oversight

Physician Workforce: Physician Supply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities Persisted

Published by the Government Accountability Office on 2003-10-31.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

               United States General Accounting Office

GAO            Report to the Chairman, Committee on
               Health, Education, Labor, and
               Pensions, U.S. Senate


October 2003
               PHYSICIAN
               WORKFORCE

               Physician Supply
               Increased in
               Metropolitan and
               Nonmetropolitan
               Areas but Geographic
               Disparities Persisted




GAO-04-124 

                                                October 2003


                                                PHYSICIAN WORKFORCE

                                                Physician Supply Increased in
Highlights of GAO-04-124, a report to the       Metropolitan and Nonmetropolitan Areas
Chairman, Committee on Health,
Education, Labor, and Pensions, U.S.            but Geographic Disparities Persisted
Senate




Through a variety of programs, the              The U.S. physician population increased 26 percent, which was twice the rate of
federal government supports the                 total population growth, between 1991 and 2001. During this period the average
training of physicians and                      number of physicians per 100,000 people increased from 214 to 239 and the mix
encourages physicians to work in                of generalists and specialists in the national physician workforce remained
underserved areas or pursue
                                                about one-third generalists and two-thirds specialists. Growth in physician
primary care specialties. GAO was
asked to provide information on                 supply per 100,000 people between 1991 and 2001 was seen in historically high-
the physician supply and the                    supply metropolitan areas as well as low-supply statewide nonmetropolitan
generalist and specialist mix of that           areas.
supply in the United States and the
changes in and geographic                       Between 1991 and 2001, all statewide nonmetropolitan areas and 301 out of the
distribution of physician supply in             318 metropolitan areas gained physicians per 100,000 people. Of those 17
metropolitan and nonmetropolitan                metropolitan areas that experienced declines in the number of physicians per
areas. To address these objectives,             100,000 people, only 2 had fewer total physicians in 2001 than 1991. Overall,
GAO analyzed data on physician                  nonmetropolitan areas experienced higher proportional growth in physicians per
supply and geographic distribution              100,000 people than metropolitan areas, but the disparity in the supply of
from 1991 and 2001.                             physicians per 100,000 people between nonmetropolitan and metropolitan areas
                                                persisted. Nonmetropolitan counties with a large town (10,000 to 49,999
                                                residents) had the biggest increase in physicians per 100,000 people of all county
                                                categories but their supplies per 100,000 people were still less than large and
                                                small metropolitan counties’ supplies in 1991 and 2001.

                                                In written comments on a draft of this report, the Health Resources and Services
                                                Administration agreed with GAO findings of persisting disparities between
                                                metropolitan and nonmetropolitan areas.

                                                Physicians Per 100,000 people, 1991 and 2001




www.gao.gov/cgi-bin/getrpt?GAO-04-124.

To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Laura A.
Dummit at (202) 512-7119.
Contents 



Letter                                                                                            1
                       Results in Brief 
                                                         2
                       Background
                                                                3
                       National Physician Supply Grew at Twice the Rate of the U.S. 

                         Population                                                               7
                       Physician Supply Per 100,000 People Increased in Most Areas but
                         Geographic Disparities Persisted                                       10
                       Agency Comments                                                          15

Appendix I             Scope and Methodology                                                     17



Appendix II 	          HRSA Programs That Address Supply and
                       Distribution of Health Professionals                                      19



Appendix III 	         Physicians Per 100,000 People by State Metropolitan
                       and Nonmetropolitan Areas, 1991 and 2001                                  23



Appendix IV 	          Comments from the Health Resources and Services
                       Administration                                                            28



Related GAO Products                                                                             31



Tables
                       Table 1: Physicians Per 100,000 People in the United States, 1991
                                and 2001                                                          7
                       Table 2: Areas with Reductions in Physicians Per 100,000 People
                                from 1991 to 2001                                               12
                       Table 3: Physicians Per 100,000 People in Statewide
                                Nonmetropolitan and Metropolitan Areas, 1991 and 2001           13
                       Table 4: HRSA Programs’ Expenditures or Appropriations and
                                Objectives                                                      20




                       Page i                                        GAO-04-124 Physician Workforce
Figures
          Figure 1: Physicians Per 100,000 People in the United States by
                   Metropolitan Areas and Statewide Nonmetropolitan
                   Areas, 1991                                                                       8
          Figure 2: Physicians Per 100,000 People in the United States by
                   Metropolitan Areas and Statewide Nonmetropolitan
                   Areas, 2001                                                                       9
          Figure 3: Physicians Per 100,000 People by Metropolitan and
                   Nonmetropolitan County Categories, 1991 and 2001                                 15




          Abbreviations

          AMA               American Medical Association 

          AOA               American Osteopathic Association 

          CMS               Centers for Medicare & Medicaid Services 

          COGME             Council on Graduate Medical Education 

          DO                doctor of osteopathic medicine 

          GMENAC            Graduate Medical Education National Advisory Committee 

          HHS               Department of Health and Human Services 

          HPSA              health professional shortage area

          HRSA              Health Resources and Services Administration 

          IOM               Institute of Medicine 

          MD                medical doctor      

          MSA               metropolitan statistical area 

          NECMA             New England county metropolitan area 

          NHSC              National Health Service Corps 

          PHSA              Public Health Service Act 

          PMSA              primary metropolitan statistical area



          This is a work of the U.S. government and is not subject to copyright protection in the
          United States. It may be reproduced and distributed in its entirety without further
          permission from GAO. However, because this work may contain copyrighted images or
          other material, permission from the copyright holder may be necessary if you wish to
          reproduce this material separately.




          Page ii                                                 GAO-04-124 Physician Workforce
United States General Accounting Office
Washington, DC 20548




                                   October 31, 2003 


                                   The Honorable Judd Gregg 

                                   Chairman 

                                   Committee on Health, Education, Labor, and Pensions 

                                   United States Senate 


                                   Dear Mr. Chairman: 


                                   The federal government has had a long-standing interest in ensuring an 

                                   adequate supply of physicians to meet the health care needs of the U.S. 

                                   population. Several federal programs provide funding to train physicians

                                   and encourage physicians to work in underserved areas. Other programs 

                                   attempt to encourage physicians to train as general or primary care 

                                   practitioners rather than specialists. 


                                   In anticipation of the reauthorization of several programs administered by 

                                   the Health Resources and Services Administration (HRSA) that fund 

                                   physician education and encourage physicians to practice primary care in

                                   underserved areas, you asked us to provide information on the physician

                                   supply in the United States. We are providing information on (1) the 

                                   national physician supply, supply per 100,000 people, and the generalist 

                                   and specialist mix in 1991 and 2001 and (2) changes from 1991 to 2001 in 

                                   physician supply, supply per 100,000 people, and the geographic 

                                   distribution of that supply in metropolitan and statewide nonmetropolitan 

                                   areas. 


                                   To address these objectives, we analyzed physician supply data from 1991 

                                   and 2001 for the nation, 318 individual metropolitan areas, 48 statewide 

                                   nonmetropolitan areas, and county categories.1 To provide information on 





                                   1
                                    Metropolitan areas are metropolitan statistical areas (MSA), primary metropolitan
                                   statistical areas (PMSA), or New England county metropolitan areas (NECMA) as of 2001.
                                   If a county was designated as metropolitan in 2001, we considered it a metropolitan area in
                                   1991. A statewide nonmetropolitan area encompasses all counties within a state that are
                                   not in an MSA, PMSA, or NECMA. The District of Columbia, New Jersey, and Rhode Island
                                   have no nonmetropolitan areas.



                                   Page 1                                                   GAO-04-124 Physician Workforce
                   the physician workforce2 and its generalist-specialist mix,3 we analyzed
                   data from the American Medical Association (AMA) Physician Masterfile
                   and the American Osteopathic Association (AOA) Physician Masterfile. We
                   used data from the Census Bureau for resident population estimates based
                   on the 2000 Census. We aggregated county-level information to
                   metropolitan and statewide nonmetropolitan areas. We used urban
                   influence codes, a county categorization system developed by researchers
                   with the Economic Research Service in the Department of Agriculture, to
                   categorize metropolitan counties according to the size of the metropolitan
                   area and nonmetropolitan counties according to the size of the county’s
                   largest city and proximity to metropolitan areas.4 We also reviewed
                   relevant literature and interviewed experts on the U.S. physician
                   workforce. For more information on our scope and methodology see
                   appendix I. We performed our work from April through October 2003 in
                   accordance with generally accepted government auditing standards.


                   The number of physicians in the United States increased about 26 percent
Results in Brief   from 1991 to 2001, twice as much as the nation’s population. The average
                   number of physicians per 100,000 people rose from 214 in 1991 to 239 in
                   2001 and the mix of generalists and specialists in the national physician
                   workforce remained about one-third generalists and two-thirds specialists.
                   Growth occurred in areas with relatively low and high supplies of
                   physicians per 100,000 people. The number of individual metropolitan and
                   statewide nonmetropolitan areas with fewer than 100 physicians per
                   100,000 people decreased and more areas had at least 300 physicians per
                   100,000 people.




                   2
                    We counted active, nonfederal, patient-care physicians with a known address.
                   3
                    Generalists are physicians whose primary specialty is family practice, general practice,
                   general internal medicine, or general pediatrics as reported in the American Medical
                   Association or American Osteopathic Association Masterfiles. Other physicians are
                   designated specialists.
                   4
                    T.C. Ricketts, K.D. Johnson-Webb, P. Taylor, Definitions of Rural: A Handbook for Health
                   Policy Makers and Researchers, Prepared for the Federal Office of Rural Health Policy,
                   Health Resources and Services Administration, United States Department of Health and
                   Human Services, June 1998. Downloaded from
                   www.shepscenter.unc.edu/research_programs/rural_program/wp.html (downloaded April
                   2003).




                   Page 2                                                    GAO-04-124 Physician Workforce
             Between 1991 and 2001, all but 17 areas gained physicians per 100,000
             people. Of the 48 statewide nonmetropolitan areas, all gained physicians
             per 100,000 people and fewer of these statewide nonmetropolitan areas
             were below 100 physicians per 100,000 people in 2001 than in 1991. Of the
             318 individual metropolitan areas, 17 experienced declines in the number
             of physicians per 100,000 people from 1991 to 2001, but only 2 had fewer
             total physicians in 2001 than in 1991. Overall, nonmetropolitan areas
             experienced larger proportional gains in physicians per 100,000 people
             than metropolitan areas, but the disparity in the supply of physicians per
             100,000 people between metropolitan and nonmetropolitan areas
             persisted. Nonmetropolitan counties that included a large town had the
             largest percentage increase in physicians per 100,000 people from 1991 to
             2001 of any type of metropolitan or nonmetropolitan county. Like
             metropolitan counties, nonmetropolitan counties with large towns had
             more specialists than generalists per 100,000 people, while
             nonmetropolitan counties without a large town and rural counties had
             more generalists per 100,000 people than specialists in 1991 and 2001.

             In written comments on a draft of this report, HRSA agreed with our
             findings of persisting disparities between metropolitan and
             nonmetropolitan areas.


             From the 1950s until the early 1970s, concerns about physician shortages
Background   prompted measures by the federal and state governments to increase
             physician supply. Federal and state governments supported the growth in
             the physician population by providing funds for constructing medical
             schools and increasing medical school class sizes, offering loans and
             scholarships to medical students, and paying hospitals through Medicare
             to subsidize residency training costs. Concurrent with these initiatives, the
             total physician supply and per-capita supply increased in the United
             States.

             By the 1980s and through the 1990s, however, concerns were raised about
             the adequacy of the physician supply. A 1981 study by the Graduate
             Medical Education National Advisory Committee (GMENAC) and a series
             of reports from 1992 to 1999 by the Council on Graduate Medical




             Page 3                                          GAO-04-124 Physician Workforce
                                                                        ,
Education (COGME) forecast a national physician surplus.5 6 COGME
based these estimates on its determination that the appropriate target for
physician supply ranged from 145 to 185 physicians per 100,000 people.
These estimates were predicated in part on the belief that managed care,
with its emphasis on preventive care and reliance on primary care
gatekeepers exercising tight control over access to specialists, would
become a more typical health care delivery model. COGME and others
have noted that managed care has not become as dominant as predicted.
By 2000, some research concluded that physician supply increased even
more than these studies predicted.7 Some researchers, however,
questioned whether there was a national surplus of physicians.8

A report from the Institute of Medicine (IOM) describes why studies of the
physician workforce vary.9 According to the IOM report, disagreement
about the adequacy of physician supply arises because there is no single
accepted approach to estimating physician supply or demand. Varying
assumptions related to factors that may affect future supply or demand
can lead to different conclusions about the adequacy of future physician
supply. Projecting future physician supply depends on the approach used
to count physicians, measure their productivity, and estimate the rate of
entrance into and exit from the profession. Estimating demand for
physicians’ services requires even more assumptions. Demand for
physicians’ services can be estimated using current and projected service
utilization patterns or by determining an ideal level of care to treat the
projected incidence and prevalence of illness among the population. In
addition, physician practice patterns, the use of new technology, the



5
 GMENAC, Summary Report to the Secretary, Department of Health and Human
Services, Vol. 1, DHHS Pub. No. (HRA) 81-651 (Washington, D.C.: Health Resources
Administration, Department of Health and Human Services, April 1981).
6
 For a complete list of COGME reports see the COGME Web site:
http://www.cogme.gov/rptmail.htm.
7
E.S. Salsberg and G.J. Forte, “Trends in the Physician Workforce, 1980-2000,” Health
Affairs, vol. 21, no. 5 (2002).
8
 See for example, Salsberg and Forte, “Trends in the Physician Workforce, 1980-2000,” J.P.
Weiner, “A Shortage of Physicians or a Surplus of Assumptions?” Health Affairs, vol. 21,
no.1 (2002), and R.A. Cooper, “Perspectives on the Physician Workforce to the Year 2020,”
JAMA, vol. 274, no. 19 (1995).
9
IOM, The Nation’s Physician Workforce: Options for Balancing Supply and
Requirements, K.N. Lohr, N.A. Vanselow, and D.E. Detmer, eds (Washington, D.C.: National
Academy Press, 1996).




Page 4                                                   GAO-04-124 Physician Workforce
supply and role of nonphysician providers,10 and rates and levels of
insurance coverage also affect estimates of the demand for and supply of
physicians’ services.

In spite of the difficulty of determining whether the overall number of
physicians is indeed the right number, there is little disagreement that
physicians have been located disproportionately in metropolitan areas
relative to the U.S. population. Geographic disparities in physician supply
have persisted even as the national physician supply has increased
steadily. Economic factors and professional preferences have all been
offered as evidence to explain why physicians, and specialists in
particular, locate in metropolitan areas.11 For example, physicians depend
on the availability of hospitals, laboratories, and other technology, and
metropolitan areas tend to have more of these facilities and equipment
than nonmetropolitan areas. Small nonmetropolitan areas generally lack a
large enough population or hospital resources to support a specialty
practice, because specialists handle less prevalent but more complicated
illnesses and require more specialized support facilities and technology.12

To influence overall physician supply and address perceived physician
shortages in certain areas, several federal programs fund efforts to address
these issues. The bulk of federal dollars to support physician education is
through Medicare’s graduate medical education (GME) payments to
teaching hospitals, which totaled an estimated $7.8 billion in 2000, the
latest year for which data were available. These GME payments are
distributed based on the number of physicians being trained and
Medicare’s share of patient days in the hospital. Medicare also pays
physicians a 10 percent bonus above the usual payment amount for
services they provide to beneficiaries in health professional shortage areas




10
 Although this report describes the supply and geographic distribution of the physician
workforce, other providers, such as physicians’ assistants and nurse practitioners, also
provide many health care services that physicians provide.
11
 H.K. Rabinowitz and N. P. Paynter, “The Rural vs. Urban Practice Decision,” JAMA, vol.
287, no.1 (2002).
12
 H.J. Jiang and J.W. Begun, “Dynamics of Change in Local Physician Supply: An Ecological
Perspective,” Social Science & Medicine, vol. 24 (2002).




Page 5                                                   GAO-04-124 Physician Workforce
(HPSAs).13 These Medicare Incentive Payments totaled $104 million in
2002.14

Programs intended to encourage health professionals to practice in
underserved areas and to support the training and education of health
professionals are administered by HRSA, within the Department of Health
and Human Services (HHS). HRSA programs include the National Health
Service Corps (NHSC) and grant and loan support programs for health
professions education and training. Most of these programs address three
objectives of improving the distribution of health professionals in
underserved areas, increasing representation of minorities and individuals
from disadvantaged backgrounds in health professions, and increasing the
supply of health professionals. They also address other objectives such as
improving the quality of education and training. In fiscal year 2001,
spending for the NHSC was $70.8 million and spending for health
professions education and training programs was $266 million. Funds for
the NHSC and for health professions education and training programs
support a range of health professions including medicine. See appendix II
for more information about program spending or appropriations and
program objectives.




13
  The Department of Health and Human Services (HHS) designates areas having a critical
shortage of primary care providers as HPSAs. A HPSA may be a distinct geographic area
(such as a county), a specified population group within the area (such as migrant farm
workers), or a public or nonprofit facility (such as a prison).
14
  The number of physicians who received these payments in 2002 cannot be readily
assessed from the Centers for Medicare & Medicaid Services (CMS) physician claims data.
In 1999, we reported that specialists receive most of the Medicare Incentive Payment
program dollars, even though primary care physicians have been identified as being in
short supply. See U.S. General Accounting Office, Physician Shortage Areas: Medicare
Incentive Payments Not an Effective Approach to Improve Access, GAO/HEHS-99-36
(Washington, D.C.: Sept. 26, 1999). In 1994, the HHS Office of Inspector General found that
the program may be paying physicians for providing care to Medicare beneficiaries who do
not live in HPSAs. See HHS Office of Inspector General, Design Flaws in the Medicare
Incentive Payment Program, OEI-01-93-00051 (Washington, D.C.: June 1994).




Page 6                                                   GAO-04-124 Physician Workforce
                       The number of physicians in the United States increased about 26 percent,
National Physician     from about 541,000 to about 681,000 from 1991 to 2001. Physician growth
Supply Grew at Twice   was twice that of national population growth during this period. As a
                       result, the total number of physicians per 100,000 people in the United
the Rate of the U.S.   States climbed 12 percent, from 214 in 1991 to 239 in 2001.15 The number of
Population             generalists per 100,000 people increased at about the same rate as the
                       number of specialists per 100,000 people. (See table 1.) The national
                       physician workforce maintained approximately a one-third generalist to
                       two-thirds specialist composition between 1991 and 2001.

                       Table 1: Physicians Per 100,000 People in the United States, 1991 and 2001

                                                                                                                         Change from
                                                                                                                         1991 to 2001
                                                                                      1991                        2001   (percentage)
                        All physicians                                                  214                        239            12
                        Generalists                                                       78                       87             13
                        Specialists                                                     133                       150             13
                       Sources: AMA, AOA, Bureau of Census, and Centers for Medicare & Medicaid Services (CMS).

                       Notes: Physicians refer to active, nonfederal, patient-care physicians with a known address. We could
                       not categorize some physicians as generalists or specialists because there was no information about
                       their specialty in the AMA or AOA Masterfiles. Specifically, records for 7,185 physicians (1 percent) in
                       1991 and 4,982 physicians (0.7 percent) in 2001 did not have information that would allow us to
                       classify them as generalists or specialists. These physicians are included in the all physicians total
                       but not in the generalist and specialist totals. The percentage change calculations are based on rates
                       prior to rounding.


                       Growth in physician supply reduced the number of metropolitan and
                       nonmetropolitan areas with fewer than 100 physicians per 100,000 people
                       and increased the number of areas with greater than 300 physicians per
                       100,000 people. In 1991, 8 metropolitan areas and 27 statewide
                       nonmetropolitan areas had fewer than 100 physicians per 100,000 people.
                       By 2001, no metropolitan areas and 7 statewide nonmetropolitan areas had
                       fewer than 100 physicians per 100,000 people. Twice as many metropolitan
                       areas and statewide nonmetropolitan areas had at least 300 physicians per
                       100,000 people in 2001 as in 1991. (See figs. 1 and 2.) In 1991, the 25
                       percent of areas with the lowest physician supplies per 100,000 people had
                       an average of 106 physicians per 100,000 people. By 2001, the 25 percent of
                       areas with the lowest physician supplies per 100,000 people had an
                       average of 132 physicians per 100,000 people. Similarly, the 25 percent of


                       15
                        The growth rate of physicians per 100,000 people was slightly higher (13 percent) from
                       1996 to 2001 than from 1991 to 1996 (11 percent).




                       Page 7                                                                       GAO-04-124 Physician Workforce
Figure 1: Physicians Per 100,000 People in the United States by Metropolitan Areas and Statewide Nonmetropolitan Areas,
1991




                                        Notes: Physicians refer to active, nonfederal, patient-care physicians with a known address. The
                                        District of Columbia, New Jersey, and Rhode Island do not have nonmetropolitan areas.




                                        Page 8                                                         GAO-04-124 Physician Workforce
Figure 2: Physicians Per 100,000 People in the United States by Metropolitan Areas and Statewide Nonmetropolitan Areas,
2001




                                        Notes: Physicians refer to active, nonfederal, patient-care physicians with a known address. The
                                        District of Columbia, New Jersey, and Rhode Island do not have nonmetropolitan areas.




                                        Page 9                                                         GAO-04-124 Physician Workforce
                          areas with the highest physician supplies per 100,000 people had an
                          average of 319 physicians in 1991 and 362 physicians in 2001. See appendix
                          III for information on physician supply by state metropolitan and
                          nonmetropolitan areas in 1991 and 2001.


                          All 48 statewide nonmetropolitan areas experienced an increase in the
Physician Supply Per      number of physicians per 100,000 people from 1991 to 2001 and 301 of 318
100,000 People            metropolitan areas experienced an increase in physicians per 100,000
                          people. Overall, the nonmetropolitan areas had higher proportional growth
Increased in Most         in physicians per 100,000 people than the metropolitan areas, but the
Areas but Geographic      disparity in the supply of physicians per 100,000 people between the
                          metropolitan and nonmetropolitan areas persisted. Rates of growth in the
Disparities Persisted     number of physicians per 100,000 people, the supply of physicians per
                          100,000 people, and the mix of generalists and specialists among
                          categories of metropolitan and nonmetropolitan counties varied. Among
                          the five county categories we analyzed, nonmetropolitan counties with a
                          large town had the biggest increase in physicians per 100,000 people from
                          1991 to 2001 and more physicians per 100,000 people than either
                          nonmetropolitan counties without a large town or rural counties, but still
                          fewer than metropolitan counties. Like metropolitan counties,
                          nonmetropolitan counties with large towns had more specialists than
                          generalists, while other nonmetropolitan counties had more generalists
                          than specialists.


Almost All Areas Gained   The 48 statewide nonmetropolitan areas, including those with the lowest
Physicians Per 100,000    supplies of physicians per 100,000 people in 1991, registered gains in
People                    physicians per 100,000 people between 1991 and 2001. However, this
                          growth rate was not even across all statewide nonmetropolitan areas and 7
                          areas remained below 100 physicians per 100,000 people. Five of these 7
                          statewide nonmetropolitan areas—Iowa, Indiana, Louisiana, Oklahoma,
                          and Texas—that remained below 100 physicians per 100,000 people, had
                          average increases in physicians per 100,000 people that were less than the
                          23 percent average increase for the nonmetropolitan United States. The
                          remaining 2—statewide nonmetropolitan Alabama and Tennessee—had
                          increases in physicians per 100,000 people that exceeded the national
                          nonmetropolitan area average, but the number of physicians in these areas
                          was so low in 1991 that this growth was not enough to elevate their
                          physician supply above 100 per 100,000 people in 2001.




                          Page 10                                       GAO-04-124 Physician Workforce
In the aggregate, the 318 metropolitan areas of the United States
experienced an increase in physicians per 100,000 people between 1991
and 2001. However, 17 (5 percent) metropolitan areas experienced
declines in the number of physicians per 100,000 people during this period.
(See table 2.) In 2001, 11 of these areas had physician supplies per 100,000
people that were below the national average of 239 physicians per 100,000
people. Only 2 individual metropolitan areas, however—the Topeka,
Kansas and Enid, Oklahoma MSAs—experienced an actual decrease in
their physician populations between 1991 and 2001. While the remaining
15 areas had more physicians in 2001 than in 1991, the population increase
for all of them was large enough that they still experienced a decline over
that decade in the number of physicians per 100,000 people. Five of these
areas had physician population growth in excess of the national average of
26 percent. However, in these areas the higher-than-average growth in
physician supply was exceeded by population growth that was also above
the national average of 13 percent, resulting in a decline in physicians per
100,000 people.16




16
 Other areas with higher-than-average population growth experienced increases in their
physician populations per 100,000 people. For example, the physician supply in the Las
Vegas, Nevada-Arizona MSA outpaced the area’s very high population growth during this
period, resulting in a 20 percent increase in the number of physicians per 100,000 people.




Page 11                                                  GAO-04-124 Physician Workforce
                              Table 2: Areas with Reductions in Physicians Per 100,000 People from 1991 to 2001

                                                                     Change in                                        Change in
                                                                      physician Population                           physicians
                                                                    population,    increase, Physicians             per 100,000,
                                                                      1991-2001   1991-2001 per 100,000,              1991-2001
                                                                   (percentage) (percentage)       2001            (percentage)
                               Phoenix-Mesa, Ariz. MSA                        41           46              197                -4
                               Yuma, Ariz. MSA                                38           47              100                -7
                               Greeley, Colo. PMSA                            38           45              136                -5
                               Raleigh-Durham-Chapel
                               Hill, N.C. MSA                                 33           38              398                -4
                               Denver, Colo. PMSA                             27           29              265                -2
                               Tucson, Ariz. MSA                              25           27              285                -1
                               Riverside-San
                               Bernardino, Calif. PMSA                        18           24              138                -5
                               Modesto, Calif. MSA                            17           21              144                -4
                               Merced, Calif. MSA                             15           18              101                -3
                               Stockton-Lodi, Calif. MSA                      13           21              134                -6
                               Miami, Fla. PMSA                               13           16              303                -2
                               Reading, Pa. MSA                                9           10              180                -1
                               Iowa City, Iowa MSA                             5           14             1004                -8
                               Los Angeles-Long Beach,
                               Calif. PMSA                                     4             8             238                -3
                               Jersey City, N.J. PMSA                          1             9             171                -7
                               Topeka, Kans. MSA                              -1             4             252                -5
                               Enid, Okla. MSA                                -4             1             212                -5

                              Sources: AMA, AOA, Bureau of Census, and CMS.

                              Note: Physicians refer to active, nonfederal, patient-care physicians with a known address.




Statewide                     The number of physicians per 100,000 people in nonmetropolitan areas, in
Nonmetropolitan Areas         which 19 percent of the U.S. population resided in 2001, increased 23
Had Greater Proportional      percent from 1991 to 2001. During this same time, the number of
                              physicians per 100,000 people in metropolitan areas, in which 81 percent
Increases in Physicians Per   of the U.S. population resided in 2001, increased 10 percent. (See table 3.)
100,000 People Than           The higher growth rate in physicians per 100,000 people in
Metropolitan Areas but        nonmetropolitan areas over the decade did not translate into a reduction
Geographic Disparities        in the gap in the supply of physicians per 100,000 people in metropolitan
Persisted                     versus nonmetropolitan areas. The disparity in the supply of physicians
                              per 100,000 people between nonmetropolitan and metropolitan areas



                              Page 12                                                        GAO-04-124 Physician Workforce
persisted because physicians continued to disproportionately locate in
metropolitan areas. On net, about 17,000 physicians (12 percent of the
physician population increase) went to nonmetropolitan areas between
1991 and 2001, while about 123,000 (88 percent of the physician population
increase) went to metropolitan areas. The difference in physician supply
between metropolitan and nonmetropolitan areas remained relatively
unchanged from 1991, when the difference in supply was 143 per 100,000
people, to 2001 when the difference was 145 per 100,000 people.

Table 3: Physicians Per 100,000 People in Statewide Nonmetropolitan and
Metropolitan Areas, 1991 and 2001

                                                                      Change from 1991 to 2001
                                                1991        2001                  (percentage)
 Nonmetropolitan
 All physicians                                  99          122                                    23
 Generalists                                     49           59                                    19
 Specialists                                     49           63                                    28
 Metropolitan
 All physicians                                 242          267                                    10
 Generalists                                     85           94                                    11
 Specialists                                    154          171                                    11

Sources: AMA, AOA, Bureau of Census, and CMS.

Notes: Physicians refer to active, nonfederal, patient-care physicians with a known address. We could
not categorize some physicians as generalists or specialists because there was no information about
their specialty in the AMA or AOA Masterfiles. Specifically, records for 7,185 physicians (1 percent) in
1991 and 4,982 physicians (0.7 percent) in 2001 did not have information that would allow us to
classify them as generalists or specialists. These physicians are included in the all physicians total,
but not in the generalist and specialist totals. The percentage change calculations are based on rates
prior to rounding.


In nonmetropolitan areas, the number of specialists per 100,000 people
increased faster than the number of generalists per 100,000 people. As a
result, the generalist and specialist composition shifted from an even mix
of generalists and specialists in 1991 to 48 percent generalists and 52
percent specialists in 2001. In metropolitan areas, generalists and
specialists per 100,000 people increased at approximately the same rate,
shifting the composition less than 1 percent from 36 percent generalists
and 64 percent specialists in 1991 to 35 percent generalists and 65 percent
specialists in 2001.




Page 13                                                         GAO-04-124 Physician Workforce
Rates of Growth in          To obtain additional information about physician supply within
Physician Supply Differed   nonmetropolitan and metropolitan areas, we aggregated county physician
Among Categories of         and population data into five categories defined by a county’s
                            nonmetropolitan or metropolitan status and the presence and size of a
Nonmetropolitan and         town within the county. All five county categories had an increase in
Metropolitan Counties       physicians per 100,000 people from 1991 to 2001. (See fig. 3.) But the rates
                            of growth in physician supply per 100,000 people, supply of physicians per
                            100,000 people, and mix of generalists and specialists varied by county
                            category. While nonmetropolitan counties with a large town (10,000 to
                            49,999 residents) had the biggest percentage increase in physicians per
                            100,000 people of all county categories, their supplies per 100,000 people
                            were still less than large and small metropolitan counties’ supplies in 1991
                            and 2001. Among nonmetropolitan counties, however, those with a large
                            town had more physicians per 100,000 people than those without a large
                            town or rural counties in 1991 and 2001. Like metropolitan counties,
                            nonmetropolitan counties that are more urbanized—those with a large
                            town—had more specialists than generalists per 100,000 people. Less
                            urbanized nonmetropolitan counties—those without a large town—and
                            rural counties had more generalists than specialists per 100,000 people in
                            1991 and 2001.




                            Page 14                                        GAO-04-124 Physician Workforce
                    Figure 3: Physicians Per 100,000 People by Metropolitan and Nonmetropolitan
                    County Categories, 1991 and 2001




                    Notes: Counties without urban influence codes are not included in these figures. Physicians refer to
                    active, nonfederal, patient-care physicians with a known address.
                    a
                        Large metropolitan areas have at least one million residents.
                    b
                        Small metropolitan areas have 50,000 to 999,999 residents.
                    c
                        Large towns have 10,000 to 49,999 residents.
                    d
                        Counties without large towns include those with or without a town of 2,500 to 9,999 residents.
                    e
                        Rural counties have fewer than 2,500 residents.




                    We provided a draft of this report to HRSA for comment. HRSA said that
Agency Comments 	   the study supports the conclusion that the disparity in the distribution of
                    physicians in rural and urban areas persists and has narrowed. HRSA also
                    agreed with our assessment of the difficulties and variation associated
                    with determining an appropriate supply for any given geographic area.
                    However, HRSA noted that the report should draw conclusions to make
                    the report more complete.




                    Page 15                                                             GAO-04-124 Physician Workforce
HRSA also commented that rural citizens are still grossly underserved,
noting that physician supply can be a rough measure of access to
physician services in a given area and that even in areas with a large
number of physicians many people still lack access due to a number of
factors. HRSA’s comments are reprinted in appendix IV.

Although we found that a geographic disparity persists, we did not find
that the disparity in the distribution between metropolitan and
nonmetropolitan areas has narrowed. Physician supply grew faster in
nonmetropolitan than metropolitan areas, on a national basis, but this did
not reduce the disparity because there are so many physicians in
metropolitan areas. As we stated in the draft report that HRSA reviewed,
while nonmetropolitan areas experienced higher growth rates in
physicians per 100,000 people, the difference in physician supply per
100,000 people remained relatively unchanged from 1991 to 2001.

HRSA noted that physician supply is only one of several factors affecting
the accessibility of health care in an area. However, assessing the
adequacy of access to physicians was beyond the scope of our work.
HRSA also provided technical comments that we incorporated as
appropriate.


We are sending copies of this report to the Administrator of the Health 

Resources Services Administration and other interested parties. We will 

also provide copies to others upon request. In addition, the report will be 

available at no charge on the GAO Web site at http://www.gao.gov. If you 

or your staff have any questions about this report, please call me at (202) 

512-7119 or Christine Brudevold at (202) 512-2669. Major contributors to 

this report were Kathryn Linehan and Ann Tynan. 


Sincerely yours, 





Laura A. Dummit 

Director, Health Care—Medicare Payment Issues 





Page 16                                         GAO-04-124 Physician Workforce
Appendix I: Scope and Methodology 



              To conduct this work, we counted active, nonfederal, patient care
              physicians with a known address, including interns and residents, in the
              United States. We used individual physician-level data on medical doctors
              (MD) from the 1991 and 2001 American Medical Association (AMA)
              Physicians’ Professional Data, also known as the AMA Masterfile and 1991
              and 2001 data on doctors of osteopathic medicine (DO) from the American
              Osteopathic Association (AOA) Masterfile. These data are widely used in
              studies of physician supply because they are a comprehensive list of U.S.
              physicians and their characteristics.

              To determine physician supply per 100,000 people, we obtained county-
              level resident population data for 1991 and 2001 from the U.S. Census
              Bureau Web site.1 We used data from the Department of Agriculture Web
              site to determine urban influence codes for each county.2 For additional
              information about physician supply in the United States, we reviewed
              relevant literature and interviewed academic researchers on the topic of
              the U.S. physician workforce.

              To obtain federal program information, we interviewed officials from the
              Health Resources and Services Administrative (HRSA) and officials at the
              Centers for Medicare & Medicaid Services (CMS). HRSA officials provided
              information on the scope and expenditures of health professions training
              and education programs and the National Health Service Corps. CMS
              officials provided information on the Medicare Incentive Payments to
              physicians providing services in health professional shortage areas.

              We combined counts of MDs and DOs to determine the total number of
              physicians in each of our study years. Each physician was counted without
              adjustment for hours worked. To determine physicians per 100,000 people,
              we divided the physician population in a given area by the total population
              in the area in that same year. To count generalists and specialists we used
              each physician’s specialty information in the AMA and AOA data files to
              categorize physicians as generalists or specialists. Physicians whose
              specialty information was listed as family practice, general practice,



              1
               Data for 1991 were from http://eire.census.gov/popest/data/counties/tables/CO-EST2001­
              12.php (downloaded on July 3, 2003). Data for 2001 were from
              http://eire.census.gov/popest/estimates_dataset.php (downloaded on March 13, 2003).
              2
               Data on urban influence codes from the Department of Agriculture were from
              http://www.ers.usda.gov/briefing/Rurality/UrbanInf/Urbinfl.xls (downloaded on March 12,
              2003).




              Page 17                                                GAO-04-124 Physician Workforce
Appendix I: Scope and Methodology




general internal medicine, and general pediatrics were categorized as
generalists. All other physicians with specialty information available were
categorized as specialists.

To assign physicians to a geographic area in the United States, we used
address information in the AMA and AOA data files. The address
information in these files does not specify whether the address refers to
the physician’s home, office, or some other location and it is possible that
some physicians live and work in different counties. Because of this
limitation, we did not analyze the data at the individual county level. We
combined multiple, adjacent counties into larger geographic units. We
assigned counties to a metropolitan statistical area (MSA), primary
metropolitan statistical areas (PMSA), or New England county
metropolitan area (NECMA). We grouped data from all areas within a state
that were not in a MSA, PMSA, or NECMA into one statewide
nonmetropolitan area for each state. We used 2001 MSA, PMSA, and
NECMA classifications for the 2001 and 1991 data.

For analysis by county categories, we used urban influence codes, which
group metropolitan and nonmetropolitan counties according to the official
metropolitan status announced by the Office of Management and Budget
in 1993, based on 1990 Census data. Urban influence codes group counties,
county equivalents, and independent cities into nine categories.3
Metropolitan counties are grouped into two categories (1 and 2) by the
size of the metropolitan area. Nonmetropolitan counties are grouped into
seven groups (3 through 9) by their adjacency to metropolitan areas and
the size of their own city. For this analysis of physician supply, we
maintained categories 1, 2, and 9 and collapsed the remaining six
categories into two, for a total of five categories. This analysis combines
codes 3, 5, and 7 into one category (i.e., nonmetropolitan with a large
town) and 4, 6, and 8 into one category (i.e., nonmetropolitan without a
large town).




3
 For more information about urban influence codes see T.C. Ricketts, K.D. Johnson-Webb,
P. Taylor, Definitions of Rural: A Handbook for Health Policy Makers and Researchers,
Prepared for the Federal Office of Rural Health Policy, Health Resources and Services
Administration, United States Department of Health and Human Services, June 1998.
Downloaded from www.shepscenter.unc.edu/research_programs/rural_program/wp.html
(downloaded April 2003).




Page 18                                                GAO-04-124 Physician Workforce
Appendix II: HRSA Programs That Address
Supply and Distribution of Health
Professionals
             HRSA administers programs that encourage health professionals to
             practice in underserved areas and support health professions education
             and training. The National Health Service Corps and the State Loan
             Repayment Program, authorized by Title III of the Public Health Service
             Act, offer scholarships and loan repayments to health professionals in
             exchange for a commitment to practice in health professional shortage
             areas.1 Grant and loan support programs that support health professions
             education and training, authorized by Title VII of the Public Health Service
             Act, have diverse objectives.2 Generally, these programs support education
             and training for a range of health professions including medicine,
             chiropractics, dentistry, optometry, pharmacy, physician assistants, allied
             health, and public health. While most of the Title VII programs address
             three objectives of improving the distribution of health professionals in
             underserved areas, increasing representation of minorities and individuals
             from disadvantaged backgrounds in health professions, and increasing the
             supply of health professionals, they also address other objectives such as
             improving the quality of education and training. Table 4 provides
             information on Title III and Title VII program spending or appropriations
             and objectives.




             1
              Public Health Service Act (PHSA), July 1, 1944, ch. 373, 58 stat. 682 (classified to 42 U.S.C.
             §§ 201 et seq.) Title III of the PHSA is classified to 42 U.S.C. §§ 241 et seq.
             2
              Title VII of the PHSA is classified to 42 U.S.C. §§ 292 et seq.




             Page 19                                                      GAO-04-124 Physician Workforce
                                            Appendix II: HRSA Programs That Address
                                            Supply and Distribution of Health
                                            Professionals




Table 4: HRSA Programs’ Expenditures or Appropriations and Objectives

                              Program expenditures
                                or appropriationsa
                              (in millions of dollars)                            Program objectives
                                                                               Increasing
                                                                            representation
                                                                             of minorities
                                                              Improving     and individuals
                                                            distribution of       from                        Improving training
                                                                health      disadvantaged      Increasing         for health
                                                           professionals in backgrounds in      supply of      professionals in
                                                             underserved         health           health       geriatrics and in
Program                          FY 1991      FY 2001            areas        professions     professionals     public health
Programs authorized by
Title III of the Public
Health Service Act
Scholarships and loan
repayments to individuals
in exchange for
commitments to practice in
underserved areas
   National Health Service          $42.5        $70.8           X
   Corps
   State Loan Repayment               6.0          7.2           X
Title III Total                     $48.5        $78.0
Programs authorized by
Title VII of the Public
Health Service Act
Scholarships and loans to
individuals in exchange for
commitment to train in and
practice primary care
medicine
   Exceptional Financial             $9.6         $1.0                            X                X
   Need Scholarships
   Financial Assistance for           6.1             .6                          X                X
   Disadvantaged Health
   Professions
   Primary Care Loanb,c, d           N.A.          9.9                                             X




                                            Page 20                                             GAO-04-124 Physician Workforce
                                             Appendix II: HRSA Programs That Address
                                             Supply and Distribution of Health
                                             Professionals




                               Program expenditures
                                 or appropriationsa
                               (in millions of dollars)                            Program objectives
                                                                                Increasing
                                                                             representation
                                                                              of minorities
                                                               Improving     and individuals
                                                             distribution of       from                        Improving training
                                                                 health      disadvantaged      Increasing         for health
                                                            professionals in backgrounds in      supply of      professionals in
                                                              underserved         health           health       geriatrics and in
Program                           FY 1991      FY 2001            areas        professions     professionals     public health
Scholarships, loans, and
loan repayments to
individuals in health
professions training
  Health Professions                   3.5          1.2                                             X
  Student Loanb, c
  Loans for                            2.8             .2                          X
  Disadvantaged
  Studentsc
  Scholarships for                     8.2         41.0           X                X
  Disadvantaged Students
  Faculty Loan                          .5          1.0                            X
  Repayment Program
Grants to institutions or
individuals for health
professions education and
training
  Quentin N. Burdick                   3.8          6.0           X
  Program for Rural
  Interdisciplinary Training
  Training in Primary Care            70.4         91.1           X                X                X
  Medicine and Dentistry
  Area Health Education               19.2         33.4           X                X                X
  Centers
  Geriatric Training for               3.9          2.9           X                                                    X
  Physicians, Dentists,
  and Behavioral and
  Mental Health
  Professionals




                                             Page 21                                             GAO-04-124 Physician Workforce
                                            Appendix II: HRSA Programs That Address
                                            Supply and Distribution of Health
                                            Professionals




                              Program expenditures
                                or appropriationsa
                              (in millions of dollars)                                         Program objectives
                                                                                    Increasing
                                                                                 representation
                                                                                  of minorities
                                                                   Improving     and individuals
                                                                 distribution of       from                                     Improving training
                                                                     health      disadvantaged               Increasing             for health
                                                                professionals in backgrounds in               supply of          professionals in
                                                                  underserved         health                    health           geriatrics and in
 Program                         FY 1991         FY 2001              areas        professions              professionals         public health
     Geriatric Academic              N.A.                .8                                                                               X
     Career Awards
     Geriatric Education              9.5              7.5                                                                                X
     Center Program
     Centers of Excellence           14.5             30.6                                     X
     Health Careers                  24.2             32.0                                     X
     Opportunity Program
     Preventive Medicine             U.A.              2.1               X                     X                                          X
     Residency Grant
     Program
     Public Health Training          N.A.              4.7                                                                                X
     Center Program
     Title VII Total              $176.2           $266.0

Source: HRSA.

                                            Legend: NA = not applicable because program not operational this year

                                            UA = data not available

                                            Notes: All programs provide support for a range of health professions including medicine,
                                            chiropractics, dentistry, optometry, pharmacy, physician assistants, allied health, and public health,
                                            except as noted.
                                            a
                                                For Title III programs, expenditures are given. For Title VII programs, appropriations are given.
                                            b
                                                Program provides support for medical students, residents, and physicians.
                                            c
                                                Loan programs financed by revolving loan fund.
                                            d
                                             The Primary Care Loan Program replaced Health Professions Student Loan Program in 1993 for
                                            allopathic and osteopathic medicine programs.




                                            Page 22                                                             GAO-04-124 Physician Workforce
Appendix III: Physicians Per 100,000 People
by State Metropolitan and Nonmetropolitan
Areas, 1991 and 2001

                                    Physicians per 100,000        Generalists per 100,000     Specialists per 100,000
                                            people                        people                      people
Areas                                     1991          2001             1991         2001          1991          2001
Alabama
Metropolitan Alabama                          201        238               69           82            129          154
Nonmetropolitan Alabama                        61            78            36           45             25           33
Alaska
Metropolitan Alaska                           176        246               60           91            115          156
Nonmetropolitan Alaska                         97        134               54           76             42           58
Arizona
Metropolitan Arizona                          214        207               73           73            138          133
Nonmetropolitan Arizona                        90        111               52           56             38           55
Arkansas
Metropolitan Arkansas                         231        265               78           91            148          172
Nonmetropolitan Arkansas                       85        101               48           55             35           45
California
Metropolitan California                       225        229               78           83            144          143
Nonmetropolitan California                    112        129               52           59             58           69
Colorado
Metropolitan Colorado                         231        240               81           85            147          154
Nonmetropolitan Colorado                      112        154               58           71             53           83
Connecticut
Metropolitan Connecticut                      288        324               96          108            188          214
Nonmetropolitan Connecticut                   125        133               53           60             72           72
Delaware
Metropolitan Delaware                         217        249               80           93            135          154
Nonmetropolitan Delaware                      153        194               53           66             99          128
District of Columbia
Metropolitan District of Columbia             544        554              169          171            363          373
Florida
Metropolitan Florida                          214        237               71           82            141          154
Nonmetropolitan Florida                        98        117               40           49             57           68
Georgia
Metropolitan Georgia                          208        228               64           77            140          150
Nonmetropolitan Georgia                        97        117               43           52             54           64




                                    Page 23                                             GAO-04-124 Physician Workforce
                                Appendix III: Physicians Per 100,000 People
                                by State Metropolitan and Nonmetropolitan
                                Areas, 1991 and 2001




                                Physicians per 100,000         Generalists per 100,000     Specialists per 100,000
                                        people                         people                      people
Areas                                  1991           2001              1991       2001          1991          2001
Hawaii
Metropolitan Hawaii                       252           284               91        101            154          181
Nonmetropolitan Hawaii                    157           190               70         80             87          109
Idaho
Metropolitan Idaho                        162           198               55         69            106          128
Nonmetropolitan Idaho                     108           129               49         54             56           73
Illinois
Metropolitan Illinois                     240           270               91        102            145          166
Nonmetropolitan Illinois                   89           108               46         54             42           53
Indiana
Metropolitan Indiana                      190           234               69         82            118          151
Nonmetropolitan Indiana                    83            99               43         49             39           50
Iowa
Metropolitan Iowa                         261           288               92        102            165          183
Nonmetropolitan Iowa                       88           100               50         58             37           42
Kansas
Metropolitan Kansas                       253           278               88        100            162          176
Nonmetropolitan Kansas                     93           114               54         61             38           53
Kentucky
Metropolitan Kentucky                     252           285               84         91            166          191
Nonmetropolitan Kentucky                   93           121               45         56             47           64
Louisiana
Metropolitan Louisiana                    226           283               65         86            157          194
Nonmetropolitan Louisiana                  68            78               39         43             28           34
Maine
Metropolitan Maine                        229           300               88        115            140          183
Nonmetropolitan Maine                     151           195               74         90             76          103
Maryland
Metropolitan Maryland                     311           335              105        112            199          217
Nonmetropolitan Maryland                  144           181               53         66             91          114
Massachusetts
Metropolitan Massachusetts                308           362              105        118            199          240
Nonmetropolitan Massachusetts             134           150               63         67             71           83




                                Page 24                                              GAO-04-124 Physician Workforce
                                Appendix III: Physicians Per 100,000 People
                                by State Metropolitan and Nonmetropolitan
                                Areas, 1991 and 2001




                                Physicians per 100,000         Generalists per 100,000     Specialists per 100,000
                                        people                         people                      people
Areas                                  1991           2001              1991       2001          1991          2001
Michigan
Metropolitan Michigan                     237           273               88        104            145          167
Nonmetropolitan Michigan                  106           129               52         60             53           68
Minnesota
Metropolitan Minnesota                    274           296              102        108            169          185
Nonmetropolitan Minnesota                  91           114               58         70             31           43
Mississippi
Metropolitan Mississippi                  224           261               73         76            148          183
Nonmetropolitan Mississippi                83           107               40         49             42           58
Missouri
Metropolitan Missouri                     270           292               92         99            174          192
Nonmetropolitan Missouri                   90           111               50         60             39           51
Montana
Metropolitan Montana                      236           302               52         82            183          219
Nonmetropolitan Montana                   124           157               63         73             59           83
Nebraska
Metropolitan Nebraska                     262           300               88        106            171          192
Nonmetropolitan Nebraska                   83           115               49         63             34           52
Nevada
Metropolitan Nevada                       161           180               53         63            106          116
Nonmetropolitan Nevada                     44           125               27         60             16           65
New Hampshire
Metropolitan New Hampshire                161           192               56         72            105          119
Nonmetropolitan New Hampshire             287           353              103        119            180          230
New Jersey
Metropolitan New Jersey                   256           296               97        110            156          184
New Mexico
Metropolitan New Mexico                   247           264               84         97            161          166
Nonmetropolitan New Mexico                 99           114               51         55             48           59
New York
Metropolitan New York                     318           357              115        127            200          228
Nonmetropolitan New York                  121           149               51         62             67           85




                                Page 25                                              GAO-04-124 Physician Workforce
                                 Appendix III: Physicians Per 100,000 People
                                 by State Metropolitan and Nonmetropolitan
                                 Areas, 1991 and 2001




                                 Physicians per 100,000         Generalists per 100,000     Specialists per 100,000
                                         people                         people                      people
Areas                                   1991           2001              1991       2001          1991          2001
North Carolina
Metropolitan North Carolina                221           257               73         86            145          170
Nonmetropolitan North Carolina              96           125               41         54             54           70
North Dakota
Metropolitan North Dakota                  283           321               95        114            184          203
Nonmetropolitan North Dakota               100           124               55         67             43           54
Ohio
Metropolitan Ohio                          239           274               87        101            149          172
Nonmetropolitan Ohio                        92           114               44         57             47           57
Oklahoma
Metropolitan Oklahoma                      220           236               79         87            138          147
Nonmetropolitan Oklahoma                    87            96               50         54             36           41
Oregon
Metropolitan Oregon                        234           249               82         92            150          156
Nonmetropolitan Oregon                     128           156               58         70             69           84
Pennsylvania
Metropolitan Pennsylvania                  277           317              100        114            173          202
Nonmetropolitan Pennsylvania               133           152               55         66             77           86
Rhode Island
Metropolitan Rhode Island                  250           313               98        115            149          196
South Carolina
Metropolitan South Carolina                192           241               65         80            124          159
Nonmetropolitan South Carolina              88           120               44         55             43           65
South Dakota
Metropolitan South Dakota                  257           315               84        100            160          212
Nonmetropolitan South Dakota                93           122               54         65             38           54
Tennessee
Metropolitan Tennessee                     255           290               83         95            168          193
Nonmetropolitan Tennessee                   77            98               42         52             35           45
Texas
Metropolitan Texas                         195           213               65         73            127          139
Nonmetropolitan Texas                       72            81               42         45             29           36




                                 Page 26                                              GAO-04-124 Physician Workforce
                                                Appendix III: Physicians Per 100,000 People
                                                by State Metropolitan and Nonmetropolitan
                                                Areas, 1991 and 2001




                                                Physicians per 100,000              Generalists per 100,000              Specialists per 100,000
                                                        people                              people                               people
 Areas                                                  1991              2001                1991            2001               1991             2001
 Utah
 Metropolitan Utah                                        203              208                   64              70                137              137
 Nonmetropolitan Utah                                      85              115                   40              50                 43               64
 Vermont
 Metropolitan Vermont                                     388              487                 142             179                 240              300
 Nonmetropolitan Vermont                                  174              223                   76              96                 97              126
 Virginia
 Metropolitan Virginia                                    224              257                   76              90                144              165
 Nonmetropolitan Virginia                                 112              135                   51              62                 60               72
 Washington
 Metropolitan Washington                                  222              245                   82              90                137              153
 Nonmetropolitan Washington                               128              152                   63              73                 63               78
 West Virginia
 Metropolitan West Virginia                               214              273                   78            106                 133              164
 Nonmetropolitan West Virginia                            156              186                   67              80                 88              103
 Wisconsin
 Metropolitan Wisconsin                                   225              268                   78              95                143              171
 Nonmetropolitan Wisconsin                                107              131                   56              68                 50               62
 Wyoming
 Metropolitan Wyoming                                     190              223                   87              87                103              134
 Nonmetropolitan Wyoming                                  112              150                   55              65                 57               85

Sources: AMA, AOA, Bureau of Census, and CMS.

                                                Note: Physicians refer to active, nonfederal, patient-care physicians with a known address. The
                                                District of Columbia, New Jersey, and Rhode Island do not have nonmetropolitan counties. We could
                                                not categorize some physicians as generalists or specialists because there was no information about
                                                their specialty in the AMA or AOA Masterfiles. Specifically, records for 7,185 physicians (1 percent) in
                                                1991 and 4,982 physicians (0.7 percent) in 2001 did not have information that would allow us to
                                                classify them as generalists or specialists. These physicians are included in the all physicians total
                                                but not in the generalist and specialist totals.




                                                Page 27                                                          GAO-04-124 Physician Workforce
Appendix IV: Comments from the Health
Resources and Services Administration




             Page 28           GAO-04-124 Physician Workforce
Appendix IV: Comments from the Health Resources and Services Administration




Page 29                                               GAO-04-124 Physician Workforce
Appendix IV: Comments from the Health Resources and Services Administration




Page 30                                               GAO-04-124 Physician Workforce
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              Health Care Shortage Areas: Designations Not a Useful Tool for
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              Health Professions Education: Role of Title VII/VIII Programs in
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(290260)
              Page 31                                      GAO-04-124 Physician Workforce
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