Physician Workforce: Physician Supply Increased in Metropolitan  
and Nonmetropolitan Areas but Geographic Disparities Persisted	 
(31-OCT-03, GAO-04-124).					 
                                                                 
Through a variety of programs, the federal government supports	 
the training of physicians and encourages physicians to work in  
underserved areas or pursue primary care specialties. GAO was	 
asked to provide information on the physician supply and the	 
generalist and specialist mix of that supply in the United States
and the changes in and geographic distribution of physician	 
supply in metropolitan and nonmetropolitan areas. To address	 
these objectives, GAO analyzed data on physician supply and	 
geographic distribution from 1991 and 2001.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-124 					        
    ACCNO:   A08808						        
  TITLE:     Physician Workforce: Physician Supply Increased in       
Metropolitan and Nonmetropolitan Areas but Geographic Disparities
Persisted							 
     DATE:   10/31/2003 
  SUBJECT:   Physicians 					 
	     Labor supply					 
	     Labor force					 
	     Labor statistics					 
	     Statistical data					 

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GAO-04-124

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

Highlights of GAO-04-124, a report to the Chairman, Committee on Health,
Education, Labor, and Pensions, U.S. Senate

Through a variety of programs, the federal government supports the
training of physicians and encourages physicians to work in underserved
areas or pursue primary care specialties. GAO was asked to provide
information on the physician supply and the generalist and specialist mix
of that supply in the United States and the changes in and geographic
distribution of physician supply in metropolitan and nonmetropolitan
areas. To address these objectives, GAO analyzed data on physician supply
and geographic distribution from 1991 and 2001.

October 2003

PHYSICIAN WORKFORCE

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

The U.S. physician population increased 26 percent, which was twice the
rate of total population growth, between 1991 and 2001. During this period
the average number of physicians per 100,000 people increased from 214 to
239 and the mix of generalists and specialists in the national physician
workforce remained about one-third generalists and two-thirds specialists.
Growth in physician supply per 100,000 people between 1991 and 2001 was
seen in historically high-supply metropolitan areas as well as low-supply
statewide nonmetropolitan areas.

Between 1991 and 2001, all statewide nonmetropolitan areas and 301 out of
the 318 metropolitan areas gained physicians per 100,000 people. Of those
17 metropolitan areas that experienced declines in the number of
physicians per 100,000 people, only 2 had fewer total physicians in 2001
than 1991. Overall, nonmetropolitan areas experienced higher proportional
growth in physicians per 100,000 people than metropolitan areas, but the
disparity in the supply of 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

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

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

                                       1

                                      2 3

                                       7

                                     10 15

Appendix I Scope and Methodology

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

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

Appendix IV 	Comments from the Health Resources and Services
Administration

Related GAO Products

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

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
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separately.

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

1Metropolitan 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.

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
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.

Results in Brief

2We counted active, nonfederal, patient-care physicians with a known
address.

3Generalists 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.

4T.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).

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
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

Background

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

5GMENAC, 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).

6For a complete list of COGME reports see the COGME Web site:
http://www.cogme.gov/rptmail.htm.

7E.S. Salsberg and G.J. Forte, "Trends in the Physician Workforce,
1980-2000," Health Affairs, vol. 21, no. 5 (2002).

8See 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).

9IOM, 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).

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

10Although 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.

11H.K. Rabinowitz and N. P. Paynter, "The Rural vs. Urban Practice
Decision," JAMA, vol. 287, no.1 (2002).

12H.J. Jiang and J.W. Begun, "Dynamics of Change in Local Physician
Supply: An Ecological Perspective," Social Science & Medicine, vol. 24
(2002).

(HPSAs).13 These Medicare Incentive Payments totaled $104 million in 14

2002.

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.

13The 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).

14The 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).

National Physician Supply Grew at Twice the Rate of the U.S. Population

The number of physicians in the United States increased about 26 percent,
from about 541,000 to about 681,000 from 1991 to 2001. Physician growth
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
States climbed 12 percent, from 214 in 1991 to 239 in 2001.15 The number
of 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 
                     Generalists           78          87 
                     Specialists          133         150 

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

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

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.

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.

Physician Supply Per 100,000 People Increased in Most Areas but Geographic
Disparities Persisted

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
number of physicians per 100,000 people from 1991 to 2001 and 301 of 318
metropolitan areas experienced an increase in physicians per 100,000
people. Overall, the nonmetropolitan areas had higher proportional growth
in physicians per 100,000 people than the metropolitan areas, but the
disparity in the supply of physicians per 100,000 people between the
metropolitan and nonmetropolitan areas persisted. Rates of growth in the
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 Physicians Per 100,000 People

The 48 statewide nonmetropolitan areas, including those with the lowest
supplies of physicians per 100,000 people in 1991, registered gains in
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.

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

16Other 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.

  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 
                            Yuma, Ariz. MSA     38         47             100 
                        Greeley, Colo. PMSA     38         45             136 
                      Raleigh-Durham-Chapel                       
                             Hill, N.C. MSA     33         38             398 
                         Denver, Colo. PMSA     27         29             265 
                          Tucson, Ariz. MSA     25         27             285 
                              Riverside-San                       
                    Bernardino, Calif. PMSA     18         24             138 
                        Modesto, Calif. MSA     17         21             144 
                         Merced, Calif. MSA     15         18             101 
                  Stockton-Lodi, Calif. MSA     13         21             134 
                           Miami, Fla. PMSA     13         16             303 
                           Reading, Pa. MSA     9          10             180 
                        Iowa City, Iowa MSA     5          14            1004 
                    Los Angeles-Long Beach,                       
                                Calif. PMSA     4          8              238 
                     Jersey City, N.J. PMSA     1          9              171 
                          Topeka, Kans. MSA     -1         4              252 
                            Enid, Okla. MSA     -4         1              212 

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
percentIncreases 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 inMetropolitan 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

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

Generalists 49 59

Specialists 49 63

Metropolitan

All physicians 242 267

Generalists 85 94

Specialists 154 171

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.

Rates of Growth in Physician Supply Differed Among Categories of
Nonmetropolitan and Metropolitan Counties

To obtain additional information about physician supply within
nonmetropolitan and metropolitan areas, we aggregated county physician and
population data into five categories defined by a county's nonmetropolitan
or metropolitan status and the presence and size of a town within the
county. All five county categories had an increase in 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.

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.

aLarge metropolitan areas have at least one million residents.

bSmall metropolitan areas have 50,000 to 999,999 residents.

cLarge towns have 10,000 to 49,999 residents.

dCounties without large towns include those with or without a town of
2,500 to 9,999 residents.

eRural counties have fewer than 2,500 residents.

Agency Comments 	We provided a draft of this report to HRSA for comment.
HRSA said that 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.

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

                       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,

1Data for 1991 were from
http://eire.census.gov/popest/data/counties/tables/CO-EST200112.php
(downloaded on July 3, 2003). Data for 2001 were from
http://eire.census.gov/popest/estimates_dataset.php (downloaded on March
13, 2003).

2Data 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).

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).

3For 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).

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.

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

2Title VII of the PHSA is classified to 42 U.S.C. S:S: 292 et seq.

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

Program FY 1991 FY 2001 Improving distribution of health professionals in
 underserved areas Increasing representation of minorities and individuals from
  disadvantaged backgrounds in health professions Increasing supply of health
 professionals Improving training for health professionals in geriatrics and in
                                 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 

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

Program expenditures or appropriationsa (in millions of dollars) Program
objectives

 Improving distribution of health professionals in underserved areas Increasing
 representation of minorities and individuals from disadvantaged backgrounds in
health professions Increasing supply of health professionals Improving training
 for health professionals in geriatrics and in public healthProgram FY 1991 FY
                                      2001

Scholarships, loans, and loan repayments to individuals in health
professions training Grants to institutions or individuals for health
professions education and 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                                                  

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                                            

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

Program expenditures or appropriationsa (in millions of dollars) Program
objectives

 Improving distribution of health professionals in underserved areas Increasing
 representation of minorities and individuals from disadvantaged backgrounds in
health professions Increasing supply of health professionals Improving training
 for health professionals in geriatrics and in public healthProgram FY 1991 FY
                                      2001

        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.

aFor Title III programs, expenditures are given. For Title VII programs,
appropriations are given.

bProgram provides support for medical students, residents, and physicians.

cLoan programs financed by revolving loan fund.

dThe Primary Care Loan Program replaced Health Professions Student Loan
Program in 1993 for allopathic and osteopathic medicine programs.

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

Physicians per 100,000 people

Generalists per 100,000 people

Specialists per 100,000 people

                      Areas 1991 2001 1991 2001 1991 2001

Alabama

Metropolitan Alabama 201 238 69 82 129

Nonmetropolitan Alabama 61 78 36 45 25

Alaska

Metropolitan Alaska 176 246 60 91 115

Nonmetropolitan Alaska 97 134 54 76 42

Arizona

Metropolitan Arizona 214 207 73 73 138

Nonmetropolitan Arizona 90 111 52 56 38

Arkansas

Metropolitan Arkansas 231 265 78 91 148

Nonmetropolitan Arkansas 85 101 48 55 35

California

Metropolitan California 225 229 78 83 144

Nonmetropolitan California 112 129 52 59 58

Colorado

                     Page 23 GAO-04-124 Physician Workforce
Metropolitan                    Nonmetropolitan                                       Metropolitan                        Nonmetropolitan                                    Metropolitan                       Nonmetropolitan                      District       Metropolitan                                       Metropolitan                       Nonmetropolitan                                  Metropolitan                                                          
  Colorado   231 240 81 85 147     Colorado     112 154 58 71 53 83 Connecticut       Connecticut  288 324 96 108 188 214   Connecticut   125 133 53 60 72 72 Delaware         Delaware   217 249 80 93 135 154    Delaware     153 194 53 66 99 128    of          District of  544 554 169 171 363 373 Florida         Florida    214 237 71 82 141 154     Florida     98 117 40 49 57 68 Georgia         Georgia    208 228 64 77 140 150 Nonmetropolitan 97 117 43 52 54 64
                                                                                                                                                                                                                                                     Columbia         Columbia                                                                                                                                                                    Georgia                     

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

Physicians per 100,000 people

Generalists per 100,000 people

Specialists per 100,000 people

                      Areas 1991 2001 1991 2001 1991 2001

Hawaii

Metropolitan Hawaii 252 284 91 101 154

Nonmetropolitan Hawaii 157 190 70 80 87

Idaho

Metropolitan Idaho 162 198 55 69 106

Nonmetropolitan Idaho 108 129 49 54 56

Illinois

Metropolitan Illinois 240 270 91 102 145

Nonmetropolitan Illinois 89 108 46 54 42

Indiana

Metropolitan Indiana 190 234 69 82 118

Nonmetropolitan Indiana 83 99 43 49 39

Iowa

Metropolitan Iowa 261 288 92 102 165

Nonmetropolitan Iowa 88 100 50 58 37

Kansas

                     Page 24 GAO-04-124 Physician Workforce
Metropolitan 253 278 88 100 162  Nonmetropolitan 93 114 54 61 38 53 Kentucky       Metropolitan 252 285 84 91 166 191 Nonmetropolitan 93 121 45 56 47 64 Louisiana       Metropolitan 226 283 65 86 157 194 Nonmetropolitan 68 78 39 43 28 34 Maine       Metropolitan 229 300 88 115 140 183 Nonmetropolitan 151 195 74 90 76 103 Maryland       Metropolitan 311 335 105 112 199 217 Nonmetropolitan 144 181 53 66 91 114 Massachusetts       Metropolitan  308 362 105 118 199 240 Nonmetropolitan 134 150 63 67 71 83 
Kansas                            Kansas                                          Kentucky                            Kentucky                                         Louisiana                            Louisiana                                     Maine                                 Maine                                            Maryland                              Maryland                                              Massachusetts                          Massachusetts                   

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

Physicians per 100,000 people

Generalists per 100,000 people

Specialists per 100,000 people

                      Areas 1991 2001 1991 2001 1991 2001

Michigan

Metropolitan Michigan 237 273 88 104 145

Nonmetropolitan Michigan 106 129 52 60 53

Minnesota

Metropolitan Minnesota 274 296 102 108 169

Nonmetropolitan Minnesota 91 114 58 70 31

Mississippi

Metropolitan Mississippi 224 261 73 76 148

Nonmetropolitan Mississippi 83 107 40 49 42

Missouri

Metropolitan Missouri 270 292 92 99 174

Nonmetropolitan Missouri 90 111 50 60 39

Montana

Metropolitan Montana 236 302 52 82 183

Nonmetropolitan Montana 124 157 63 73 59

Nebraska

        Metropolitan Nebraska        262    300     88    106    171   
       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 

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

Physicians per 100,000 people

Generalists per 100,000 people

Specialists per 100,000 people

                      Areas 1991 2001 1991 2001 1991 2001

North Carolina

Metropolitan North Carolina 221 257 73 86 145

Nonmetropolitan North Carolina 96 125 41 54 54

North Dakota

Metropolitan North Dakota 283 321 95 114 184

Nonmetropolitan North Dakota 100 124 55 67 43

Ohio

Metropolitan Ohio 239 274 87 101 149

Nonmetropolitan Ohio 92 114 44 57 47

Oklahoma

Metropolitan Oklahoma 220 236 79 87 138

Nonmetropolitan Oklahoma 87 96 50 54 36

Oregon

Metropolitan Oregon 234 249 82 92 150

Nonmetropolitan Oregon 128 156 58 70 69

Pennsylvania

       Metropolitan Pennsylvania      277    317    100    114    173   
     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 

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

Physicians per 100,000 people

Generalists per 100,000 people

Specialists per 100,000 people

                      Areas 1991 2001 1991 2001 1991 2001

Utah

Metropolitan Utah 203 208 64 70 137

Nonmetropolitan Utah 85 115 40 50 43

Vermont

Metropolitan Vermont 388 487 142 179 240

Nonmetropolitan Vermont 174 223 76 96 97

Virginia

Metropolitan Virginia 224 257 76 90 144

Nonmetropolitan Virginia 112 135 51 62 60

Washington

Metropolitan Washington 222 245 82 90 137

Nonmetropolitan Washington 128 152 63 73 63

West Virginia

Metropolitan West Virginia 214 273 78 106 133

Nonmetropolitan West Virginia 156 186 67 80 88

Wisconsin

Metropolitan Wisconsin 225 268 78 95 143

     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.

Appendix IV: Comments from the Health Resources and Services
Administration

Appendix IV: Comments from the Health Resources and Services
Administration

Appendix IV: Comments from the Health Resources and Services
Administration

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