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:
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];
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;
An assessment of the
state’s internal capacity and existing strategies for addressing the above
workforce issues and influences; and
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:
States with limited
as well as substantial involvement in one or more of the following areas:
statewide health workforce planning, monitoring, policymaking and research;
States with presence
of unique or especially challenging health workforce concerns or issues requiring
policy attention;
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;
Distribution of states
across Department of Health and Human Services regions;
States with Bureau of
Health Professions (BHPr) - supported centers for health workforce research
and distribution studies;
States with primarily
urban and primarily rural health workforce requirements; and
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:
Phone and mail interviews
with state higher education, professions regulation, and recruitment/retention
program officials;
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;
Tabulations of data
from the most recent edition of federal and state government databases (e.g.,
National Health Service Corps field strength);
Site visit interviews
with various officials in the eight profile states;
Personal phone conversations
with other various state and federal government officials;
Most recently available
secondary data sources from printed and online reports, journal articles,
etc.; and
Comments and guidance
from members of the study’s expert advisory panel.
STATE
SUMMARY
Arizona’s population
is rapidly becoming urban and more minority in composition. The percent of
children and non-elderly adults without health insurance is rising and is now
above the national average. Perhaps related to this trend, the percent of the
population that resides in federally designated primary and dental care health
professional shortage areas (HPSAs) also exceeds the U.S. average. Efforts
by the state to improve recruitment and retention of physicians to such communities
receive mixed reviews for effectiveness by state officials. The state does
not give favorable rankings as to the impact of Medicaid incentives (reimbursement
rates, payment bonuses, payment for telemedicine) in improving physician recruitment
and retention in serving medically underserved areas of the state. However,
the state's loan repayment program (viewed by state officials as significantly
underfunded) involving physicians and dentists reports that on average about
half of the recipients are retained in an underserved practice location upon
completion of the program.
Indicative of the fact that
the ratio of National Health Service Corps professionals per 10,000 population
living in the state’s HPSAs exceeds the national average is the larger problem
of the overall health workforce shortages in the state. Arizona's number of
active physicians, nurses, dentists and pharmacists per 100,000 total population
generally is well below national averages as are the number of health care workers
practicing in public health settings. In response, the state's health professions
schools appear to be making efforts to expand training capacity. The state's
two medical schools collectively saw a major increase between 1999 and 2001
in the number of enrolled students. Moreover, nearly 100 percent of all incoming
students to medical school are state residents. In the fall of 2003, the state's
first new (private) dental school began enrolling students. Just recently,
the Arizona Board of Regents received nearly $2 million in state discretionary
funds from the state's federally-funded Workforce Investment Board and other
sources to expand the number or registered nurses graduating from community
colleges and universities in the state. Between 2001 and 2002 alone, registered
nurse (RN) candidate enrollments, particularly in baccalaureate and masters
degree training programs increased dramatically.
As is particularly true
in this region of the country, Arizona's shortage of nurses is more acute than
elsewhere. In addition to efforts to expand educational capacity, various statewide
entities have stepped forward to better understand and address the nursing shortage.
The Arizona Hospital and Healthcare Association established the Healthcare Institute
to provide workforce advocacy opportunities for members. In addition, one member
hospital--Saint Luke's Medical Center--produced their own report in 2002 that
examined both physician and nurse shortages in the state and recommended widespread
changes to improve the workforce practice environment. Also in 2002, the Governor
established a nursing shortage task force to evaluate the shortage problem and
make recommendations.
Through the creation of
state's new dental school, Arizona has a growing recognition of the problem
of access to oral health care across the state. A 2002 report by Saint Luke's
Health Initiatives and ongoing work by the Arizona Office of Oral Health point
to the many challenges and opportunities for improving the dental health workforce.
Despite the low per capita
number of pharmacists in the state, there appears to be no major concern yet
with their overall supply in hospitals and chain drug stores. However, shortages
are becoming more apparent in the state's rural areas.
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.
Table I-a.
POPULATION
AZ
U.S.
Total
Population (2001)
5,307,331
284,796,887
Sex
(2000)
%
Female
50.1
50.9
%
Male
49.9
49.1
Age
(2000)
%
less than 18
26.6
25.7
%
18-64
60.4
61.9
%
65 or over
13.0
12.4
%
Minority/Ethnic
(2002)
37.3
30.9
%
Metropolitan (2002)
86.4
81.3
Sources:
U.S. Census Bureau, AARP.
Arizona has higher
proportion of minorities and a higher proportion of residents living in metropolitan
areas than the U.S. as a whole.
Table
I-b.
Sources: CDC,
AARP, GAO.
PROFESSION
UTILIZATION
AZ
U.S.
%
Adults who Reported Having Routine Physical Exam Within Past Two Years
(1997)
87.0
83.2
(Median)
Average
# of Retail Prescription Drugs per Resident (2002)
8.6
10.6
%
Adults who Made Dental Visit in Preceding Year by Annual Family Income (1999):
Less
than $15,000
55
$15,000
- $34,999
61
$
35,000 or more
74
Eighty-seven percent
of Arizona adults report having a routine physical exam within the past two
years. Table I-c.
ACCESS
TO CARE
AZ
U.S.
%
Non-elderly (under age 65) Without Health Insurance
2000-2001
19
17
1999-2000
21
16
%
Children Without Health Insurance
2000-2001
17
12
1999-2000
17
12
%
Not Obtaining Health Care Due to Cost (2000)
11.8
9.9
%
Living in Primary Care HPSA(2003)
24.2
21.3
#
Practitioners Needed to Remove Primary Care HPSA Designation (2003)
204
--
%
Living in Dental HPSA (2003)
17.2
14.7
#
Practitioners Needed to Remove Dental HPSA Designation (2003)
133
--
HPSA = Health Professional
Shortage Area Sources: KFF, AARP, BPHC-DSD.
Arizona
has a greater proportion of non-elderly and children without health insurance,
a larger percentage of people living in primary care and dental HPSAs, and a
greater proportion of people not obtaining health care due to cost than the
U.S. average.
Table I-d.
PROFESSIONS
SUPPLY
Profession
#
Active Practitioners
#
Active Practitioners per 100,000 Population
AZ
U.S.
Physicians
(1998)
8,226
176.2
198
Physician
Assistants (1999)
525
11.0
10.4
Nurses
RNs
(2000)
42,658
628
782
LPNs
(1998)
8,650
185.3
249.3
CNMs
(2000)
131
2.7
2.1
NPs
(1998)
1,173
25.1
26.3
CRNAs
(1997)
139
3.1
8.6
Pharmacists
(1998)
2,200
47.1
65.9
Dentists
(1998)
1,760
37.7
48.4
Dental
Hygienists (1998)
2540
54.4
52.1
%
Physicians Practicing Primary Care
28.0
(30.0 U.S.)
%
Registered Nurses Employed in Nursing
75.5
(81.7 U.S.)
%
of MDs Who Are International Medical Graduates (IMGs)
Arizona has a
lower percentage of physicians practicing primary care and a much lower percentage
of registered nurses employed in nursing than the U.S. as a whole.
Table I-e.
NATIONAL
HEALTH SERVICE CORPS (NHSC) FIELD STRENGTH
Total
Field Strength (FY 2003)
* Includes mental/behavioral health officials
%
in Urban Areas
%
in Rural Areas
#
Per 10,000 Population Living in HPSAs
102
29
71
0.79(0.49 U.S.)
Field
Strength by Profession
Physicians
41
Nurses
11
Physician
Assistants
18
Dentists/Hygienists
9
HPSA= Health
Professional Shortage Area Source: BPHC-NHSC.
Arizona’s ratio
of National Health Service Corps professionals working in HPSAs is much larger
than the national average. Table I-f.
MANAGED
CARE
Penetration
Rate of Commercial and Medicaid HMOs (as % of total population), 2000
AZ
U.S.
30.0
28.1
Profession
MCOs
required by state to include profession on their provider panel*
Profession
allowed by state to serve as primary care provider in MCOs
Profession
allowed by state to coordinate primary care as part of a standing referral
Physicians
No
Yes
No
Nurses
No
No
No
Pharmacies
No
No
No
Dentists
No
No
No
State
requires certain individuals enrolled in MCOs to have direct access to
certain specialty (OB/GYN, etc.) providers.
No
State
requires certain individuals enrolled in MCOs to receive a standing referral
to a specialist (OB/GYN, etc.).
Yes
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.
Thirty
percent of Arizona residents receive their health care from an HMO.
Table I-g.
REIMBURSEMENT
OF SERVICES
Medicaid
Profession
%
Active Practitioners Enrolled
%
Enrolled Receiving Annual Payments Greater Than $10,0001
Increase
of 10% or More in Overall Payment Rates 1998-2003
Bonus
or Special Payment Rate for Practice in Rural or Medically Underserved
Area
Physicians
90
N/A
No
No
NPs
50
N/A
No
No
Dentists
15
N/A
Yes
No
#
of Enrolled Pharmacies
1,980
%
Change in Physician Fees (All Services), 1993-1998
N/A
Recent
State-Mandated Payment Increases
Yes
(for dentists)
Medicare
#
Active Practitioners Enrolled (2000)
7,453
%
Practitioners who Accept Fee as Full Payment (2003)
91.1
1 Generally
seen as an indicator of significant participation in the Medicaid program. 2 Denominator number from HRSA State Health Workforce Profile,
December 2000.
N/A- Data was not applicable Sources: State Medicaid programs, Norton and Zuckerman “Trends”,
HPTS, AARP.
Ninety
percent of physicians in Arizona are actively enrolled in Medicaid.
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.
Table II-a.
UNDERGRADUATE
MEDICAL EDUCATION
#
of Medical Schools (Allopathic and Osteopathic)
2
Public
Schools
1
Private
Schools
1
Osteopathic
Schools
1
#
of Medical Students (Allopathic and Osteopathic)
1998-1999
628
2000-2001
895
#
Medical Students per 100,000 Population1
1998-1999
11.8
2000-2001
16.9
%
Newly Entering Students (Allopathic) who are State Residents,
2002-2003
98.6
Requirement
for Students in Some/All Medical Schools to Complete a Primary Care
Clerkship
By
the State
No
By
Majority of Schools
Yes
#
of Medical School Graduates (Allopathic and Osteopathic)
1998
89
2001
198
#
Medical School Graduates per 100,000Population1
1998
1.67
2001
3.73
%
Graduates (Allopathic) who are Underrepresented Minorities,
1994-1998
9.98
(10.5 U.S.)
%
1987-1993 Medical School Graduates (Allopathic) Entering
Generalist Specialties
34.0
(26.7 U.S.)
State
Appropriations to Medical Schools (Allopathic and Osteopathic), 2000-2001
Total
$48.1
million
Per
Student
$76,592
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.
Ninety-eight percent
of newly entering medical students in Arizona are state residents.Table II-b.
GRADUATE
MEDICAL EDUCATION (GME)
#
of Residency Programs (Allopathic and Osteopathic), 2002-20031
83
#
of Physician Residents (Allopathic and Osteopathic), 2002-20031
1066
#
Residents Per 100,000 Population, 2002-2003
20
%
Allopathic Residents from In-State Medical School, 2000-2001
17.3
%
Residents who are International2
Medical Graduates, 2000-2001
12.4
Requirement
to Offer Some or All Residents a
Rural
Rotation
By
the State
No
By
Most Primary Care Residencies
No
Medicaid
Payments for Graduate Medical Education, 20023
$18.6
million
Payments
as % of Total Medicaid Hospital Expenditures
3.4
(8.0 U.S.)
Payments
Made Directly to Teaching
Programs
Under Capitated Managed Care
Yes
Payments
Linked to State Workforce Goals/
Goals
of Improved Accountability
No
Medicare
Payments for Graduate Medical Education, 19983
$47.3
million
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. Sources: AMA, AMA State-level Data, AACOM, State higher
education coordinating boards, Henderson “Funding”, Oliver et al. “State Variations.”
Less than one-fifth of
allopathic residents in Arizona are from in-state medical schools. Table
II-c.
FAMILY
MEDICINE RESIDENCE TRAINING
#
of Residency Programs, 2001-2002
6
#
Residencies Located in Inner City
4
#
Residencies Offering Rural Fellowships or Training Tracks
0
#
of Family Medicine Residents, 2001-2002
18
#
Family Medicine Residents per 100,000 Population, 2001-20021
0.33
%
Graduates (from state’s Allopathic and Osteopathic medical schools)
who were
First Year Residents in Family Medicine, 1995-2001
17.4
%
Graduates (from state’s Allopathic medical schools) Choosing a
Family Medicine Residency Program Who Entered an In-State Family Medicine
Residency, 1995-2001
41.9
1 Denominator
number is state population from 2000 U.S. Census. Sources: AAFP
Over forty percent of
graduates who chose a family medicine residency program entered a family medicine
residency program in Arizona. Table II-d.
NURSING
EDUCATION
#
of Nursing Schools
21
Public
Schools
18
Private
Schools
3
#
of Nursing Students1
7,732
#
Associate Degree, 2001-2002
2,291
#
Baccalaureate Degree
2001-2002
744
2002-2003
3,414
#
Masters Degree
2001-2002
169
2002-2003
1,958
#
Doctoral Degree
2001-2002
53
2002-2003
69
#
Per 100,000 population2
145.7
#
of Nursing School Graduates1
2,784
#
Associate Degree, 2002
933
#
Baccalaureate Degree
2001
313
2002
1,124
#
Masters Degree
2001
66
2002
723
#
Doctoral Degree
2001
8
2002
4
#
Per 100,000 population2
52.5
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 baccalaureate
and master’s degree nursing students and graduates rose dramatically between
2001 and 2002.
Table II-e.
PHARMACY
EDUCATION
#
of Pharmacy Schools
2
Public
Schools
1
Private
Schools
1
#
of Pharmacy Students, 2002-2003
585
#
Baccalaureate Degree
0
#
Doctoral Degree (PharmD)
585
#
Per 100,000 population*
11.0
#
of Pharmacy Graduates, 2001-2002
144
#
Baccalaureate Degree
0
#
Doctoral Degree (PharmD)
144
#
Per 100,000 population*
2.7
* Denominator number is
state population from 2000 U.S. Census. Source: AACP.
Table II-f.
PHYSICIAN
ASSISTANT EDUCATION
#
of Physician Assistant Training Programs, 2002-2003
2
Public
Schools
1
Private
Schools
1
#
of Physician Assistant Program Students, 2002-2003
253
#
Physician Assistant Program Students per 100,000 Population, 2002-20031
4.76
#
of Physician Assistant Program Graduates, 2003
N/A
#
Physician Assistant Program Graduates per 100,000 Population, 20031
N/A
1 Denominator
number is state population from 2000 U.S. Census. Sources: APAP, APAP Annual Report.
Table II-g.
DENTAL
EDUCATION
#
of Dental Schools
New school
accepted first students in Fall 2003.
1
Public
Schools
0
Private
Schools
1
#
of Dental Students, 2000-2001
N/A
#
Dental Students per 100,000 Population, 2000-2001*
N/A
# of
Dental Graduates, 1999-2000
N/A
# Dental
Graduates per 100,000 Population, 2000*
N/A
State
Appropriations to Dental Schools, 1997
Per Student:
N/A*
As %
of Total Revenue: N/A*
* Denominator number is
state population from 2000 U.S. Census. Source: ADA.
Table II-h.
DENTAL
HYGIENE EDUCATION
#
of Dental Hygiene Training Programs
4
Public
Schools
4
Private
Schools
0
#
of Dental Hygiene Program Students, 2001-2002
229
#
Dental Hygiene Program Students per 100,000 Population*
3.9
#
of Dental Hygiene Program Graduates, 2000-2001
112
#
Dental Hygiene Program Graduates per 100,000 Population*
2.1
* 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 medical school training in Arizona between
1975 and 1995.
Table III-a.
ARIZONA
Number
of physicians who were trained in AZ and who are now practicing in AZ
as a percentage of all physicians practicing in AZ.
14.07
Number
of physicians who were trained in AZ and are practicing in AZ, by practice
location (metro code2), as a percentage of all physicians
practicing in AZ.
#00
11.68
#01
6.98
#02
19.93
#03
7.14
#04
18.87
#05
11.76
#06
36.84
#07
10.34
#08
0.00
#09
0.00
Number
of physicians who were trained in AZ and who are now practicing in AZ
as a percentage of all physicians who were trained in AZ.
47.77
Number
of physicians who were trained in AZ and are practicing in AZ, by practice
location (metro code2), as a percentage of all physicians
trained in AZ.
#00
49.70
#01
14.29
#02
56.03
#03
7.00
#04
60.61
#05
51.35
#06
25.00
#07
9.68
#08
0.00
#09
0.00
11995
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.
Practice location (URBAN/
RURAL) of physicians who received their most recent GME training in Arizona
between 1978 and 1998.
Table III-b.
ARIZONA
Number
of physicians who received their most recent GME training in AZ and who
are now practicing in AZ as a percentage of all physicians practicing
in AZ.
33.21
Number
of physicians who received their most recent GME training in AZ and are
practicing in AZ, by practice location (metro code1),
as a percentage of all physicians practicing in AZ.
#00
32.77
#01
17.02
#02
41.43
#03
16.07
#04
23.64
#05
15.27
#06
26.32
#07
24.00
#08
0.00
#09
0.00
Number
of physicians who received their most recent GME training in AZ and who
are now practicing in AZ as a percentage of all physicians who were
trained in AZ.
47.64
Number
of physicians who received their most recent GME training in AZ and are
practicing in AZ, by practice location (metro code1),
as a percentage of all physicians trained in AZ.