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The Southern Rural Access Program Evaluation Program Report # 2 - Physician and Primary Care Professionals This is the second in a series of occasional discussions of issues related to the evaluation of the Southern Rural Access Program (SRAP). In working with the several states and organizations involved in the SRAP, the Evaluation Design Team has attempted to provide feedback and guidance to help the states participate in the evaluation and to make the evaluation activities useful for both the Robert Wood Johnson Foundation as well as the National Program Office and the Participating States. We welcome your response. Contact Tom Ricketts (tom_ricketts@unc.edu) if you have any comments or suggestions. One of the key elements in the Evaluation of the Southern Rural Access Program's effects is the "Availability" Component of Access. Availability is defined as the spatial proximity of clinically active primary care professionals. This Evaluation Planning paper discusses the data that are needed to assess availability and suggests several approaches for the gathering of comparable and consistent data on primary care professionals. There are excellent examples of systems of data collection and the use of those data for analysis and policy decision making within the SRAP region. Georgia, for example, has developed a very sophisticated data collection and analysis system that includes a user-operated analysis system that is distributed on disk; more details on that system are included at the end of this paper. There are a core set of data elements that can be collected to yield an accurate picture of the supply of physicians and primary care professionals in a state or region of a state. These data can be used to identify areas of need, trends in future supply, and provide hints on how the training of physicians and primary care professionals affects local and statewide supply. These data are collected by states as part of their licensing process, through special surveys by state agencies, through national surveys conducted by professional associations, and from public records by commercial firms which market the data. Potentially the most reliable and useful data can be captured within the licensing and re-licensing process which each state has in place to oversee the competency of clinical professionals. This document provides a template for a data system that can be used to register and inventory physicians for policy and analysis purposes, making use of the licensing or registration system. This template can easily be modified to make it appropriate for inventories of non-physician health programs. The data from such a system can also assist in the review of the quality of the professional workforce; however, the data we discuss here are primarily for purposes of assessing the supply and need for practicing health professionals, especially physicians and other primary care professionals. The number of data elements are restricted to those that can be captured on a single letter-sized sheet. The data collection process may vary; the system may use forms which are reviewed and entered into a computer system by data entry personnel, read by machine using mark-sense forms, or scanned to read in data entered by the practitioners. The specifics of the data collection process are not as important as the uniformity of the data, its reliability and validity, and its timeliness. The License Process and Policy Information State licensure boards are in a unique position to gather complete data concerning physicians since they regularly contact every individual licensed to practice under their jurisdiction. In the process of collecting the information required for licensure and renewals, a reasonable additional effort can result in a data set which can be very useful for the professionals themselves as well as policy makers, planners and researchers. We recommend that the policy information collection process be part of the official license application and renewal process because it makes use of a standard legal definition of the professionals. Such a system links policies intended to protect citizens to policies which affect the numbers and types of health professionals who practice. The re-registration cycle may vary from state to state. Annual updates provide the continuous flow of data necessary to track policy decisions and programs. Annual re-registration forms should be a required element in the license process and allows the licensing board to know the names, practice and home addresses, and activity status of all licensed professionals within a reasonable time frame to determine their continuing competency. Reporting to a licensing board is sometimes seen as an onerous intrusion by some professionals and it is important to recognize the immense continuing reporting and data burden of professionals. The overriding criteria for inclusion of a data element into a licensing system is that it contributes to an important policy information need, is a reliable indicator, and does not depart unnecessarily from the original and fundamental purpose of the information gathering—ensuring the quality of care provided by the licensed professionals. It is our position that this goal is served by understanding the size and location of the professional workforce. This information is relevant to the goal of maintaining quality because it tells policy makers and the licensing board whether there are shortages that can causes stress on professionals or where there are situations where there are an abundance of professionals creating incentives that may affect quality of care. The extant medical and health professional licensing or regulatory systems are not always supported by the states which benefit from the services of the professionals. A registration process should be recognized as a essential element of each state's responsibility to its citizens although it is usually carried out by an independent professional body. Such boards or agencies should view the reporting process as an integral part of their licensing responsibility, both for the addition of important information concerning licensed professionals as well as their ability to communicate with the public using the data. Financing such systems is difficult. Boards can make use of the registration fees to support the review and registration process; in some places, state funds can be appropriated. The systems that are able to effectively track the licensed professionals often make use of registration fees to support the regulatory activities and the workforce analysis process. The analysis of the data can be completed by outside agencies or universities working in partnership with the licensing board. University systems that support medical schools, Area Health Education Center (AHEC) systems, and consortia concerned with the availability of useful health system data may also provide support to the system and the analysis of the data. Currently there are projects underway that are designed to give consumers information concerning the competency of professionals through publication via the Internet. Such systems require the computerization of data on the professionals and their practices. These systems can provide value to the public and their construction can create the data systems necessary for policy information to be extracted. Specific Data Elements For the several sections below, we discuss the data elements that would optimally fit into a policy data base developed from the licensing re-registration process. We strongly suggest an annual license re-registration cycle because there are many changes that can occur in a two year period that will make the data irrelevant or misleading. The registration cycle may require re-registration on a single data each year, on several dates, or on the licensee's birthday depending upon the resources available to the licensing agency or its partners or contractors. The specific data items are included in a brief table at the end of each section following this format:
Provider Personal Characteristics: The initial license process usually involves a detailed review of a candidate's qualifications and sets a standard for identification and verification. It also creates a unique identifier that may be merged with other systems for statutory monitoring. The unique identifier is critical to tracking health professionals for policy purposes since names can and often do change. Date of birth, place of birth, race, ethnicity, and gender may be collected for each licensed individual to ensure accuracy in identification when verifying an applicant's credentials. These data are essentially invariant and once collected and included in a data file can remain there and do not need updates in re-registration systems. These data items are useful for planning and making workforce projections given the relatively predicable changes in practice activity and content that occur as practitioners age. Gender has been shown to predict different patterns of activity and place of birth is often a key to retention. The race and ethnicity questions are important if a state has a policy of matching the diversity in the state. Practice location: The locations and the numbers of medical care physicians provide are vital information in terms of workforce assessment and planning. Physicians should be asked to provide their locations of practice as a ZIP code or town or county, and the information for the practice activity linked to the location. The system should allow for multiple locations; three ZIP code locations appears to provide sufficient options for those with multiple practice locations.
Clinical Activity Status. Many professionals devote some, and a few, most of their working time to administration, research and teaching. All are important to the organization of health care delivery. However, policies are mostly targeted to improving the supply of clinical professionals who directly treat patients. It is important to understand the net patient care contribution of a population of practitioners. This can be understood only by determining the proportion of total professional time spent in clinical practice and can be asked directly. This means that the total professional time needs to be calculated, usually in hours per week, then the proportion in clinical time reported as a percentage or as hours per average week. Reports of professional activity are not meant to be measures of productivity. The fundamental policy issue that is considered most often is access to clinical care and access is best measured in terms of time when the practitioner is available in a clinical setting. Visit rates, procedures, assessments, and other clinical activity vary widely by specialty, age, and gender. While it may seem more appropriate to measure productivity directly, it requires much greater detail in the data collection process and is more subject to recall bias. Reporting average hours per week creates a maximum and minimum framework within which estimates can be considered more reliable. However, question construction is very important as practitioners may report total work hours and clinical work hours in a way that "double counts," producing inflated estimates of the actual availability of the practitioner.
Specialty Information. Specialty designation is not a precise and unchanging characteristic of a practitioner, especially for physicians. There is little research on the degree to which physicians change specialty, add a specialty or sub-specialty, or de-specialize. In most data systems for licensing, specialty is provided by the licensee. The number of "approved" specialties has increased dramatically over time and there are always a few emerging or "unapproved" specialties that practitioners wish to designated themselves as. The information that is most useful for policy purposes is the specialty or branch of medicine or clinical discipline in which the professional practices at the time of re-registration. Physicians often practice a generalist specialty as well as devote substantial time to a second, usually, specific specialty or subspecialty. For example, general internists often devote large portions of their time to cardiology. Data systems thus often ask for a "primary" or main specialty and a secondary specialty. Changing the specialty distribution of physicians and primary care providers including physician assistants and nurse practitioners has been an important state policy. Because of the volatility of this designation and its importance to policy, it is very desirable to know the main and substantial secondary specialty of professionals at regular periods. Our recommendation is that the licensee be requested to indicate main and secondary specialty with an estimate of proportion of practice time devoted to each. There may be practitioners who can best be described in three classifications, however, this may not yield much information for a population of professionals. There are often specific access related practice activities that are of great interest to policy makers. These have been, in the past, whether the practitioner does obstetrical deliveries, provides primary care, accepts Medicaid patients, is involved in a managed care network, or other characteristics which are important to state level policy. These specific issue questions are reflected in two of the suggested questions below. However, they are optional questions and not necessary to general understanding of the clinical workforce. However, the ability to ask a limited number of policy relevant questions in a registration process may help relieve the burden of more intrusive surveys which are directed to practitioners. It may be possible to create a system that protects the licensees from receiving surveys by having certain data collected as part of registration to satisfy important policy needs and not allowing the release of address files for survey purposes given the availability of data via the licensing process.
Provider training information: Medical, nursing or other professional school and residency locations may be collected during initial licensure, and can be used to examine the origins of physicians practicing in the state, assess the preparedness of the overall professional population and potentially predict their patterns of activity and retention. Many states request information concerning continuing education as part of the re-licensure process. This may be pursuant to statute or the wishes of the licensing board. Continuing education, for most policy purposes, is not a key data element. However, further specialty training, certification, or formal fellowships that qualify for expanded or redirected practice are important measures of the potential quality and clinical content of a population of licensees. The data system can be updated as licensees report to the licensing agency or board. This may be required by statute. If such a system is in place the data set can be updated without the use of a date collection form or process. However, if such reporting is not required, then the annual license form may include subsequent residency training and continuing education questions.
Applicability to Other Primary Care Professionals This document has been structured to apply to a number of primary care disciplines. There are states that require all primary care professionals to register with the Medical Board or a Joint licensing board; other states have separate licensing and registration systems. Where there are separate system the two may develop their own data systems and the data may diverge due to timing of licensing or the data that are collected. Theses issues can produce tension and cause problems for the overall accuracy of a data system unless protocols and mechanisms are in place to determine which data are used at any given time. Because the true picture of primary care access for populations must include more than one discipline and the data must be comparable, a common set of definitions and some form of coordination of the data collection should be high priority for workforce systems. Implementation The implementation of any form of registration and workforce analysis system can be very difficult and involves mixed and overlapping jurisdictions, uncertain statutory language, as well as working across professional boundaries where there are existing tensions. However, having a reliable system in place can provide the professionals, their associations, policy makers and the public, with a correct and continuous picture of the effects of policy decisions concerning the development of training programs, support and assistance programs. Having a regularized system in place also foregoes the expense of creating data through special surveys where response rates are low and the data soon out of date. Many states have implemented special workforce studies when there was a need to inform policy making only to have to recreate those special surveys some few years later to determine if the decisions they made had any effect. Thomas C. Ricketts, Ph.D. Assistance in Developing a Health Professions Data System A good overview of the issues related to health professions data at the state level can be found in: Data Systems to Support Health Personnel Planning and Policymaking: A Resource Guide for State Agencies, by Paul Wing and Edward S. Salsburg (Albany, NY: New York State Department of Health, 1992). The Georgia Board for Physician Workforce in cooperation with the Mercer University School of Medicine, Department of Community Science has created a comprehensive data collection and analysis system that includes a user-operated software package, "Physician Workforce for the 21st Century" that displays and analyzes physician workforce data for Georgia. The program generates tables, charts and maps making use of an inventory of all practicing Georgia physicians as of 1996. The Board has begun publishing a series of Resource Papers including: a physician profile; and analysis of physicians by specialty, a physician demographic summary, and an analysis of physician migration patterns. The Board is led by C. Dee Hanson, Executive Director (cdhanson@peachnet.campuscwix.net). with G. E. Alan Dever, Associate Dean for Primary Care and Director of the Community Science Program at the Mercer University School of Medicine leading the analysis team (dever.a@gain.mercer.edu). The Georgia Board for Physician Workforce can be contacted at: Two Northside 75, Suite 302; Atlanta, Georgia 30318-7701 Phone 404.352.6476; fax 404.352.6021. COMING IN FUTURE SRAP EVALUATION UPDATES Pipeline Data--What is the best way to develop and maintain a database that allows you to assess the success of your pipeline efforts. Evaluation Team E-Mail Addresses |