V. Health Manpower and Health Services Inventory

The purpose of this section is to identify the available health care providers and health care facilities that are located in Humboldt and Del Norte Counties and to assess the adequacy of these providers and facilities in meeting the area’s needs.

A. Health Provider Supply

Assuring an adequate supply of physicians is important for ensuring a community’s health and economic well-being. Physicians are at the center of the health care delivery system. They provide ambulatory services in their offices and clinics. Hospitals are structured around the availability of physicians. Patients in long-term care facilities require the involvement of a physician. Home health services and rehabilitation services are all initiated under the direction of physicians. Along the continuum of health care services, the physician is the individual responsible for ensuring accessible, comprehensive and coordinated care.

To evaluate the supply of physicians in Humboldt and Del Norte Counties, the number of physicians practicing by specialty was identified by using four different data sources: The AMA Directory of Physicians (1996), the Humboldt/Del Norte County Medical Society’s 1997-98 Membership Directory, the California Department of Consumer Affairs (licensing board) and the local Yellow Pages. The Medical Society was helpful in resolving any discrepancies between data sources, particularly since there is a lag time between the publication of physician locations by other organizations. At the time this listing was compiled in the summer of 1997, 111 primary care physicians and 177 specialists were identified in the two counties. For purposes of this report, primary care physicians included family physicians, general practitioners, general medicine internists, and general pediatricians. Thus, 38.5% of all physicians in the region are primary care providers.

One limitation to this way of collecting data is that the number of physicians who practice only part-time are not identified. Anecdotally, we have been told that some physicians, when moving to the area, have made lifestyle choices not to practice full-time. Without conducting a specific survey of area physicians, there is no easy way of assessing the degree to which such choices have an impact on local physician numbers.

In Table 5.1, on the following page, the Humboldt/Del Norte ratio of physicians per 100,000 is compared to the current U.S. supply. The U.S. ratio includes physicians in all locations, both urban and rural, and in all kinds of practice arrangements (fee-for-service private practices, HMOs, community clinics, etc.) but excludes physicians in the military or resident physicians. When compared to the U.S., Humboldt/Del Norte has slightly more primary care physicians than in the U.S. (70.1 per 100,000 compared to 65.7 per 100,000) and slightly fewer specialists (112.2 per 100,000 in Humboldt and Del Norte compared to 114.4 per 100,000 in the U.S.) However, the total number of physicians is nearly identical to the U.S. average (181.9 per 100,000 vs. 180.1 per 100,000).

To respond to the demand for physician services, many rural areas have arranged for specialists from larger urban areas to visit the rural area routinely to provide care (i.e., once or twice a month). No evidence was found that this was occurring to any degree in the Humboldt/Del Norte region. For this reason, the second column in Table 5.1 is left blank.

Managed care is changing the pattern of need for physicians in many areas of the United States. Expansion of managed care is particularly accelerated in many of the urban areas of California and is gradually expanding into rural areas, including Humboldt and Del Norte Counties. Table 5.2, on page 35, is provided to give a perspective of physician need requirements in a managed care environment. The information for developing this table was heavily drawn from two articles: "Forecasting the Effects of Health Reform on US Physician Workforce Requirements" by Jonathan Weiner, DrPH, (JAMA, 1994)⁷ and "Physician Resource Planning must keep pace with Evolving Markets" by Lohkamp and Simmons, (Health Care Strategic Manager, 1995).⁸ Both of these studies, which can be found in the appendices, provided information on physician staffing ratios used by a variety of health maintenance organizations and integrated delivery systems.

Table 5.2, provides a range of physician ratios under the headings "Average," "Moderate" and "Maximum" Rate. These are defined as follows:

"Average"	Developed by averaging the rates reported in ten different studies of HMO physician staffing averages, by specialty (Lohkamp and Simmons).
"Moderate"	Developed for integrated networks such as an IPA, Network HMOs, Point of Service Plans, etc. (Weiner)
"Maximum"	Represents the rates developed for Staff/Group model HMOs. (Weiner)

In each of these scenarios, primary care physicians represented approximately 40-45% of all physicians. The final columns of this table compare current Humboldt/Del Norte ratios of physicians and the variance by specialty when compared to the Average Rate.

Comments on Specific Area Variances:

• Primary Care Physicians: Of the 111 physicians identified as primary care physicians, eleven work in a public health setting which would not be involved in a managed care plan. These physicians included two who worked for the Public Health Department, four who worked for Student Health at Humboldt State University, and five who worked at Pelican Bay Prison. If these numbers are deducted from the total, it reduces the number of primary care physicians to 100, and the ratio of physicians to 100,000 population to 63.2.
• Psychiatrists: Of the eighteen psychiatrists identified in the region, six were identified as working in public settings. One worked at Pelican Bay Prison and five worked for a County Mental Health Department. If these numbers are deducted, it reduces the number of psychiatrists to 12 and the ratio of psychiatrists to 100,000 population to 7.6.
• Surgeons: When comparing the various types of surgeons in Table 5.1, by individual specialty, there are significantly fewer general surgeons and more orthopedic surgeons and cardiothoracic surgeons in Humboldt/Del Norte than in the U.S. When these numbers are averaged together, we find that there are 19.0 surgeons per 100,000 population in the Humboldt/Del Norte region compared with 18.0 per 100,000 of these three surgical specialists in the U.S. Given the training of these specialists and the few numbers of general surgeons in the region, we assume that these specialists’ practices include additional general surgery cases. Comparing the local ratio, 19.0 per 100,000, with the averaged rate for managed care plans reveals that the average managed care plan utilized 11.0 of these three surgical specialists, for a variance of 8.0 per 100,000. This is illustrated in Table 5.2.

Additional Adjustments to Managed Care Ratios: In reality, health care is a local product and variations may result in different physician practice patterns. While such models are a useful tool in helping to conceptualize and plan for a new model of managed care organization, additional local adjustments should be factored into this model. Such adjustments include:

• Adjusting for Demographics: Populations of differing age/gender composition as compared to HMOs can be expected to require different amounts of health care resources and staffing levels. For example, Medicare patients are known to require a higher utilization of services. With HMOs known to enroll a generally younger population and the fact that Humboldt/Del Norte Counties have a significant elderly population, such adjustment would be important.
• Adjusting for MediCal and Uninsured Populations: Experience from HMOs indicate that MediCal patients receive more ambulatory care and hospitalizations than other enrollees of similar age. Various studies indicate that persons without insurance have greater needs than those who are insured, even though their actual use is significantly less.
• Adjusting for Out-of-Plan Use: These are services which members seek outside of the HMO, for a variety of reasons. Thus, a patient’s true resource requirements may be underestimated if these are not accounted for.

Other limitations include the fact that the majority of physician manpower studies, including the ones cited here, involved predominantly large (over 100,000 enrollees) staff or group model HMOs based in urban settings. How staffing patterns would necessarily change in a rural environment such as Humboldt/Del Norte Counties with a smaller population base and using an integrated network model, is unknown. In fact, Thomas Dial et al, in the article "Clinical Staffing in Staff- and Group-Model HMOs" (Health Affairs, Summer 1995, 168-180) found in a survey of 106 HMOs nationwide that there was far greater variability in physician staffing patterns for HMOs with below 80,000 enrollees than in HMOs with larger enrollments.

Ratio of Primary Care Physicians to Age-Adjusted Population: Some planners argue that the need for primary care physicians should incorporate an age-adjustment for the population 65 years old and older, due to higher utilization rates. In the report, "Managed Medicare and Medicaid, Benchmarks PMPM Rates, Utilization Data, Model Programs" (National Health Information, LLC), an adjustment by a factor of three is recommended. This revision of the primary care physician to population ratio is calculated in Table 5.3.

Utilization of Mid-Level Practitioners: Many rural areas have been successful in recruiting mid-level practitioners to supplement patient care services. Although the education, licensure, and regulation of nurse practitioners and physician assistants differ, many have similar job descriptions. They diagnose illness, perform physical exams, order and interpret laboratory tests, establish and carry out treatment plans, suture wounds, and provide preventive health services. Physicians Assistants and Nurse Practitioners practice under the supervision of a physician and within defined protocols. In Humboldt/Del Norte County, 34 Physicians Assistants and 51 Nurse Practitioners were identified, for a total of 85. This equates to a ratio of 53.7 per 100,000 population compared to 19.6 per 100,000 in the U.S. population. It appears that at least 40% of these providers work in a community clinic or public health setting. A survey is currently being conducted to identify the practice specialty of each mid-level provider (primary care vs. specialty care) and the percentage of time each individual works. This information will allow for a more precise understanding of the extent these health care providers contribute to the health manpower pool in the Humboldt/Del Norte region.

Certified nurse midwives are registered nurses with advanced education in the provision of prenatal, perinatal, post-partum, newborn and routine gynecologic care. They also practice under the supervision of an appropriately trained physician. A total of 18 certified nurse midwives were identified in the Humboldt/Del Norte area.

Table 5.4 recalculates the need for primary care physicians, taking the impact of these mid-level practitioners into account. For purposes of this table, the productivity of one mid-level practitioner has been equated to a 0.50 full-time equivalent (FTE) physician.⁹ No adjustments were made to account for mid-level practitioners who do not work in primary care, work only part-time and/or work in a public setting. Thus, the estimates are assumed to overestimate the impact of these providers; however, the degree to which this occurs is unknown. Certified Nurse Midwives are not included in this table since the majority of their care is focused on obstetrical issues.

The utilization of mid-level practitioners varies widely in HMOs across the country. Some HMOs utilize mid-level providers extensively; some barely at all. With increasing pressure on health care providers to control costs, health care delivery organizations have a strong incentive to find the most efficient combination of health care individuals to provide care to patients. The degree to which mid-levels are utilized in Humboldt/Del Norte will have to be a local decision.

Findings

While there appears to be a relative consensus in the medical literature about the method of estimating current physician supply, there is no similar agreement as to the best way to project physician requirements in the future. However, many health planners acknowledge that workforce planning must be a local undertaking which makes adjustments to different models by factoring in the many complex, regional issues of the particular health care market under study. Thus, acknowledging the various limitations of the managed care model presented here, we believe the comparison of local physician supply to this managed care model can serve as a useful framework in advancing the local discussion regarding future provider manpower requirements in a managed care setting.

The most striking finding of the overall physician supply data is the large number of physicians who are currently in practice in the Humboldt/Del Norte area. This rural area is fortunate to have so many physicians, including a wide range of specialists. The overall ratio of physicians to population is 182.0 per 100,000. In contrast, a large number of rural areas are faced with severe problems of under-supply, creating serious access problems for local residents. The average ratio of all physicians in practice in non-metropolitan areas of the U.S. is approximately 80.0 per 100,000, significantly below the average in Humboldt/Del Norte.

When comparing the total numbers of all physicians per 100,000 in Humboldt/Del Norte counties to the average rate for managed care plans, Table 5.2 showed there was a variance of 63.6 more physicians in Humboldt/Del Norte. In order to better understand this variance, it is necessary to evaluate the various components of this model. They are broken down into four components: Primary Care, Medical Specialties, Surgical Specialties and Hospital-Based Specialties. Note: When discussing the variance, keep in mind that the physician numbers are a rate per 100,000.

Variance in Primary Care Specialties: The average rate in the managed care model for primary care physicians is 48.0 compared to the current supply of 70.1 in the Humboldt/Del Norte region, a variance of 22.1 physicians. This accounts for 35% of the variance found in the total physician variance. When the numbers of primary care physicians who are practicing in public health settings are taken out, the ratio drops to 63.2, with a variance of 15.2. When the population was adjusted by age to factor in the additional utilization of services by elderly persons, the ratio dropped even lower to 56.3. This amount falls within the range of rates displayed in the managed care Table 5.2.

Distribution of the primary care physicians over the large geographic two county area was examined to discern any local variations. While the Humboldt Bay area did have a slightly higher concentration of primary care physicians to population than the rest of the region (58% of the physicians vs. 48% of the population), it was not felt to be excessive. Furthermore, no area in the region was found to have a shortage of primary care physicians as defined by federal or state standards. Given the large, rural and isolated nature of the area, potential variance from managed care ratios could be considered necessary. Thus, the rate of primary care physicians in the Humboldt/Del Norte region is considered "adequate."

The issue of the large numbers of mid-level practitioners adds a degree of complexity to the primary care manpower projections for the area. Sekscenski, et al ["State Practice Environments and the Supply of Physician Assistant, Nurse Practitioners, and Certified Nurse-Midwives", New England Journal of Medicine, (1994) 331:19, 1266-1271] found that 44% of physician assistants and 75% of nurse practitioners nationally worked in primary care specialties. Until such figures are developed locally, when these national percentages are applied to local numbers, it is estimated that there are 13.6 Physician’s Assistants (PAs) and 38.2 Nurse Practitioners (NPs) working in primary care settings in the region. If a 0.5 FTE is applied to these numbers, there is the equivalent of an additional 25.9 FTE primary care providers in the Humboldt/Del Norte region. Again, this number could be modified when additional information on the extent these providers are working full-time is gathered. It is noted that a significant number of these NPs and PAs are practicing in area community clinics, public health departments, Planned Parenthood, etc.

In spite of the many adjustments that should be made for local needs, when primary care physician and mid-level practitioners numbers are combined, it appears that there are "more than adequate" numbers of primary care providers for a managed care environment in the region (as compared to the Longshore-Simmons model).

Variance in Medical Specialties: The average rate in the managed care model for medical specialists is 17.6 compared to the current supply of 26.7 in the Humboldt/Del Norte region, a variance of 9.1 physicians. This accounts for 14% of the total physician variance found. The largest single variance found was in the specialty of psychiatry (11.4 vs. 4.1, variance 7.3). When the psychiatrists who are practicing in public settings are withdrawn, the ratio drops to 7.6, and the variance for psychiatrists is reduced to 3.5. The overall medical specialist variance decreases to 5.3 FTE. Again, given the geographic characteristics of this region, the number of medical specialties appears to be "adequate" for a managed care environment.

Variance in Surgical Specialties: The average rate in the managed care model for surgical specialties is 32.8 compared to the current supply of 43.1 with a variance of 10.3. This accounts for 16.3% of the total physician variance.

Obstetricians/Gynecologists (OB/GYN) Variance: There are 2.1 FTE fewer per 100,000 in the region than in the average managed care rate. With a total of 13 OB/GYNs in the region and 1882 births in 1995, this averages 144 births per OB/GYN per year, which is about average. In addition, the presence of 18 certified nurse midwives in the region provides additional low-risk obstetrical provider capacity for area residents. Again, there is no current information as to whether or not these midwives work full-time: considerable anecdotal evidence suggests that a large number work part-time. As a result, no precise FTE equivalent can be suggested. However, midwifery services should not be considered an exact replication of physician-provided obstetrical services. Midwifery provides a birthing experience that is quite different from the medical model, often spending more time with the laboring patient on average and managing labor through non-technical or natural means than do physician providers. The presence of so many certified nurse midwives suggests local support and demand for such services. As a result, it appears that there is an "adequate," and potentially "more than adequate" supply of obstetrical providers in the area for a managed care environment.

Variance in Other Surgical Specialties: When OB/GYNs are deducted from both the average managed care rates and the local rates, the rate for all other surgical specialties drops to 22.5 per 100,000 and the local rate drops to 34.9, with a variance increasing to 12.4. The surgical specialties which showed the largest variance above the average are cardiothoracic surgeons (6.5), orthopedic surgeons (5.9) and ophthalmologists (2.3). General surgeons had a variance of 4.4 below the average rate. While it is assumed that much of the general surgical patient load is picked up by the other surgical specialists, a greater variance still exists. As a result, it appears that there is a "more than adequate" supply of surgical specialists in the Humboldt/Del Norte area for a managed care environment.

Variance in Hospital-Based Specialties: With the exception of emergency physicians, hospital-based specialty physicians do not initiate patient care services themselves; rather their services are requested as needed by other physicians. Pathologists and radiologists in particular have little patient contact. Thus, these specialities have limited ability to authorize additional services or care.

For hospital-based specialties, the average rate in the managed care model is 19.7 compared to the current supply of 41.8 in Humboldt/Del Norte Counties, with a variance of 22.1. This accounts for 35% of the total physician variance. In the Humboldt/Del Norte area, there are three times the number of emergency physicians per 100,000 compared to the average managed care ratio (15.2 vs. 5.4), and twice the number of anesthesiologists (10.7 vs. 5.5). These numbers most likely are over counted as it is not uncommon for emergency physicians to have contracts for hospital coverage in areas other than where they live. Anesthesiologists, pathologists, and radiologists may or may not be contract physicians, but their services are utilized as needed. Thus, for purposes of envisioning a managed care environment for the region, there appears to be a "more than adequate" number of these specialities in the area.

Final Thoughts: Physician workforce planning for the future is a complex local process that must incorporate many local variables including rural geography, population demographics, physician dispersion, higher utilization rates for special populations, the impact of an integrated physician network vs. the managed care model presented here, information on percentage time worked by provider type and decisions regarding utilization of mid-level practitioners, to name just a few. While the apparent "adequate" or "more than adequate" supply of many types of physicians and mid-level practitioners in the Humboldt/Del Norte area offers its own planning challenges, it also offers the opportunity for the community to focus its goal on providing high quality, cost-efficient care to its residents.

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