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Economic

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Rural

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Report

Number 46

Physicians in

Nonmetro Areas

During the Seventies

Mary C. Ahearn

Michelle D. Fryar t/>:.:;

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Physicians in Nonmetro Areas During the Seventies, by Mary C. Ahearn and

Michelle D. Fryar. Economic Development Division, Economic Research

Service, U.S. Department of Agriculture. Rural Development Research Report

No. 46.

Abstract

The gap between number of physicians in nonmetro and metro areas widened

during the seventies, with nonmetro areas lagging by almost 100 physicians per

100,000 population, Nonmetro areas had more general practitioners and fewer

specialists per 100,000 population than did metro areas. While the number of

physicians in all nonmetro areas rose, the rate of increase was slower than in

metro areas, except in urbanized nonmetro areas not adjacent to a standard

metropolitan statistical area (SMSA). The number of office-based general practitioners per 100,000 population fell while the number of office-based specialists

rose in all regions and for all residential categories.

Keywords: Rural health, physicians, nonmetro area

Washington, D.C. 20250 March 1985
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Acknowledgments

The authors thank Tom Carlin, Bernai Green, Sam Cordes, David Brown, Bob

Hoppe, and John Love for their comments and suggestions and Sharon Black for

her typing assistance.
Contents

Page

Summary vi

Glossary—Residential Classification Scheme of Counties and Regional

U.S. Map vi

Introduction 1

Background 1

Data and Concepts .... 2

Trends in Physician Location 2

Total Physicians 2

Hospital-Based Physicians , 3

Office-Based Physicians 3

Regional Trends 5

Physicians in Low-Income Areas 5

Why Do Physician Location Trends Differ Among Areas? 7

Summary of Regression Results 7

Conclusions 7

References 8

Appendix Tables: Residential Distribution of Physicians-Population,

by Region 10

Appendix: Regression Results of the Distribution of General Practitioners

and Specialists, by Region 16
Summary

The gap between the number of physicians in nonmetro and metro areas widened during the seventies, with nonmetro areas lagging by almost 100 physicians

per 100,000 people in 1979. This report analyzes changes in the per capita

distribution in nonmetro areas during the seventies. Major findings include:

• Nonmetro areas had more general practitioners and fewer specialists per

100,000 population than metro areas.

• While the number of physicians per 100,000 population rose in all

nonmetro areas during the seventies, the rate of increase was slower than

in metro areas, except for urbanized nonmetro areas not adjacent to a

standard metropolitan statistical area (SMSA).

• The number of office-based general practitioners per 100,000 population

fell, while the number of office-based specialists per 100,000 population

rose in all regions and for all residential categories.

• Distribution of physicians in nonmetro areas varied widely among regions.

Nonmetro areas in the Northeast had the most physicians per 100,000

population in 1979 (106), while the South had the fewest (71).

• Availability of hospital resources had the strongest impact on patterns of

physician location.

• Nonmetro persistent low-income areas had 38 physicians per 100,000

population in 1979, compared with 82 in other nonmetro areas. This gap

widened during the seventies.

® Both the increase in the national supply of physicians and the increase in

Federal programs of the last two decades have contributed to the increase

in the number of physicians in nonmetro areas.

Glossary—Residential Classification Scheme of Counties

This classification system is based on the metro-nonmetro county delineation announced in 1973 based on the results of the 1970 Census of Population.

Conf/guoüs—Geographic contiguity at more than a single point or corner and

where at least 1 percent of the labor force commutes to the metro central

county for work.

Urban—Place or township, incorporated or unincorporated, of 2,500 or more

population.
Metropolitan counties—Counties classified as Standard Metropolitan Statistical

Areas (SMSA's) are defined as counties or groups of counties with at least one

city of 50,000 residents or more, or twin cities with a combined population of

at least 50,000. Contiguous counties are included in an SMSA if, according to

a set criteria, they are socially and economically integrated with the central

city.

Nonmetropolitah counf/es—Counties not classified as SMSA's.

urban/zed—Counties with 20,000 or more urban residents.

Adjacent to 5MSA—Counties contiguous to an SMSA with 20,000 or more

urban residents.

Not adjacent to SMSA—Counties not contiguous to an SMSA with 20,000 or

more urban residents.

Less urban/zed—Counties with 2,500-19,999 urban residents.

Adjacent to SMSA—Counties contiguous to an SMSA with 2,500-19,999

urban residents.

Not adjacent to SMSA—Counties not contiguous to an SMSA with 2,500-

19,999 urban residents.

Thinly populated—Counties with fewer than 2,500 urban residents.

Adjacent to SMSA—Counties contiguous to an SMSA with fewer than 2,500

urban residents.

Not adjacent to SMSA—Counties not contiguous to an SMSA with fewer than

2,500 urban residents.

Regional Classification Scheme

Hawaii in West Region.

Alaska data not available

VII
Physicians in Nonmetro Areas During the

Seventies

Mary C. Ahearn and Michelle D. Fryar^

Introduction

Adequate medical care is important in maintaining the

productivity of the labor force and enhancing the wellbeing of society. This fact was recognized in the Rural

Development Policy Act of 1980, charging the Secretary of Agriculture to develop a comprehensive rural

development strategy to improve rural health care

services {24).'^ Maintaining an adequate supply of

physicians is particularly important. Physicians act as

the gatekeepers to our medical delivery system,

although the demand for physician services is derived

from the demand for medical and institutional services,

A patient cannot get private hospital care, ambulatory

care, nursing care, or medication without the

authorization of a physician.

This study describes the availability of physicians in

nonmetro areas during 1970-79 in light of the changes

in population, supply of physicians, and demand for

medical care over that decade. Physician availability in

chronically low-income areas, which have been important target areas for many economic and social programs, is emphasized through description and analysis

of physician distribution patterns.

Background

The lack of medical care, particularly physicians, in

nonmetropolitan areas has long been a matter of concern and study (7, 76, 20).^' ^ As of 1970, there were 67

^Agricultural economist, National Economics Division, Economic

Research Service, U.S. Department of Agriculture; and formerly

sociologist, Economic Development Division, Economic Research

Service, U.S. Department of Agriculture.

Mtalicized numbers in parentheses refer to references listed at the

end of this report.

^Nonmetro areas are defined as those counties not designated

SMSAs. Alaska was omitted because of data availability considerations.

^See Roemer for an historical account (23).

physicians per 100,000 population in nonmetro areas,

compared with 143 per 100,000 population in metro

areas."^

The demand for physician services in nonmetro areas

remained high and may have grown during the seventies. Nonmetro people experience poorer health than

metro people. They suffer from more numerous

chronic conditions and have higher maternal and infant mortality rates than their urban counterparts (70,

77). Growth of the nonmetro population was a major

factor in increasing the demand for medical services.

As the seventies progressed, population growth in

nonmetro areas exceeded that in metro areas. The

general rural-to-urban migration of the previous

decades had begun to reverse; nonmetro counties experienced a 15.8-percent increase in population during

1970-80, compared with 9.8 percent in metro areas

(3). Retirement, urban flight, resort activities, energy

developments, and economic decentralization were

thought to be the important sources of this growth (3,

4). Many of the new residents—the elderly and the

well-educated, for example—were those who had

traditionally been frequent users of medical care.

Population growth in nonmetro areas was accompanied by important changes to the medical care

delivery system which affected patterns of physician

location. First, the number of the Nation's physicians

increased by 34 percent during the seventies, compared with about a 10-percent increase in total U.S.

population. The increase in the number of physicians

has been so remarkable that some researchers feel an

oversupply currently exists (72). This has led to an increase in the incentives for physicians to relocate in

underserved nonmetro areas to develop a full-time

practice.

^Physicians are defined as active, non-Federal physicians in patient

care. Office and hospital-based physicians, including residents, are

included but doctors of osteopathy are not.
Mary C. Ahearn and Michelle D. Fryar

Second, demand for medical care has increased and

has affected physician location patterns. The establishment of the publicly funded medical finance programs

in 1965 for the aged and poor/Medicare and Medicaid, respectively, has also affected physician location

patterns. These programs covered over 21 percent of

ail personal health care expenditures in 1979. Thus,

the elderly, and especially the poor, have access to

medical care which otherwise would be unavailable to

them.

Data and Concepts

Data on the distribution of U.S. physicians is presented

by physician specialty and geographic location. Physicians are defined as physicians actively engaged in patient care and not employed by the Federal Government. They are divided into two major categories:

office-based physicians by specialty, and hospital-based

physicians. This report describes and analyzes changes

in the residential and regional distribution of the physician categories during 1970-79 using the latest set of

years for which data are available.^

Although some data are reported as the total number

of physicians, most data are reported as the ratio of

the number of the physicians per 100,000 population.

The physician-population ratio is calculated on an aggregate basis for regional and residential categories.

The ratio is the primary instrument used to measure

the availability of medical care. The ratio standardizes

for population size and is thus useful in making comparisons across areas of different population size.

There are two major limitations, however, in using the

physician-population ratio for measuring the availability of physicians. First, it does not give a precise

measure of availability. For example, the ratio does not

adjust for the fact that physicians are unequal in terms

of hours worked, productivity, and quality of care. In

addition, the ratio only measures availability within a

specified geopolitical boundary, although residents

sometimes do cross boundaries when seeking care.

The ratio is not the only concept useful in analyzing

the medical care delivery system. Concepts such as access (for example, the ability to pay for care or

distance to care), an economic view of a shortage,

equilibrium, or surplus, or the medical profession's

view of adequacy or need are also useful for understanding and describing the medical care situation,^

The physician-population ratio is adequate for many

purposes, however, and national-level data are more

readily available for it than for other measures.

The data analyzed in this study are at the county level.

The data were obtained from the U.S. Department of

Health and FHuman Services' (DHHS) Area Resource

File {26)7 The file is a compendium of health data

which includes measures of availability of practitioners

and services, health status, utilization of medical services, and general population characteristics.

Trends in Physician Location

Although the number of physicians per 100,000

population increased in all nonmetro areas during the

seventies, the rate of increase was less than in metro

areas, except in urbanized nonmetro areas not adjacent to an SMSA. Nonmetro areas still experienced a

relative shortage of physicians—79 per 100,000 population, compared with 177 in metro areas.

Total Physicians

The number of U.S. physicians in patient care grew

about three times as rapidly as the U.S. population

during 1970-79 [25, 26). The physician-population ratio

increased by 21 percent (table 1). In 1970, there were

123 physicians per 100,000 population: by 1979, there

were 149. Most physicians in patient care are in officebased rather than hospital-based practices. Hospitalbased physicians per 100,000, how^ever, grew slightly

faster than office-based physicians during the seventies

(25 versus 20 percent).

Metro residents continued to have more physicians per

100,000 population than nonmetro residents during

the seventies. The ratio of physicians per 100,000

population in nonmetro areas was 79 by 1979, compared with 177 in metro areas. Thinly populated areas

^Residential distribution refers to the classification scheme

developed at the U.S. Dept. of Agriculture which delineates counties

into metro and nonmetro categories. Regional distribution refers to

the four Census regions—Northeast, Midwest, South, and West.

^The U.S. Dept. of Health and Human Services has proposed that

there should be at least one primary care physician per 2,000

population (9).

^The only exception to this were the data on percentage of the

population 65 years old or older, obtained from unpublished data

provided by the DHHS' Administration on Aging.
Physicians ¡n Nonmetro Areas During the Seventies

Table 1—Distribution of residential population and physicians per 100,000 population, by type of practice

PopulationPhysiicians per 100,000 population^

f

Total Office-based Hospital-baset 4 nrar'tii'P Residential

PercentJ [Jl dL-LIL-t:

1 X\_ -J 1 \_J \_ 1 1 L 1 LA 1

distribution^ Percent- Percent- Percent1970 1980 age

change

1970 1979 age

change

1970 1979 age

change

1970 1979 age

change

Thousand Percent —Number— Percent -Number- Percent -Number- Percent

United States 203,213 226,546 11 123 149 21 91 109 20 32 40 25

Metro total 148,809 163,526 10 143 177 24 102 124 22 41 52 27

Nonmetro total 54,404 63,020 16 67 79 18 60 69 15 7 10 43

Urbanized 21,045 24,396 16 86 108 26 76 92 21 10 16 60

Adjacent 12,650 14,802 17 81 97 20 71 84 18 9 13 44

Not adjacent 8,395 9,594 14 95 124 31 83 104 25 11 20 82

Less urbanized 26,726 30,879 16 59 67 14 54 60 11 5 7 40

Adjacant 13,092 15,350 17 55 62 13 50 55 10 6 7 17

Not adjacent 13,634 15,529 14 62 71 15 57 65 14 5 6 20

Thinly populated 6,633 7,745 17 37 40 8 36 37 3 1 3 200

Adjacent 2,268 2,737 21 35 36 3 33 32 -3 1 4 300

Not adjacent 4,365 5,008 15 39 43 10 37 40 8 2 3 50

^See glossary for definition.

2As of April.

^Physicians are defined as active, non-Federal patient-care physicians. Population data are as of July and physician data are as of December 31.

Source: {25, 26).

had only 40 physicians per 100,000 population in

1979, or 1 physician for every 2,500 residents (table 1).

Although the absolute numbers of physicians locating

in thinly populated areas increased, the increase in

total population in these areas was relatively high. The

ratio of physicians per 100,000 population in thinly

populated areas thus increased only 8 percent during

1970-79,

Distribution of physicians within nonmetro areas in

1979 was about the same as in 1970. As the level of

urbanization increased from thinly populated to less urbanized to urbanized areas, the physician-population

ratio increased. Within each urbanization level, areas

not adjacent to metro areas had more physicians per

100,000 population than areas adjacent to metro areas

in all cases for both years. This fact likely reflects the

willingness and ability of some residents in adjacent

nonmetro areas to travel to nearby metro areas to seek

medical care.

Hospital-Based Physicians

Hospital-based physicians (including resident physicians) have increased much faster in nonmetro areas

than in metro areas (43 versus 27 percent, respectively). This is a curious finding given that the number of

hospital beds grew more slowly in nonmetro areas

than in metro areas during 1970-79 (26). Perhaps this

can be explained by the need for nonmetro hospitals

to 'catch up.' Hospital-based physicians and hospital

beds are complementary inputs into the production of

hospital care. Nonmetro areas have a higher hospital

bed-population ratio than metro areas. But because

nonmetro areas continue to have lower physicianpopulation ratios for hospital-based physicians, the

surge in the number of hospital-based physicians has

allowed the number of physicians to catch up with the

number of beds. There were 10 hospital-based physicians per 100/000 population in nonmetro areas in

1979 compared with 52 in metro areas. Physicians

may also be more willing to locate in nonmetro hospitals rather than set up nonmetro office practices because they have access to more advanced technology

and support from their counterparts in hospitals.

Office-Based Physicians

Office-based physicians are generally considered a patient's regular source of medical care, representing 73

percent of all physicians. The American Medical Association classifies physicians as general practitioners and
Mary C. Ahearn and Michelle D, Fryar

specialists. General practitioners (GPs), generally the

physicians of first contact, accounted for 19 percent of

all office-based physicians in 1979, down from 27 per=

cent in 1970.^ The remaining 81 percent of officebased physicians in 1979 were comprised of medical

specialists, 27 percent; surgical specialists, 31 percent;

and other specialists, 23 percent. Because the residential distribution patterns of the three groups of

specialists are similar, they are combined into one

specialist group for this report (table 2).

The number of office-based GPs per 100,000 population fell by 17 percent, from 24 to 20, between 1970

and 1979 (table 2). For an increasing population, a

decrease in the physician-population ratio can result

from either the population increasing faster than the

increase in physicians, or from a decrease in the absolute number of physicians. For the GP situation, the

latter was true as the number of office=based GPs fell

from 50,304 to 46,061 during the seventies. Total

number of GPs, however, did increase slightly from

57,948 in 1970 to 58,130 in 1979.

Although GPs are about evenly distributed over residence types, there were 19 GPs per 100,000 population in metro areas compared with 24 in nonmetro

areas in 1979. The percentage decrease in the GP-

^CPs include family practitioners. Certain specialists do provide

primary care, such as pediatricians, specialists in obstetrics and

gynecology, and internists.

population ratio during the seventies was also rather

uniformly distributed. GPs per 100,000 population fell

17 percent in both metro and nonmetro areas. The

number of GPs within nonmetro areas varied somewhat, with urbanized areas not adjacent to an SMSA

experiencing the smallest decline (13 percent), and

thinly populated adjacent areas experiencing the

largest decline (21 percent), but overall the trend is

rather consistent.

Unlike GPs, the specialist-population ratios vary greatly

across county types. Specialists must draw their patients from larger base populations and need more advanced medical technology than GPs, so it is not surprising that specialists are more prevalent in metro

areas. There were 105 specialists per 100,000 population in metro areas in 1979, compared with 45 in

nonmetro areas. The uneven distribution of specialists

thus accounts for some of the uneven distribution of

all physicians by residence.

Within nonmetro areas, the specialists per 100,000

population were positively related to the degree of urbanization; the more urbanized the area, the more

specialists per unit of population. Within nonmetro urbanization levels, adjacency to an SMSA was associated with lower specialist-population ratios. The

areas with the lowest specialist-population ratios, thinly

populated areas, had 12 specialists per 100,000 population in 1979. These were the only areas where GPs

Table 2—Office-based physicians per 100,000 popuiation by specialty and residential distribution^

Residential

distribution^

General practitioners

1970 1979 Percentage change

Specialists

1970 1979 Percentage change

United States

Metro total

Nonmetro total

Urbanized

Adjacent

Not adjacent

Less urbanized

Adjacent

Not adjacent

Thinly populated

Adjacent

Not adjacent

=—Number——

24 20

23 19

29 24

25 21

26 21

24 21

32 27

31 25

34 28

29 24

29 23

30 25

Percent

-17

-17

-17

-16

-19

-13

-16

-19

-18

-17

-21

-17

-Number67

80

31

51

45

59

21

19

24

7

5

7

89

105

45

71

63

83

33

29

37

12

9

14

Percent

33

31

45

39

40

41

57

53

54

71

80

100

^Active, non-Federal physicians in patient care.

^See glossary for definition.

Source: (26).
Physicians in Nonmetro Areas During the Seventies

still outnumbered the specialists. The seventies, however, did see a tendency toward a more even distribution of specialists. The number of specialists per

100,000 population increased by 45 percent in nonmetro areas, compared with a 31-percent increase in

metro areas. The rate of increase within nonmetro

areas was also greater the more rural the area.

Regional Trends

Regional trends parallel the national trends of fewer

total physicians, fewer hospital-based physicians, and

fewer specialists but more GPs per 100,000 population

in nonmetro areas than in metro areas (see app. tables

1-4), The physician-population ratio was also positively

related to the level of urbanization in almost all the

nonmetro areas, except for GPs. The less urbanized

and thinly populated areas actually had more GPs per

unit of population than did urbanized nonmetro areas

and metro areas, but GPs were more evenly distributed than specialists.

Although the trends are similar, the number of physicians per 100,000 population and the changes which

occurred during the seventies vary by region (fig. 1).

The Northeast had the highest physician-population

ratio of ail regions in both metro and nonmetro areas

in 1970 and 1979. In 1979, there were 106 physicians

in patient care per 100,000 population in nonmetro

Figure 1

Physicians per 100,000 Population in Metro

and Nonmetro Areas, by Region

Physicians

300

250

200

150

100

50

Active nonfederal physician

Source: (26),

Northeast Midwest

in patient care.

South West

areas of the Northeast, 93 in the West, 74 in the

Midwest, and 71 in the South. The physician-population ratios vary among regions for all nonmetro

residential categories. In general, the Midwest and

South had much lower physician-population ratios than

other regions.

Metro/nonmetro differences in physician distribution

patterns also vary by region. In 1979, total physicians

per 100,000 population in nonmetro areas were only

45 percent of the total physicians per 100,000 population in metro areas. This indicator of the disparity between metro and nonmetro areas for the four regions

shows that the greater the physician availability in the

region, the less the metro-nonmetro disparity. Regions

with the lowest physician-population ratios in 1979,

the Midwest and South, had the greatest disparity between metro and nonmetro areas—a disparity which

worsened during the seventies.

Since the physician-population ratio standardizes only

for population variation, one must be cautious in comparing regions which differ in such respects as population density and topography. Nowhere is this more

true than in very sparsely populated areas of the West,

which compare favorably to other regions in physician-population ratios, but where the distance to the

nearest physician may be considerable. The population

density of the West in 1980 was 24.6 persons per

square mile, compared with the national average of

,64. The rural population also grew faster in the

West—18.2 percent—than in any other region during

the seventies. Although the great majority of

Westerners live in urbanized areas, approximately 7

million residents live in rural areas. These individuals

likely travel longer distances to obtain physician care

than rural residents of other regions.

Physicians in Low-Income Areas

Many of the economic and social gaps between metro

and nonmetro areas are narrowing, but in 1980, nonmetro residents accounted for 28 percent of the total

population but 34 percent of the persons (9.3 million)

living in poverty (25), Some nonmetro areas, bypassed

by development, have been persistently poor during

the past several decades. Low-income areas are identified either as those with large portions of the population below the poverty line, or with low per capita incomes. Davis used the per capita concept in defining

nonmetro persistent low-income (PLI) areas (8). PLI
Mary C. Ahearn and Michelle D, Fryar

crease in the national supply of physicians and Federal

programs of the last two decades have contributed to

the increase in the number of physicians in nonmetro

areas. These findings are consistent with the general

improvement in the quality of life in nonmetro areas.

The number of specialists per 100,000 population is

still much lower in nonmetro areas than in metro

areas, but nonmetro areas saw a higher rate of increase during the seventies. The population density of

an area has generally had a strong positive effect on

the specialist-population ratio.

The number of office-based CPs per 100,000 population, on the other hand, declined nationwide during

the seventies. Nonmetro areas actually had a higher

ratio of GPs to population than did metro areas; the

decline in the number of GPs to the population was

constant between metro and nonmetro areas. Because

GPs traditionally were more evenly distributed than

specialists, the decline in general practitioners had a

strong impact on the nonmetro medical delivery

system.

Availability of hospital resources had the strongest effect on patterns of physician location. The medical

education system has recognized both the increasing

dependence of physicians on sophisticated technology

as well as the decline in the number of GPs. The

medical system has thus focused on the family practitioner as a specialty, and offered training in this

specialty in underserved areas. This new focus may encourage new physicians to locate in these areas, particularly thinly populated areas. Some specialists, such

as pediatricians, are already providing general primary

care, a practice likely to continue with the decrease in

GPs. Further research is needed to determine the extent that specialists are providing general primary care

before the effects of the decline in number of GPs can

be understood.

Despite improvements in the availability of physician

services in nonmetro areas, some nonmetro areas have

been overlooked. This is particularly evident in sparsely populated areas and in PLI areas. Sparsely populated areas, through development, may be linked to

regional medical systems. Until that occurs, however,

emergency medical systems will be the only source of

care in the most isolated communities. Government

intervention through such programs as the National

Health Service Corps will remain necessary where

poverty, or lack of demand, has deterred development

and been the root cause of lack of physicians.

References

(1) Ahearn, Mary C., Health Care in Rural America.

U.S. Dept. of Agriculture, Economics, Statistics,

and Cooperatives Service, AIB-428, July 1979.

(2) American Public Health Association. 'Testimony

Urges Child Health Benefits," The Nation's

Health. Aug. 1983.

(3) Beale, Calvin L., Rural and Small Town Population Change. 1970-1960. U.S. Dept. of Agriculture, Economics, Statistics, and Cooperatives Service, ESS=5, Feb. 1981.

(4) The Revival of Population Growth in

Nonmetro America. U.S. Dept. of Agriculture,

Economic Research Service, ERS-605, June

1975.

(5) Chow, Gregory C, 'Test of Equality Between

Sets of Coefficients in Two Linear Regresions,"

Econometrica. Vol. 28, pp. 591-605, July 1960.

(6) Cordes, Sam M. and Richard Blair, "Factors Influencing the Location and Distribution of Physi=

cians in the Northeastern U.S.," ¡ournal of the

Northeastern Agricultural Economics Council.

Vol. 10, No. 1 pp. 31-39, Apr. 1981.

(7) Davis, Karen and Cathy Schoen, Health and the

War on Poverty: A Ten Year Appraisal. Washington, D.C.: Brookings Institution, 1978.

(8) Davis, Thomas F., Persistent Low-lncome Counties in Nonmetro America. U.S. Dept. of Agriculture, Economics, Statistics, and Cooperatives Service, RDRR-12, May 1979.

(9) Federa/ Register, "DDHS, PHS, National

Guidelines for Health Planning; Proposed Rules."

Vol. 45, No. 29, Nov. 25, 1980.

(10) Gentile, Augustine, Health Characteristics by

Geographic Region, Large Area, and Other Places.

U.S. Dept. of Health, Education and Welfare,

National Center for Health Statistics, (PHS)

78-1540, Nov. 1977.
Physicians in Nonmetro Areas During the Seventies

(11) Gibson, Robert, ''National Health Expenditures,

1979," Health Care Financing Review. U.S. Dept.

of Health and Human Services, Health Care Financing Administration, (HCFA) 03054, Summer

1980.

(12) Graduate Medical Education National Advisory

Committee, CMENAC Summary Report U.S.

Dept. of Health and Human Services, Health

Resources Administration, Vol. 1, Sept. 1980.

(13) Health Care Financing Administration, The

Medicare and Medicaid Data Book, 1981. U.S.

Dept, of Health and Human Services, Off. of

Research and Demonstration, Apr. 1982.

(14) Heald, Karen, James Cooper, and Sinclair Coleman, Choice of Location of Practice of Medical

School Graduates; Analysis of Two Surveys. Santa

Monica: Rand Corporation, Nov. 1974.

(15) Hoppe, Robert A., "A Decade of Change in Persistent Low-Income Counties." U.S. Dept. of

Agriculture, Economic Research Service. Paper

presented at Eighth Annual National Institute on

Social Work in Rural Areas, Cheney, Wash., July

1983.

(16) Inter-Bureau Commission on Post-War Programs,

U.S. Dept. of Agriculture, "Better Health for

Rural America," Oct. 1945.

(17) Kleinman, Joel C, "Medical Care Use in Nonmetropolitan Areas," Health, United States, 1981.

U.S. Dept. of Health and Human Services, National Center for Health Statistics, (PHS) 82-1232,

Dec. 1981.

(18) Luft, Harold, Poverty and Health: Economic

Causes and Consequences of Health Problems.

Cambridge, Mass.: Balllnger, 1978.

(19) Makuc, Diane, "Changes in Use of Preventive

Health Services/' Health, United States, 1981.

U.S. Dept. of Health and Human Services, National Center for Health Statistics, (PHS) 82-1232,

Dec. 1981.

(20) Matthews, Tresa H., Health Services in Rural

America. U.S. Dept. of Agriculture, Rural Development Service, AIB-362, July 1973.

(21) Pindyck, Robert S. and Daniel L. Rubinfeld,

Econometric Models and Economic Forecasts.

Second ed., McGraw-Hill, 1981.

(22) President's Commission for the Study of Ethical

Problems in Medicine and Biomédical and Behavioral Research, Securing Access to Health

Care. 1983.

(23) Roemer, Milton L, Rural Health Care. St.

C.V. Mosley Co., 1976.

Louis:

(24) U.S. Congress, Rural Development Policy Act of

1980. P.L. 96-355, 94 Stat. 1171, Sept. 24, 1980.

(25) U.S. Department of Commerce, Bureau of the

Census, Census of Population and Housing, 1980.

Summary tape file 111. 1982.

(26) U.S. Department of Health, Education, and Welfare, The Area Resource File: A Manpower Planning and Research Tool. 1976.
Mary C. Ahearn and Michelle D. Fryar

Appendix Tabie 1—Residential distribution of total active, non-Federal, patient care physicians per 100,000 population, by region

Residential Northeast Midwest South West

distribution Percentage Percentage Percentage Percentage

1970 1979 change 1970 1979 change 1970 1979 change 1970 1979 change

-Number- Percent -Number- Percent -Nunnber- Percent -Number- Percent

Total 157 186 18 108 135 25 100 129 29 140 164 17

Metro total 168 200 19 127 163 28 125 163 30 155 183 18

Nonmetro total 89 106 19 65 74 14 59 71 20 77 93 21

Urbanized 91 108 19 87 109 25 82 106 29 89 109 22

Adjacent 82 96 17 86 103 20 72 90 25 85 103 21

Not adjacent 130 166 28 89 119 34 91 121 33 94 117 24

Less urbanized 87 103 18 58 62 7 53 61 15 68 83 22

Adjacent 92 110 20 52 54 4 50 58 16 65 79 22

Not adjacent 81 94 16 63 69 10 56 65 16 69 84 22

Thinly populated 69 83 20 36 35 -3 34 37 9 51 55 8

Adjacent 55 58 5 36 32 -11 31 34 10 54 49 -9

Not adjacent 77 98 27 36 36 0 36 40 11 49 57 16

Source: (26).

Appendix Table 2—Residential distribution of active, non-Federal, patient care, hospital-based physicians,

per 100,000 population, by region

Residential Northeast Midwest South West

distribution Percentage Percentage Percentage Percentage

1970 1979 change 1970 1979 change 1970 1979 change 1970 1979 change

-Number- Percent -Number- Percent -Number- Percent -Number- Percent

Total Si 63 21 Id 38 36 22 31 41 26 33 17

Metro total 57 71 25 38 52 37 33 45 36 31 39 26

Nonmetro total 14 20 43 6 9 50 5 9 80 5 7 40

Urbanized 13 19 46 11 17 55 10 16 60 6 9 50

Adjacent 8 13 63 15 20 33 6 9 50 7 9 29

Not adjacent 37 52 41 4 12 200 14 23 64 4 9 125

Less urbanized 16 22 38 4 5 25 4 6 50 5 6 20

Adjacent 22 31 41 4 4 0 4 6 50 6 6 100

Not adjacent 8 11 38 5 6 20 4 6 50 4 6 50

Thinly populated 1 9 800 1 2 100 2 3 50 3 5 67

Adjacent 1 4 300 1 2 100 1 4 300 6 5 -17

Not adjacent 1 12 1100 1 2 100 2 3 50 2 5 150

Source: (26).

10
Physicians in Nonmetro Areas During the Seventies

Appendix Table 3—Residential distribution of active, non-Federal, patient care, office-based general practitioners per 100,000

population, by region

Residential Northeast Midwest South West

distribution Percentage Percentage Percentage Percentage

1970 1979 change 1970 1979 change 1970 1979 change 1970 1979 change

-Number- Percent -Number- Percent -Number- Percent -Number- Percent

Total 24 18 -25 24 21 -13 22 19 -14 30 24 -20

Metro total 24 17 -29 21 18 -14 19 17 -11 29 23 -21

Nonmetro total 27 21 -22 31 27 -13 27 22 -19 34 28 -18

Urbanized 25 19 -24 25 22 -12 23 20 -13 30 26 -13

Adjacent 26 19 -27 27 22 -19 24 20 -17 29 26 -10

Not adjacent 23 18 -22 22 21 -5 22 19 -14 31 26 -16

Less urbanized 30 23 -23 35 30 -14 30 24 -20 38 31 -18

Adjacent 28 23 -18 35 28 -20 29 23 -21 36 30 -17

Not adjacent 32 24 -25 36 31 -14 30 25 -17 38 32 -16

Thinly populated 39 29 -26 30 26 -13 26 22 -15 40 31 -23

Adjacent 41 30 -27 30 24 -20 26 21 -19 44 32 -27

Not adjacent 37 28 -24 30 26 -13 26 23 -12 39 31 -21

Source: (26).

Appendix Table 4—Residential distribution of active, non-Federal, patient care, office-based specialists

per 100,000 population, by region

Residential Northeast Midwest South West

distribution Percentage Percentage Percentage Percentage

1970 1979 change 1970 1979 change 1970 1979 change 1970 1979 change

'Number- Percent -Number- Percent -Number- Percent -Number- Percent

Total 82 104 17 55 75 36 56 78 39 83 107 29

Metro total 87 111 28 67 93 39 74 100 35 95 120 26

Nonmetro total 48 65 35 27 39 44 27 40 48 38 58 53

Urbanized 52 69 33 51 70 37 49 70 43 54 75 39

Adjacent 48 64 33 44 61 39 42 61 45 48 68 42

Not adjacent 70 96 37 63 86 37 55 79 44 60 82 37

Less urbanized 41 57 39 18 27 50 20 31 55 25 45 80

Adjacent 41 56 37 14 21 50 17 28 65 22 44 100

Not adjacent 41 59 44 21 32 52 22 34 55 27 46 70

Thinly populated 28 45 61 5 7 40 6 12 100 7 19 171

Adjacent 12 25 108 5 6 20 5 9 80 4 12 200

Not adjacent 38 58 53 5 8 60 8 14 75 8 21 163

Source: {26).

11
Mary C. Ahearn and Michelle D, Fryar

Appendix Table 5—Regression estimates of active/non-Federal, office-based, patient-care general practitioners

per 100,000 population, by region in nonmetro counties

Region/i ndependent

variables

1970

Beta Beta

1978

Number

Northeast:

Per capita income

Percent 65 years and older

Percent nonwhite

Hospital beds per population

Population per square mile

Constant

R^

N

F

0.182

.411

-.027

.073

-.187

NA

NA

NA

NA

0.005 0.177 0.004

^2.256 .271 21.130

-.199 -.033 -.181

.003 .101 .003

-.024 -.262 3-.026

10.981 NA -4.361

.2678 NA .1543

116 NA 116

^8.05 NA 24.01

Chow test—Northeast 1970 versus

Northeast 1978 1F 6,220 = 9.38

Number

Midwest:

Per capita income

Percent 65 years and older

Percent nonwhite

Hospital beds per population

Population per square mile

Constant

R2

N

F

0.148

.143

-.070

.370

-.046

NA

NA

NA

NA

Chow test—Midwest 1970 versus

Midwest 1978

10.005 0.118

^720 .095

^-.195 -.051

1.019 .419

-.022 -.044

-.054 NA

.2247 NA

873 NA

150.25 NA

1F6J734 - 16.44

10.003

^447

-.117

1.019

-.020

2.420

.2474

873

156.99

See footnotes at end of table. Continued12
Physicians in Nonmetro Areas During the Seventies

Appendix Table 5—Regression estimates of active, non-Federal, office-based, patient-care general practitioners

per 100,000 population, by region in nonmetro counties—Continued

Region/independent

variables

1970

Beta

1978

Beta

Number

South:

Per capita income

Percent 65 years and older

Percent nonwhite

Hospital beds per population

Population per square mile

Constant

R2

N

F

0.101

.151

.012

.307

-.109

NA

NA

NA

NA

10.003 0,036

^581 .144

.010 .002

\016 .286

1-.041 -.109

ni.086 NA

.1711 NA

1106 NA

M5.41 NA

0.001

^479

.001

^014

1-.033

M 2.394

.1407

1106

^36.02

Chow test—South 1970 versus

South 1978 ip 6,2200 = 15.44

Number

West:

Per capita income

Percent 65 years and older

Percent nonwhite

Hospital beds per population

Population per square mile

Constant

0.043

.070

-.108

.336

-.057

NA

0.001

.045

3-.242

^025

-.059

123.921

0.086

.055

-.132

.210

-.034

NA

0.002

.024

3-.228

1.012

-.025

119.545

R2

N

F

NA

NA

NA

.1451

351

111.71

NA

NA

NA

.0933

351

17.10

Chow test- -West 1970 versus

West 1978 2F 6,690 = 3.29

NA = Not applicable.

^p < .001.

2p < .01.

3p < .05.

Source: (26).

13
Mary C. Ahearn and Michelle D. Fryar

Appendix Table 6—Regression estimates of active, non-Federa!, office-based, patient-care specialists

per 100,000 population, by region in nonmetro counties

Region/independent

variables

1970

Beta

1978

Beta

Number

Northeast;

Per capita income

Percent 65 years and older

Percent nonwhite

Hospital beds per population

Population per square mile

Constant

R2

N

F

0.117

.027

-.078

.802

.110

NA

NA

NA

NA

^0.017 0.094

.565 -.039

-2.143 -.056

M39 .786

.052 .158

77.963 NA

.6841 NA

116 NA

M7.65 NA

0.012

-1.003

-1.912

M50

^098

-46.618

.6435

116

139.71

Chow test—Northeast 1970 versus

Northeast 1978 F 6,220 = .41

Number

Midwest:

Per capita income

Percent 65 years and older

Percent nonwhite

Hospital beds per population

Population per square mile

Constant

R2

N

F

0.002

-.098

.004

.366

.390

NA

NA

NA

NA

Chow test- -Midwest 1970 versus

Midwest 1978

0.0001

2-.677

.016

\026

\263

4.432

.3182

873

^80.92

0.026

-.172

.005

.322

.388

NA

NA

NA

NA

ip 6,1734 = 4.83

0.001

1-1.482

.020

1.026

1.324

^15.521

.3233

873

182.84

See footnotes at end of table. Continued—

14
Physicians in Nonmetro Areas During the Seventies

Appendix Table 6—Regression estimates ofactive, non-Federal, office-based, patient-care specialists

per 100,000 population, by region in nonmetro counties—Continued

Region/independent

variables

1970

Beta

1978

Beta

Number

South:

Per capita income

Percent 65 years and older

Percent nonwhite

Hospital beds per population

Population per square mile

Constant

R2

N

F

0.194 ^0.007 0.167

.040 .234 .054

.040 .047 .054

.275 1.021 .288

.516 \290 .542

NA 1-26.928 NA

NA .4552 NA

NA 1106 NA

NA n83.81 NA

^0.007

^404

^093

\031

1.377

-35.406

.4796

1106

1202.73

Chow test- -South 1970 versus

South 1978 ip 6,2200 = 5.15

Number

West:

Per capita income

Percent 65 years and older

Percent nonwhite

Hospital beds per population

Population per square mile

Constant

R2

N

F

0.097

-.019

.027

.102

.407

NA

NA

NA

NA

0.004 0.258

-.015 -.056

.073 .082

^009 -.060

1.508 .316

1.721 NA

.1955 NA

351 NA

16.77 NA

10.011

-.042

.251

-.006

1.403

18.049

.2007

351

117.33

Chow test—West 1970 versus

West 1978 F 6,690 = 1.83

NA = Not applicable,

ip < .001.

2p < .01.

3p < .05.

Source: {26).

15
Mary C, Ahearn and Michelle D. Fryar

Appendix: Regression Results of the Distribution of General Practitioners and Specialists, by Region

The distribution of physicians differs by specialty as a

result of the division of labor within the medical

system. Separate equations are thus estimated for GPs

and specialists because the factors in the analysis

should affect location patterns differently. The distribution of physicians also differs by Census region. Preliminary analyses used a single national level equation

for GPs and for specialists, and included dummy

variables for the Census regions to determine whether

the regional differences are accounted for by differences in other variables. All dummy variables for

the specialists model and two of the dummy variables

in the GP model were statistically significant (p< .05).

This result indicates that relationships differ among

regions. Separate equations were thus estimated by

Census region and the regional trends became apparent. The regional equations allow for a better

understanding of the factors affecting physician

distribution throughout the Nation.

Although differences were expected between the GPs'

and specialists' models and by regions, these differences were generally expected to be one of the

magnitude of the relationships rather than the direction of the relationships, Vv/ith one exception. Based on

evidence from the descriptive section (table 2),

population density was expected to be negatively

related to the distribution of GPs and positively related

to the distribution of specialists. The independent variables and the direction of their expected relationship

to the physician-population ratios were hypothesized

to be:

— Per capita income was expected to be positively

related to the physician-population ratio because

higher income persons can better afford to pay

for physician care and because higher incomes

may indicate a higher quality of life which would

attract more physicians. The magnitude of this

relationship may be greater for specialists than

for GPs because of the added expense of specialty care.

— Percentage of the population 65 or older was expected to be positively related to the physicianpopulation ratio because older persons require

more health care than persons in other age

groups. Thus, the magnitude of the relationship

in the specialist model was expected to be

greater than in the GP model.

— Percentage of the population which was nonwhite was expected to be negatively related to

the physician-population ratio because nonwhite

persons may use physician services less than

white persons for social and economic reasons.

No difference in magnitude or direction was expected between this factor and its relationship to

the specialists- or GPs-population ratio.

— Hospital beds per 100,000 population was expected to be positively related to the physicianpopulation ratio because many medical procedures require the technology and support services of a hospital. The magnitude of this relationship was expected to be greater in the specialists' model because their practice generally

requires more dependence on hospital

technology.

— Population per square mile was expected to be

positively related to the specialists-population

ratio and negatively related to the GP-population

ratio. This is because a financially successful

medical practice for a specialist requires a larger

minimum population base within easy travel

distance than does a GP practice. Therefore, GPs

have a comparative advantage when locating in

less dense areas.^^

The regressions are estimated with ordinary least

squares (OLS), the most common regression estimation

technique, which is equivalent to determining the

parameter estimates which minimize the residual sum

of squares. Regression analysis results include (1) the

statistical significance of the overall model based on

the "F" distribution, (2) the total variation in the

physician-population ratio explained by the model, R^,

(3) the statistical significance of the independent

variables based on the 'T' distribution, and (4) the

amount of change in the physician-population ratio

with a one-unit change (unstandardized coefficient

^^Multicollinearity between these variables is not viewed as a serious

concern since 90 percent of the correlations between pairs of

variables have a correlation coefficient less than 0.3 and the majority

are less than 0.1,

16
Physicians in Nonmetro Areas During the Seventies

denoted as ''b") or a one-standard deviation change

(standard coefficient denoted as Beta) in the independent variable. The Chow test is based on a statistic

computed from the residual sum of squares of the

regressions and follows an "F" distribution (5, 20).

General practitioners

The results of the regression analyses indicate that the

models were all statistically significant (p< .05), and

the.proportion of variation explained ranged from 9 to

27 percent for the four regions and two time periods

(app. table 5)^^ When the variables were significant,

per capita income, percentage of the population 65

and over, and hospital beds-population ratios were

positively related to GPs per 100,000 population.

Percentage of the population which was nonwhite and

population density were negatively related to GPs per

100,000 population when they were statistically significant. All independent variables had the expected relationship to GP availability. The statistical tests for structural differences between the factors affecting distribution of GPs in 1970 and 1978 also indicated that there

indeed were structural differences between the two

time periods for all regions.

Very few variables were significant in the Northeast

model. The percentage of the population 65 years or

older was significant during both time periods and was

the most important community attribute explaining

variation in physician location. Population density was

also significant in 1978. Comparison of the regression

estimates for the two time periods suggests that

percentage of the population 65 years or older and the

population density may be the source of the structural

change indicated by the significant Chow statistic.

Overall, the 1970 equation explained more of the

variation in the distribution of GPs than did the 1978

equation. The percentage of the population which was

elderly was much stronger in 1970 than in 1978 in

terms of unit effects, and the population density was

significant in the 1978 equation but not in the 1970

equation.

Per capita income, percentage of population which

was elderly, and the number of hospital beds per

population were significant in both time periods in the

Midwest. The number of hospital beds was the most

important explanatory variable in this region as in-

^Hereafter, significant implies significance at p< .05.

dicated by the size of Beta. Percentage of the population which was nonwhite was also significant in the

1970 model. The source of the structural change between the two time periods in the Midwest may be

due to the differences in the significance and size of

the percentages of the elderly and nonwhite

coefficients.

Percentage of the population which was elderly,

hospital beds per population, and density were significant in both time periods, and per capita income was

significant in 1970 in the South. As in the Midwest, the

number of hospital beds was the most important explanatory variable in the South. The structural change

between the two time periods there may be due to differences in the significance of per capita income.

Percentage of the population which was nonwhite and

hospital beds per population were significant in both

time periods in the West. Again, the number of

hospital beds was the most important explanatory

variable. Both variables were somewhat stronger in the

1970 equation than in the 1978 equation, suggesting

that they may have been the source of the structural

change.

Specialists

As in the models for GPs, the models for specialists

were ail statistically significant (p< .05) and the proportion of variation in specialists per population explained varied substantially among regions (app. table

6). The proportion of variation explained by the

selected independent variables, however, was higher

for specialists (from 20 in the West to 68 in the Northeast) than it was for GPs.

The independent variables which were significant in

each region had the hypothesized relationships to

availability, with two exceptions. Contrary to expectations, the percentage of the population which was

nonwhite was positively related to availability in 1978

in the South. Multicollinearity with other independent

variables does not appear to explain this surprising

result, and no other explanation is obvious. This result

should consequently be interpreted with caution until

further analysis can provide a better understanding of

the relationships. The percentage of the population

which was elderly was unexpectedly found to be negatively related to availability in both time periods in the

17
Mary C. Ahearn and Michelle D. Fryar

Midwest. This may be due to multicollinearity between

population density and percentage of the population

which was elderly, making it impossible to separate

out the independent effects of the variables. A positive

effect of the percentage of the population which was

elderly may have been overshadowed, since density

and percentage of the population which was elderly

are negatively correlated and density is a significant

and positive factor in explaining specialist distribution.

The test for structural differences between the two

time periods indicated that structural change occurred

only in the Midwest and South.

The number of hospital beds per population was significant in both time periods in the Northeast, and was

the most important explanatory variable. Per capita income in 1970 and population density in 1978 were

also significant. Percentage of the population which

was elderly, number of hospital beds per population,

and population density were significant factors in explaining the per capita distribution of specialists in

both time periods in the Midwest. Population density

was the most important explanatory variable followed

closely by number of hospital beds. Percentage of the

population which was elderly and population density

may have been the sources of structural change between the two time periods in the Midwest because

both variables had stronger effects in 1970 than in

1978. Per capita income, number of hospital beds per

population, and population density were significant in

both time periods in the South; population density was

by far the strongest explanatory variable. Percentages

of the population which were elderly and nonwhite

were also significant in 1978; the change in their

significance between the two time periods may have

been the source of the structural change in this region.

The stronger unit effect of hospital beds and population density in the 1978 equation may also have contributed to the structural change. The population density was significant in both time periods, number of

hospital beds was significant in 1970, and per capita

income was significant in 1978 in the West.

^U.S. GOVERNMENT PRINTING OFFICEs 1985-460^94l:20050-ERS

18