Facts about ...Rural Physicians
Over 51 million Americans live in areas classified by the U.S. Office of Management and Budget (OMB) as nonmetropolitan. They comprise one-fifth of the US population. Yet less than 11% of the nation's physicians are practicing in nonmetro areas. Over 20 million of those nonmetro residents live in areas that have a shortage of physicians to meet their basic needs.
A majority of physicians (54%) in nonmetropolitan areas are in the primary care specialties of family or general practice, general internal medicine, pediatrics, and obstetrics/gynecology, compared with 38% of metropolitan physicians. In 1995, there were 56,635 office-based patient care MDs in nonmetropolitan areas compared with 370,000 office-based patient care MDs in metropolitan areas.2
According to the Council on Graduate Medical Education (COGME,1994),
family physicians are three times more likely than general internists,
and five times as likely as general internists or general pediatricians,
to practice in nonmetropolitan areas. Further, family practitioners
are the only physicians among all specialties who are as likely
to settle in nonmetropolitan areas as is the general population.
Total U.S. Patient Care Physicians in Metropolitan
Between 1975 and 1995 both metro and nonmetropolitan areas experienced
an overall growth in the number of patient care physicians. Nonmetro
experienced a growth of 31% while the metro supply grew by over
59%. However, the growth rate was less for smaller counties. The
smallest counties (<2,500 population) experienced a drop in their
physician-to-population ratio during this period.2
Primary Care Physicians per 100,000 Population in
Characteristics of Nonmetropolitan Physician Practice
Physicians: Hours Worked Per Week (source: 4)
Two commonly used indicators of physician work load are the number of hours a physician spends in direct patient care each week and the total number of patient visits per week. 1995 data show that nonmetropolitan physicians worked longer hours and had more patient visits per week than their metropolitan colleagues. Nonmetropolitan physicians spent as much as 16 percent more time per week in direct patient care and had 38 percent more patient visits per week than physicians in the largest metropolitan areas.4
Physicians: Total Number of Patient Visits Per Week (source: 4)
Nonmetropolitan physicians derived a larger share of their gross practice revenue from Medicare and Medicaid patients than metropolitan physicians. These public programs pay physicians at lower rates than private insurers.
Percentage of Physician Revenue from
Nonmetropolitan physicians, on average, work more and earn less
than their metropolitan counterparts.
Primary Care Physician Shortage
The Federal government designates areas with a shortage of practitioners as Health Professional Shortage Areas or HPSAs. Such designation qualifies these areas for federal grant dollars, National Health Service Corps placement of practitioners, and some enhancement of federal insurance reimbursements in order to bolster health care services in those localities. The Department of Health and Human Services uses a ratio of one primary care physician per 3,500 population or more (1:3,500) as the standard for a primary care HPSA designation.The Department's recommended ratio for an "adequately served" population is one primary care physician for 2,000 people.5
More than 20 million Americans live in nonmetropolitan areas with a shortage of primary care physicians. Persons living in nonmetropolitan areas are nearly 4 times more likely to live in a HPSA than persons in metropolitan areas.
In 1997, more than 2,200 physicians are needed in nonmetropolitan areas to remove all nonmetropolitan HPSA designations for primary care. More than twice that number are needed to achieve a 2,000:1 ratio in those HPSAs.5
As of June 1997, of the 2,597 designated primary medical care HPSAs, 1,742 (67%) were in nonmetropoltian areas:5 763 whole county nonmetropolitan HPSAs and 732 partial county nonmetropolitan HPSAs.
As an incentive to physicians to practice in HPSAs, both nonmetropolitan and metropolitan, Medicare adds a 10% bonus to its payments for services provided in HPSAs. Physicians in nonmetropolitan areas received a higher percentage of gross practice revenue (33%) from Medicare than metropolitan physicians (27%) in 1994.7
A greater proportion of bonus payments in nonmetropolitan areas is for primary care physicians' services than in metropolitan areas. Nearly two-thirds of payments in nonmetropolitan HPSAs were made to primary care physicians, compared to about one-third of payments in metropolitan HPSAs.
The nation's southern states (Public Health Service Region IV: AL, FL, GA, KY, MS, NC, SC, TN), which have substantial nonmetropolitan populations, have the greatest need for primary care physicians. In order to remove all their Health Professional Shortage Area designations, they would require an additional 1,096 physicians. To be considered adequately served, there would need to be an additional 2,732 physicians practicing in shortage areas in these states.
View map, Primary Health Care Shortage Areas (HPSAs) in Nonmetropolitan Counties, 1996
National Health Service Corps Field Strength,