V. Health Manpower and Health Services Inventory

The purpose of this next section is to identify the available health care providers and health care facilities that are located in Imperial County. In numerous instances, it appears that Imperial County has an under-supply of manpower or health care facilities for its population, when compared to California or U.S. ratios or standards. However, hospital utilization data which is presented in Section VI, Utilization of Services shows that many residents are leaving Imperial County to go to other California counties or Arizona for hospitalization. Based on the results of the Imperial County Employers' Health Benefits Survey (Section VIII) as well as anecdotal comments, many Imperial residents travel across the border to seek care in Mexicali. Factors encouraging this pattern most likely include health care coverage by a Mexican Preferred Provider Organization, lower cost, easier access to prescription drugs, or fewer cultural barriers to care. The extent to which Imperial residents seek health care services in Mexicali is unknown but it is likely significant. Therefore, the following data must be viewed from the perspective that it captures only a portion of the larger health care environment in the Imperial Valley.

A. Health Provider Supply

An adequate supply of physicians is an important factor 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.

The lack of adequate access to health care services locally can have an impact on the health of a community. Researchers are just beginning to analyze the relationship between physician supply and health status outcomes for a population. Nesbitt et al (1990) examined how the supply of obstetric providers in rural areas affects birth outcomes. These authors found that in rural areas with few obstetrics providers, women had to travel further from home to deliver their babies and their newborns were more likely to experience medical complications. Limited access can also have an impact on early intervention and treatment, often delaying care until a patient’s condition is more serious.

To evaluate the supply of physicians in Imperial County, the number of physicians practicing in Imperial by specialty was identified by six different data sources:

• List of physicians with medical staff privileges at Pioneers Hospital
• List of physicians with medical staff privileges at El Centro Regional Medical Center
• AMA Masterfile of Physicians, 1996
• List of physician members of the Imperial County Medical Society,
• Physician licensing information from the California Department of Consumer Affairs,
• Physician listings in the Imperial County Yellow Pages.

When a physician was identified by only one or two of the sources listed above, attempts were made to call the physician’s practice in Imperial County for verification. There is the perception that a significant number of specialists come to Imperial County on a part-time basis. Since, specialists on staff at the local hospitals with consulting or courtesy privileges were called to verify the percentage of time they spend seeing patients in Imperial County. One day a week was calculated as 0.20 FTE.

At the time this listing was finalized in April 1998, a total of 142 physicians were identified in practice in Imperial County. Of this number, 33 were identified as Primary Care Physicians for a total of 32.4 FTE physicians. Primary Care Physicians include Family Physicians, General Practice Physicians, General Medicine Internists, and Pediatricians. In addition, 109 Specialists were identified as practicing in Imperial County for a total of 78.05 FTE physicians. Of this number, 70 were identified as practicing full-time in Imperial County and 39 were identified as practicing part-time. For purposes of this report, if a physician identified a subspeciality, he was counted by that subspeciality to provide an overview of the scope of speciality services available locally.

In Table 5.1, The Imperial County ratio of physicians per 100,000 is compared to the current U.S. supply. While the use of the U.S. ratio is not meant to infer that it is the ideal ratio in terms of "need" or "demand" for physicians, it is one way of putting the Imperial physician ratios in context. The U.S. ratio includes physicians in all kinds of practice arrangements but excludes physicians in the military or resident physicians. When compared to the U.S., Imperial County has significantly fewer primary care physicians per 100,000 (42.5 per 100,000 fewer) and fewer specialists (57.7 per 100,000 fewer.)

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 Imperial County. Table 5.2 is provided to give a perspective of physician need requirements in a managed care environment. The methodology for developing this table was heavily drawn from two articles: "Forecasting the Effects of Health Reform on US Physician Workforce Requirement" by Jonathan Weiner, DrPH, (JAMA, 1994) and "Physician Resource Planning must keep pace with Evolving Markets" by Lohkamp and Simmons, (Health Care Strategic Manager, 1995). Both of these studies provided information on physician staffing ratios used by a variety of health maintenance organizations and integrated delivery systems. The table provides a range of physician ratios under the headings "Average," "Moderate" and "Maximum" Rate. These are defined as follows:

In each of these scenarios, primary care physicians represent approximately 40-45% of all physicians. The final columns of this table compares current Imperial County ratios of physicians and the variance by specialty when compared to the Average Rate.

In reality, health care is a local product and variations in a community may result in different physician staffing 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 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.
• Adjusting for MediCal and Uninsured Populations: Experience from HMOs indicate that MediCal patients receive more ambulatory care and hospitalizations than other enrollees of the same 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 or the service area, for a variety of reasons.

Other limitations include the fact that these studies were of 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 Imperial County with a smaller population base using an integrated network model is unknown.

Health Manpower Conclusions

Given the implied imprecision of using such models, what, if any conclusions can be drawn regarding the adequacy of physician supply in Imperial County? The single most significant factor that emerges from these comparisons is the apparent shortage of primary care physicians in Imperial County. By federal standards, a rationally-defined geographic area can be declared as having a shortage of primary care health manpower if the ratio of primary care physicians to population is greater than 1:3,500. Our calculations indicate that the current ratio of primary care physicians to population is 1:4,251. Others argue that the need for primary care physicians should incorporate an age-adjustment for the population 65 years old and older. In the report, "Managed Medicare and Medicaid, Benchmarks PMPM Rates, Utilization Data, Model Programs" by National Health Information, LLC, an adjustment factor of three is recommended. This revision of the physician to population ratio is calculated in Table 5.3.

Many rural areas that experience difficulty in recruiting primary care physicians have pursued the strategy of utilizing mid-level practitioners to supplement patient care services. Physician Assistants, Nurse Practitioners and Certified Nurse Midwives practice under the supervision of a physician and within defined protocols. In Imperial County, a total of 8 Physician Assistants, 12 Nurse Practitioners and 1 Certified Nurse Midwife (Total: 20) were identified. Various studies of NP and PA productivity indicate that the substitution ratio of PAs and NPs for physicians is roughly 0.5. (Scheffler et al, 1996). Table 5.4 recalculates the need for primary care physicians, taking the impact of these mid-level practitioners into account.

Even when mid-level practitioners are included in the formula, Imperial County still appears to have a significant under-supply of Primary Care providers. Currently Primary Care Physicians comprise only 29% of all physicians in Imperial County, well below the 40-50% average in most HMOs. As Primary Care Physicians are utilized by most managed care plans as the "gatekeeper" to other services, any future development of managed care offerings in Imperial County will be hindered by this lack of primary care providers.

With regards to adequacy of specialty physicians, the data also appear to reveal a lack of specialty physicians. Not only is the ratio of specialists to population in Imperial County significantly below current national ratios, when compared to various models for integrated health systems, the data also suggests an overall shortage of specialists. Furthermore, when viewed as part of a larger system, the apparent shortage of primary care physicians may mean that area specialists are also providing more primary care services to their patients, further reducing their availability as specialists.

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