state population from 2000 U.S. Census.

Sources: AAMC, AAMC Institutional Goals Ranking Report, AACOM, Barzansky et al. “Educational Programs”, State higher education coordinating boards.

Only 4% of medical school graduates in Missouri between 1994 and 1998 were underrepresented minorities.

¹ Includes estimated number of osteopathic residencies/residents not accredited by the Accreditation Council for Graduate Medical Education.

² Does not include residents from Canada.

³ Explicit payments for both direct and indirect GME cost.

⁴ Funds largely are for graduate education.

⁵Dollar amounts refer largely to funding for family medicine training programs. However, these funds that flow directly to teaching hospitals are not necessarily earmarked by the state for graduate medical education.

Sources: AMA, AMA State-level Data, AACOM, State higher education coordinating boards, Henderson “Funding”, Oliver et al. “State Variations.”

¹ Denominator number is state population from 2000 U.S. Census.

2 Dollar amounts refer largely to funding family medicine training programs. However, these funds that flow directly to teaching hospitals are not necessarily earmarked by the state for graduate medical education.

Sources: AAFP, AAFP State Legislation, Kahn et al., Pugno et al. and Schmittling et al. “Entry of U.S. Medical School Graduates”.

Less than 40% of graduates choosing a family medicine program entered an in-state family medicine residency.

¹ Annual figure for Associate, Baccalaureate, Masters and Doctoral students/graduates for most recent years available.

² Denominator number is the state population from the 2000 U.S. Census.

Sources: NLN, AACN, State higher education coordinating boards.

The number of nursing school graduates in Missouri declined from 1999 to 2000.

* Denominator number is state population from 2000 U.S. Census.

Source: AACP.

¹ Denominator number is state population from 2000 U.S. Census.

² In general, state appropriations are not directly earmarked for these programs, but rather to their sponsoring institutions.

Sources: APAP, APAP Annual Report.

* Denominator number is state population from 2000 U.S. Census.

Source: ADA.

* Denominator number is state population from 2000 U.S. Census.

Sources: ADHA, AMA Health Professions. 

III.  PHYSICIAN PRACTICE LOCATION

The following tables examine in-state physician practice location from two different vantage points: (1) of all physicians who were trained (went to medical school or received their most recent GME training) in the state between 1975 and 1995, and (2) of all physicians who are now practicing in the state, regardless of where they were trained.  Complied from the American Medical Association’s 1999 Physician Masterfile by Quality Resource Systems, Inc., the data importantly illustrates to what extent physician graduates practice in many of the state’s small towns, using the rural-urban continuum developed by the U.S. Department of Agriculture.

Practice location (URBAN/ RURAL) of physicians who received their ALLOPATHIC medical school training in MISSOURI
between 1975 and 1995.

¹ 1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale. Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:      

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

NA: Not Applicable; no counties in the state are in the R/U Continuum Code

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

¹  1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale.  Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

NA: Not Applicable; no counties in the state are in the R/U Continuum Code.

IV.  LICENSURE AND REGULATION OF PRACTICE

States are responsible for regulating the practice of health professions by licensing each provider, determining the scope of practice of each provider type and developing practice guidelines for each profession.  The tables below illustrate the licensure requirements for each of the health professions covered in this study as well as additional information on recent expansions in scope of practice or other novel regulatory measures taken by the state.

Sources: State licensing board, HPTS.

Source: State licensing board.

Sources: State licensing board, AANA, ACNM, Pearson “Annual Legislative Update”, HPTS.

Source: State licensing board.

Source: State licensing board.

Source: State licensing board, ADHA.

Glossary of Acronyms

CNM: Certified nurse midwife.

CRNA: Certified registered nurse anesthetist.

NP: Nurse practitioner.

V.    IMPROVING THE PRACTICE ENVIRONMENT

States have the challenge of not only helping to create an adequate supply of health professionals in the state, but also ensuring that those health professionals are distributed evenly throughout the state.  Various programs and incentives are used by states to encourage providers to practice in rural and other underserved areas.  The tables in this section describe Missouri’s programs as well as the perceived effectiveness of these programs.

RECRUITMENT/ RETENTION INITIATIVES

Source: State health officials.

The state of Missouri provides no funding to place pharmacists, dental hygienists, or physician assistants in rural or underserved areas.

LOAN REPAYMENT/ SCHOLARSHIP PROGRAMS *

* Includes only state-funded programs which require a service obligation in an underserved area.  (NHSC state loan repayment programs are included since the state provides funding.)

Source: State health officials.

WORKFORCE PLANNING ACTIVITIES*

* One state health official supplied these responses. Therefore, data may be limited and may not accurately reflect all current workforce-planning activities in the state.

Missouri collects and analyzes statewide supply data for physicians, nurses, dentists, and dental hygienists.

The following abstracts describe several of Missouri’s recent endeavors to understand and describe the status of the state’s current health care workforce.

Legislation and Programs

S-393 (2001)

This act expands provisions regarding dental services:

· Allows physicians to administer fluoride treatments to a child's teeth during such immunizations.

· Adds dental students to the Medical School Loan Repayment Program and changes the name to Health Professional Student Loan Repayment Program.

· Removes the reference to summer camps, allowing gratuitous services to be provided anywhere for no more than fourteen days.

· A five member Advisory Commission for Dental Hygienists is established to make recommendations to the Missouri Dental Board.

·        Creates an exception to supervision requirements by allowing a dental hygienist practicing in a public health setting to provide fluoride treatments, teeth cleaning, and sealants to children who are eligible for Medicaid. These procedures may be done without the supervision of a dentist. Medicaid shall reimburse all dentists, dental hygienists and pediatricians who provide the above services at 75% of the usual and customary cost, which will be determined by the Division of Medical Services.

Health Professions Scholarships

Missouri Hospital Association, 2001

The Educational and Research Trust of the Missouri Hospital Association (MHA) established a $1million scholarship program for students in nursing and allied health in 2001. Work repayment on a yearly basis is required in a MHA-member hospital.

Studies

Missouri Coalition for Oral Health Access

Felix, Burdine and Associates, December 2000

The report provides a summary of background research and efforts to define the oral health problem and improve access to services for the underserved across the state.  In addition, it offers a work plan for the Missouri Coalition for Oral Health Access.  The plan outlines the coalition’s strategy for educating dental professionals about integrating Medicaid patients into their practices, expanding the ability of community health centers to provide preventive services, and implementing recruitment efforts to bring more dentists to the state.

Workforce Status in Missouri Hospitals: an Overview

Missouri Hospital Association, August 2001

The report outlines the demographics of the nursing population, the demand for hospital practical and professional nurses, and the educational opportunities for nursing in the state.  The report suggests that workforce shortages may lead to the closure of some departments, floors, and services, and will affect the care that hospitals are able to provide.  It calls for hospitals, legislators, regulators and communities to address the problem.

Health Systems Development Unit Activities Report 2001

Center for Health Improvement, Missouri Department of Health and Senior Services

This report examines the availability and accessibility of health care services across the state and evaluates several initiatives designed to improve health outcomes across the state.  According to the report, overall access to primary health care services in Missouri has improved in the past ten years.  While there have been increases in the number of health professionals practicing in the state, there have also been increases in the number of Health Professional Shortage Areas (HPSAs). The coalition also notes that the number of dentists in the state has not increased and that roughly half of them are currently 50 years old or older, and that HPSAs for dentists have increased dramatically as well.

The state has several initiatives underway to address issues relating to access. They include the State Loan Repayment Program, the Primary Care Resources Initiative for Missouri (PRIMO), placement programs for foreign medical graduates, and the Healthy Communities Incentive Program. The report provides information about participation and placement rates for each of the programs.

HRSA State Health Workforce Profile

Bureau of Health Professions, December 2000

The State Health Workforce Profiles provide current data on the supply, demand, distribution, education and use of health care professionals in each state. Each state profile has an overview of the health status of state residents and health services within the state. In addition the profiles have breakdowns of health care employment by place of work and profession.

http://bhpr.hrsa.gov/healthworkforce/profiles/default.htm

VII.  POLICY ANALYSIS

Organizations with Significant Involvement in Health Workforce Analysis/Development

· Missouri Department of Health and Senior Services: Center for Health Improvement

· Missouri Dental Association

· University of Missouri-Columbia: Area Health Education Centers School of Nursing

· Missouri Hospital Association

Evidence of Collaboration:  Minimal (largely associated with workforce data collection and analysis and provider recruitment to rural underserved areas)

With the exception of two major metropolitan areas, Missouri is largely a very rural state with a lower than average minority/ethnic population. 

Missouri is an example of a state where having health insurance does not guarantee access to health services.  The good news is that the proportion of the state’s population without health insurance is substantially below the national average.  The bad news is that the percentage of the population residing in health professional shortage areas (HPSAs) is well above U.S. figures.  In fact, just four counties in Missouri are not designated as HPSAs. 

The proportion of the state’s population living in dental HPSAs is twice the national average, and statewide, Missouri has a significantly smaller ratio of dentists and dental hygienists than the U.S. as a whole.  Furthermore, just over a fourth of all practicing dentists in the state participate in the Medicaid program.  Low participation rates can be attributed to Medicaid payment rates that are less than 50 percent of usual and customary charges.  Medicaid in Missouri has mandatory managed care enrollment only in urban areas, in part because there are not enough health professionals in largely-HPSA rural areas to staff the managed care plans.  Only urban Medicaid providers are required to deliver oral health services.  Such services for rural providers remain reimbursable on a fee-for-service basis.  Recently, Missouri’s governor, in an effort to curb rising Medicaid costs, proposed cutting adult dental care as a covered service.

Although state officials boast of having an effective relationship with the National Health Service Corps (NHSC) in terms of receiving field large numbers of placements, the ratio of NHSC professionals (primarily physicians) per 10,000 HPSA population in Missouri is below the national average.  Missouri has also a smaller ratio of physicians statewide than the U.S. as a whole.  However, reports show that the state has a larger ratio of nurses and pharmacists than national figures.

Missouri has several health professions loan repayment and primary care grant programs that in general have a good track record of retaining a significant proportion of service-obligated primary care physicians and nurses in medically underserved communities in the state.  However, the state has placed little attention to the need to better understand the health workforce supply issue and to collect additional information.  Thus, there appear to be gaps in awareness and understanding of the health workforce.  However, various efforts are underway to address these gaps, including the following:

· The Center for Health Improvement in the Department of Health and Senior Services routinely surveys physicians, dentists and nurses to gain more insight as their location of practice and demographics. 

· The Board of Nursing Examiners regularly receives updates on the number of licensed nurses through the relicensure process.

· The state hospital association has examined nursing workforce supply and demand, and, in concert with the state’s Colleagues-in-Caring nursing projects, has initiated a health workforce data collection and analysis collaborative at both a state and regional level with member hospitals and other groups.

· The Department of Economic Development routinely issues occupational projections for Missouri.

· Missouri Coalition for Oral Health Access produced a 2000 report summarizing available research and efforts to define the state’s oral health problem.

Recently, the Legislature has taken some steps to address health workforce shortages in dentistry and rural underserved areas.  A 2001 law 1) adds dentists to the state’ health professional loan program, which will support access to dental services in underserved communities, 2) allows dental hygienists practicing in public health settings to provide certain services to Medicaid-eligible children without the supervision of a dentist (regulations not yet published as of early 2002), and 3) requires the creation of a donated dental services program, through which volunteer licensed dentists will provide comprehensive dental care to needy, disabled, elderly and medically-compromised individuals.  The measure also granted a significant Medicaid fee increase to dental providers. 

As follow up to efforts by the state hospital association, another 2001 law approved the development of an analysis of the state’s allied health workforce.  The source of funding for this initiative is not clear.  In 2001, the state hospital association also established a $1 million scholarship/work repayment program for students in nursing and allied health.

In 2002, a rapidly declining fiscal climate in the state has made further significant efforts unlikely.  Missouri faces a $612 million budget deficit in fiscal year 2003 in addition to a $340 million shortfall in the previous budget period.  Major across-the-board cuts in state agency spending are expected.  Such constraints are exacerbated by the so-called Hancock amendment to the Missouri constitution in the early 1990s which caps the state budget at 103 percent of the previous year’s budget, with any cost overruns refunded to the state citizenry.  Items on the 2002 legislative agenda for consideration include measures that would limit mandatory overtime for nurses and examine the development of nurse staffing plans in hospitals.

Physicians

Despite the fact that Missouri’s ratio of physicians is lower than the national average, major attention to address this problem appears nonexistent.  Less than half of newly entering medical students to the state’s four allopathic medical schools (the state has also two osteopathic schools) are state residents.  Just 40 percent of all physicians completing their graduate medical education in Missouri now practice in the state. 

The mission of the statewide Area Health Education Centers (AHECs) program aims to improve the recruitment and retention of physicians (primarily) to rural and underserved areas of the state.  Over 350 physicians and other primary care practitioners are needed to remove the state’s primary care HPSAs.  Currently, the AHEC program hopes to assist in Missouri’s new (federally-funded) workforce development initiative to assist unemployed workers to be retrained and to work whenever possible in underserved areas.

Nursing

Data suggests that Missouri faces less of a shortage of nurses than many states.  However, expected demand for nurses is a major factor in the state’s projected health workforce.  Registered nurses as an occupation have the third highest number of all projected jobs openings in the state, according to state estimates.  However, graduations of baccalaureate-trained nurses have been flat or in decline in recent years, and data suggest that there are only a small percent of nurses licensed but not working as nurses in the state.  The board of nursing and state hospital association support expansion of nurse training capacity in the state’s nursing schools.  Lack of training capacity remains a problem in many of the schools.  Missouri’s nurses association is one of five state nursing associations nationwide that recently cut their affiliation with the American Nurses Association (ANA) in order to advocate for government-mandated nurse-to-patient ratios in acute care hospitals and elsewhere.  The ANA opposes government mandated ratios. 

The market for nurse practitioners appears to be saturated with reports that recent graduates are still looking for work.  Also, a number of rural health clinics—traditional locations for nurse practitioner employment—are closing across the state.  Advanced practice nurses in Missouri enjoy the opportunity to practice independently from a physician.

Dentists

Data indicate that the dental workforce has the most significant shortage of any health profession in the state.  About two-thirds of all practicing dentists are reported to be over age 55 years.  The state suffers from having an inadequate number of pediatric dentists in practice and training.  The shortage of dentists appears to be the most acute in rural areas. 

The state’s current number of dental school graduates is not enough to offset such shortages.  In response, the state’s one dental school plans to increase enrollment of first-year students from 80 to 100, effective fall 2002.  Of that number, the school hopes to admit 70 Missouri resident applicants by fall 2004, while maintaining its relationship with Kansas to buy slots.  Insufficient training capacity is compounded by the fact that Missouri has no pre-dental educational programs.  In increasing class size, the dental school will need to increase faculty size as well as compensation.  Additional state funds to do so do not appear to be readily available.  The dental school is also interested in placing more students in publicly funded clinics for training than private dentist offices.  In addition, many of the state’s community health centers are interested in establishing or expanding their dental practices.  There are also calls to increase the number of dental hygiene programs and/or class size in the state and to include hygienists in current state loan repayment and primary care grant programs.

Pharmacists

To date, there appears to be no statewide attention to pharmacy workforce issues.  Although no data is readily available that would point to a current shortage of pharmacists, some state officials point to a looming shortage.  Several hospitals report difficulty filling pharmacy positions.  The current statewide hospital vacancy rate is about 7 percent.

Data Sources

Workforce Supply and Demand

American Association of Retired Persons, Public Policy Institute (AARP). Reforming the Health Care System: State Profiles 2001.  (Washington, DC: 2002).

Bureau of Primary Health Care, Division of Shortage Designation (BPHC-DSD). Selected Statistics on Health Professional Shortage Areas (Bethesda, MD: December 2001).

Bureau of Primary Health Care, National Health Service Corps (BPHC-NHSC). National Health Service Corps Field Strength: Fiscal Year 2001 (Bethesda, MD: March 2002).

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report: State Specific Prevalence of Selected Health Behaviors, by Race and Ethnicity—Behavioral Risk Factor Surveillance System, 1997.  (Atlanta, GA: March 24, 2000) Vol. 49, No. SS-2.

Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis (HRSA-BHPr). State Health Workforce Profiles (Bethesda, MD: December 2000).

Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing (HRSA-BHPr). The Registered Nurse Population, March 2000: Findings from the National Sample Survey of Registered Nurses (Rockville, MD: February 2002).

Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured (KFF). Health Insurance Coverage in America: 1999 Data Update (Palo Alto, CA: January 2001).

National Conference of State Legislatures, Health Policy Tracking Service (HPTS).

Personal conversations with HCFA regional office officials.

S. Norton and S. Zuckerman. “Trends in Medicaid Physician Fees” Health Affairs. 19(4), July/August 2000.

State Medicaid programs (data from NCSL survey).

United States Department of Commerce, U.S. Census Bureau.

United States General Accounting Office (GAO). Oral Health: Dental Disease is a Chronic Problem Among Low-Income Populations.  (Washington, DC: April 2000) GAO/HEHS-00-72.

Health Professions Education

American Academy of Family Physicians (AAFP)

American Academy of Family Physicians. State Legislation and Funding for Family Practice Programs. (Washington, DC).

American Association of Colleges of Nursing (AACN)

American Association of Colleges of Osteopathic Medicine (AACOM). Annual Statistical Report. (Chevy Chase, MD).

American Association of Colleges of Pharmacy (AACP). Profile of Pharmacy Students. (Alexandria, VA).

American Dental Association (ADA)

American Dental Association. 1997-1998 Survey of Predoctoral Dental Educational Institutions. (Washington, DC).

American Dental Hygienist Association (ADHA)

American Medical Association (AMA). Health Professions Career and Education Directory.

American Medical Association. State-level Data for Accredited Graduate Medical Education Programs in the U.S.: 2000-2001. (Washington, DC: 2002)

Association of American Medical Colleges (AAMC)

Association of American Medical Colleges.  Institutional Goals Ranking Report. (AAMC website).

Association of Physician Assistant Programs (APAP).

Association of Physician Assistant Programs. Seventeenth Annual Report on Physician Assistant Educational Programs in the United States, 2000-2001. (Loretto, PA: 2001).

Barzansky B. et al., “Educational Programs in U.S. Medical Schools, 2000-2001” JAMA. 286(9), September 5, 2001.

Henderson, T., Funding of Graduate Medical Education by State Medicaid Programs, prepared for the Association of American Medical Colleges, April 1999.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1997-1998 and 3-year Summary” Family Medicine. 30(8), September 1998.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1996-1997 and 3-year Summary” Family Medicine. 29(8), September 1997.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1995-1996 and 3-year Summary” Family Medicine. 28(8), September 1996.

National League for Nursing (NLN)

Oliver T. et al., State Variations in Medicare Payments for Graduate Medical Education in California and Other States, prepared for the California HealthCare Foundation. (Data from the Health Care Financing

Administration, compiled by the Congressional Research Service.)

Pugno P. et al.. “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1999-2000 and 3-year Summary” Family Medicine. 32(8), September 2000.

Pugno P. et al.. “Entry of U.S. Medical School Graduates into Family Practice Residencies: 2000-2001 and 3-year Summary” Family Medicine. 33(8), September 2001.

Schmittling G. et al. “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1998-1999 and 3-year Summary” Family Medicine. 31(8), September 1999.

State higher education coordinating board/university board of trustees (data from NCSL survey).

Physician Practice Location

1999 American Medical Association Physician Masterfile. Computations were performed by Quality Resource Systems, Inc. of Fairfax, Virginia.

Licensure and Regulation of Practice

American Association of Nurse Anesthetists (AANA)

American College of Nurse Midwives (ACNM). Direct Entry Midwifery: A Summary of State Laws and Regulations. (Washington, DC: 1999).

American College of Nurse Midwives. Nurse-Midwifery Today: A Handbook of State Laws and Regulations. (Washington, DC: 1999).

American Dental Hygienist Association

National Conference of State Legislatures, Health Policy Tracking Service.

Pearson L., editor.  “Annual Legislative Update: How Each State Stands on Legislative Issues Affecting

Advanced Nursing Practice” The Nurse Practitioner. 25(1), January 2001.

State licensing boards (NCSL survey).

Improving the Practice Environment

State health officials (NCSL survey)