Health Care Worker Deficits in Indiana

I recently became ill and tried to get an urgent appointment to my insurance assigned clinic. The scheduler told me they could squeeze me in, in three weeks. When I explained I was hoping for the next few days since I was in distress, I was told I could try to get a waiver to go to the emergency room. Not wanting to clog the already over-burdened Wishard ER, I offered to see anybody who was available, since I didn't have a preferred primary care physician. In fact, the last several times I have been to the clinic in the last 5 years, I have randomly seen whomever was available, including a nurse practitioner. Apparently now I was only able to see the exact physician I saw 2 years ago, whose first available appointment was in three weeks. After spending several hours on the phone complaining to every administrator I could find, I was finally given an appointment in 4 days (2 if you don't count the weekend).

This inspired me to investigate the geography of the physician shortage in the U.S. As a baseline, I looked at the international data about physician and nurse distribution. According to OECD data, the U.S. ranks 18th of top 20 OECD countries for number of physicians per 1,000 population (see Table 1). I obtained the physician and nursing data by averaging 2005-2010, and ranked countries by physician density.

TABLE 1: HEALTH CARE WORKERS BY COUNTRY (OECD)

Country	Rank	Physicians /1,000	Nurses /1,000
Austria	1	4.6	7.4
Norway	2	3.9	13.9
Switzerland	3	3.8	14.7
Spain	4	3.7	4.5
Sweden	5	3.6	10.9
Germany	6	3.5	10.5
Italy	7	3.4	6.2
Denmark	8	3.4	14.5
France	9	3.3	8.0
Israel	10	3.3	5.0
Ireland	11	2.9	12.7
Belgium	12	2.9	14.8
Australia	13	2.9	10.0
Netherlands	14	2.8	8.3
Luxembourg	15	2.7	11.0
Finland	16	2.7	9.4
UK	17	2.6	9.7
US	18	2.4	10.6
New Zealand	19	2.4	9.4
Canada	20	2.3	9.0

Then I examined the U.S. by state, since research indicates that physicians tend to congregate geographically unevenly, typically based on compensation rates, so there is likely to be greater physician density in some states, and greater physician deficit in other states. Similarly nursing and other non-MD health care professionals are not evenly distributed. I used American Community Survey data (2011, 3-year estimate) to obtain number of health care workers by state for three specific occupations: physicians, registered nurses, and "other health care diagnosing and treating practitioners." I divided these by the 2010 Census total population for each state. Additionally, I obtained the number of residents per state over the age of 60 years, presuming this population will tend to utilize health care services far more frequently than younger populations. I list the relevant data for each of these groups per state (Table 2).

Additionally, I ranked each state by an index formula based on these four populations. Using a Z-score for each state for each group, I added the health care workers, and subtracted the older population, creating a composite score indicating the accessibility of health care workers per population in each state. In the composite formula, it seemed that physician totals were the most important for general health care access, so doubled that number in the equation. Each state's ranking is listed in Table 2, from least available health care workers per state, to most, per population.

Indiana ranks 40th (Graph 1). A 2012 study by the Association of American Medical Colleges states that, for Indiana, "These already severe shortages are going to become even more prevalent when considering that the number of Indiana residents over age 65 will double between 2000 and 2030, the segment of the population that uses health care services the most." The study specifically identifies, as of 2007, a 5,000 physician shortage for Indiana alone.

As a check on my health care worker index, I used CDC death rates to generate a comparison for validity. I used two measures, CDC infant mortality rates from 2007-2008 by state (CDC Wonder), and death rates (age adjusted) for all causes from 1998-2010 by state (CDC Wonder). My health care worker index had a correlation of -0.46 with infant mortality, and -0.55 for all-age death rates (see Graph 2), indicating a reasonably strong relationship--as the density of health care workers increases, both infant mortality and death rates go down, and vice versa. The correlation with the composite index is greater than any of the individual measures.

GRAPH 1: PHYSICIAN DENSITY BY STATE

GRAPH 2: RATES OF DEATH VS HEALTH CARE WORKER INDEX (CDC, 1998-2010, ALL CAUSES, AGE ADJUSTED)

TABLE 2: HEALTH CARE WORKERS BY STATE

State	Rank	Physicians & surgeons /1,000	Registered nurses /1,000	Other health practitioners /1,000	60+ Population	Z-Index
Florida	50	2.5	8.6	2.7	23%	-1.96
Nevada	49	2.1	6.8	2.4	17%	-1.55
West Virginia	48	2.2	10	2.9	23%	-1.5
Arkansas	47	1.9	9.4	2.7	20%	-1.48
Oklahoma	46	2	7.9	2.6	19%	-1.43
Arizona	45	2.2	7.6	2.6	19%	-1.38
South Carolina	44	2.4	8.5	2.6	20%	-1.25
Alabama	43	2.1	9.7	2.7	19%	-1.12
Mississippi	41	2	9.5	2.6	18%	-1
New Mexico	41	2.3	7.4	2.8	19%	-1
Indiana	40	2.2	10	2.6	18%	-0.95
Idaho	38	1.9	7.1	3.1	17%	-0.67
Hawaii	38	2.7	7.1	3.1	20%	-0.67
Georgia	36	2.1	7.4	2.6	16%	-0.63
Louisiana	36	2.6	8.5	2.6	18%	-0.63
Texas	35	2.3	7.3	2.5	15%	-0.58
Delaware	34	2.9	11	2.6	20%	-0.47
Kentucky	33	2.6	10.2	2.8	19%	-0.45
Tennessee	32	2.7	9.1	2.9	19%	-0.38
Missouri	31	2.8	9.8	2.9	20%	-0.28
Oregon	30	3	7.5	3.1	20%	-0.25
Michigan	29	2.9	8.9	3	20%	-0.18
Illinois	27	2.8	9.1	2.7	18%	-0.16
Ohio	27	2.9	10.5	2.9	20%	-0.16
Maine	26	3.4	10.5	3	22%	-0.14
California	25	2.6	7.1	2.9	16%	-0.13
Virginia	24	2.7	8.2	3	18%	-0.1
Wyoming	23	1.3	7.4	3.6	16%	-0.09
Montana	22	2.4	9.8	3.4	21%	-0.02
Wisconsin	21	2.4	10.2	3.2	19%	0.01
North Carolina	20	2.7	9.1	3.1	19%	0.07
Iowa	18	2.1	11.2	3.6	20%	0.14
Kansas	18	2.7	10.4	2.9	18%	0.14
Utah	17	2.2	6.6	2.8	13%	0.36
South Dakota	16	2.2	11.6	3.4	19%	0.45
Pennsylvania	15	3.5	10.7	3.4	21%	0.67
New Jersey	14	3.4	8.9	3.2	19%	0.69
New Hampshire	13	2.9	12.1	3.3	19%	0.75
North Dakota	12	2	11.3	3.7	19%	0.76
Rhode Island	11	4	10.3	2.9	20%	0.79
Washington	10	2.9	8.5	3.5	18%	0.92
Connecticut	9	3.9	10.2	3.3	20%	1.2
Minnesota	8	3.1	10.7	3.5	18%	1.28
New York	7	4	9	3.4	19%	1.31
Colorado	6	2.8	8.3	3.7	16%	1.39
Nebraska	5	2.7	10.7	3.8	18%	1.41
Maryland	4	4	9.9	3.2	18%	1.64
Massachusetts	3	4.3	11	3.3	19%	1.77
Vermont	2	3.3	11	4	20%	1.85
Alaska	1	2.5	8.7	3.2	10%	1.98